This article was downloaded by: [Carnegie Mellon University] On: 21 November 2014, At: 17:05 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Marital therapy formats: An analysis of acceptability ratings with married spouses a
Marian R. Flammang & Gregory L. Wilson
a
a
Department of Psychology , Washington State University , Pullman, WA, 99164-4820 Published online: 14 Jan 2008.
To cite this article: Marian R. Flammang & Gregory L. Wilson (1992) Marital therapy formats: An analysis of acceptability ratings with married spouses, Journal of Sex & Marital Therapy, 18:3, 159-172, DOI: 10.1080/00926239208403405 To link to this article: http://dx.doi.org/10.1080/00926239208403405
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Marital Therapy Formats: An Analysis of Acceptability Ratings with Married Spouses Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
M A R I A N R. F L A M M A N G and GREGORY L. W I L S O N
One hundred thirty-five married individuals evaluated the accepubility of alternative therapeutic formats commonly employed in murital thera p y Distressed and nondistressed spouses were randomly assigned to experimental conditions including two types of educational information (descriptive and group-oriented) presented across three treatment formats (i.e., individual, conjoint, und group). Primary dependent variables included the Treatment Evaluation Inventory and the Semantic Differential. Results revealed that conjoint format was most acceptable, followed by group and individual, respectively. However, distressed spouses rated the group and conjoint formats as equal i n acceptability. Group-oriented information increased nondistressed subjects’ ratings of group format. The implications of these results f o r clinicians and researchers offering marital therapy are discussed. Marriage is exceedingly common in the United States. In fact, it is estimated that over 90% of Americans will marry at least once in their lifetimes.’ However, nearly 50% of those who marry will eventually divorce.2 Moreover, the average length of a first marriage is only five to seven years3 Previous research has found evidence that links divorce and marital distress to a wide variety of emotional disorders in spouses and their children.4~~ Marital distress is also one of the most common complaints for patients seeking psychological help in the United States.6 Whereas demands for marital treatment services have expanded over the last t w o decades, few investigations have systematically evaluated the efficacy and acceptability of alternative marital therapy formats. Comparative investigations have revealed minimal differences in terms of efficacy across alternative marital treatment format^.^-^ Bennun7 documented the effectiveness of marital therapy regardless of whether the Marian R. Flammang, M.S., and Gregory L. Wilson, Ph.D., are at the Department of Psychology. Washington State University, Pullman. WA 99164-4820. Address correspondence to the first author.
Journal of Sex & Marital Therapy, Vol. 18, No. 3, Fall 1992 0 Brunner/Mazel, Inc.
159
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
160
Journal oJSex k3 Manta1 Therapy, Vol. 18, No. 3 , Fall 1992
format was individual, conjoint, or group. Likewise, other investigations”’ comparing group and conjoint treatment formats of marital therapy have demonstrated that couples in both formats showed significant improvements in targeted areas as compared to wait-list couples. Moreover, Wilson” showed some evidence that dysfunctional couples in conjoint treatment improved more in learning to share feelings with each other than did couples in group treatment. However, this same study found group marital therapy to be more effective than conjoint treatment in teaching couples improved communication strategies, as well as in maintaining improvements in sexual relations and childrearing practiccs. T h e choice o f which treatment format to offer clients seeking marital therapy is based on a host of factors including documented effectiveness, differential advantages for meeting treatment goals, and the clients’ perceived acceptability of treatment formats. Acceptability refers to the fairness, appropriateness, and intrusiveness of treatment procedures as judged by patients, lay persons, and professionals.” Acceptability is a n important criterion for evaluating treatment formats because it offers a mcans to discriminate among equally viable treatment formats, and because highly acceptable treatment formats may be more fre uently selected and adhered to than those rated as less acceptable.’*Only four previous studies have examined the acceptability of marital therapy procedures. Bornstein et al.I5 evaluated the acceptability of alternative marital therapy “schools” (ix.. analytic, behavioral, systems, and eclectic) and found the behavioral and systems approaches to be rated consistently superior to alternative approaches. In a later study examining the “politics and values” associated with behavioral marital therapy, Bornstein et al.16 revealed that traditional behavioral marital therapists were rated as more acceptable and credible than “egalitarian” behavioral marital therapists. More recently, Wilson and Flammang“ examined the acceptability of four alternative treatment formats used in the resolution of marital dysfunction: individual, concurrent, conjoint, a n d group. O n e hundred subjects were randomly assigned to experimental conditions which included two forms of information (ie., descriptive versus research-oriented). Results revealed that conjoint treatment was consistently rated as most acceptable, followed by concurrent, group, and individual, respectively. It was also found that providing efficacy information about alternative formats did not alter acceptability ratin s. Later, Wilson, Flammang, and D e h l J 7 expanded the above study to include 356 college students who rated the four treatment formats. Additionally, three forms of information (i.e., descriptive, research-oriented, and group-oriented) and t w o differing case histories were presented across the treatment formats. Again, conjoint treatment format was rated as most acceptable followed by concurrent, group, and individual, rcspectively. T h e type of information given to subjects did not affect acccptability ratings, neither did varying case histories. O n e limitation o f all the previous marital acceptability studies is that college students were employed as subjects. T h e r e has been considerable
’1
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Marital TherapV Formu&
161
controversy over the use of nonclinical populations in acceptability studies. Pickering et al.“ found that parents and nonparents differed in acceptability ratings. Cross Calvert and JohnstonIR also reported that parents and college students significantly differed in acceptability ratings, By using distressed and nondistressed married individuals as subjects, this study surveyed the population that is most likely to seek marital therapy for purposes of marital enrichment or the alleviation of distress. In addition, this study also evaluates whether length of marriage influences ratings of acceptability. Based on a median-split procedure, partners who have been married less than six years are contrasted with partners who have been married over six years. Since the average length of first marriages is between five to seven years, six years is representative of the national average for first marriage^.^ Another important question in acceptability research concerns whether the use of educational information influences acceptability ratings. Educational information includes reports on the efficacy of various treatments and the comparative advantages or disadvantages of each treatment. Research has produced mixed results, with some studies showing that educational information did little to alter subjects’ acceptability ratings, 12.13.I7,l9 while other studies found that educational information did increase acceptability ratings.20,21I n a n attempt to examine the relative influence of educational information presented to married subjects, t w o types of educational information were used in this study: I ) descriptive, which defined the three different formats of marital therapy; and 2) group-oriented, which summarized the advantages of group marital therapy. Group-oriented information was developed in a n attempt to systematically influence ratings of group marital treatment. Because research has consistently shown group marital therapy to be as effective as conjoint marital therapy,’-’ and group marital treatment generally has the added advantage of costing less than con-joint treatment, it seems important to examine which variables may improve acceptability ratings of group marital therapy. Thus, the current investigation compared the acceptability ratings of distressed and nondistressed married subjects involved in short- and long-term marriages who received different forms of information across three common therapeutic formats. Specifically, it was hypothesized that subjects would rate group treatment as a more acceptable option following the presentation of group-oriented information. Moreover, it was hypothesized that conjoint and group treatment would be consistently rated as more acceptable than individual therapy of one spouse. Finally, this investigation represents the first acceptability study to employ married spouses as subjects.
METHODS Subjects
One hundred and thirty-five married spouses (63 males and 72 females) were recruited through media announcements. A raffle of t w o $50 cash
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
162
Journal of Sex &f Manta1 Thnapy, Vol. 18, No. 3 , Fall 1992
prizes was offered in exchange for participation. Approximately 25% of the subjects were prospective clients seeking marital therapy at mental health agencies. These subjects participated in this study prior to beginning marital treatment. Length of marriage ranged from 2 months to 37 years (M = 8.16 years, SD = 7.46 years). T h e median length of marriage across subjects was 6 years. These subjects ranged in age from 19 to 6 3 years (M = 33.13, SD = 9.28). Forty-three subjects (32%) scored in the distressed range on the Dyadic Adjustment Scale. Scores o n the Dyadic Adjustment Scale ranged from 21 t o 147 points (M = 109.19. SD = 21.32). Fiftyfour percent of the subjects had previously participated in therapy. Of those subjects who had previous therapy experience, individual treatment was most common (44%), followed by relationship treatment (32%). Twenty-five couples (i.e., 50 subjects) were included in the total sample of 135 participants. Data were analyzed to determine whether there were significant correlations in the acceptability ratings of thcse married partners. Only t w o significant correlations were revealed. Specifically, married couples scored similarly o n SD-Potency Scale ratings of conjoint treatment (correlation coefficient = .42, p = .05), a n d o n SD-Evaluative Scale ratings of group treatment (correlation coefficient = .48, p = .05). Therefore, w e concluded that married spouses revealed limited similarity across experimental conditions o n the various dependent variables. Thus, all married partners were evaluated as independent subjects. Using a completely crossed Latin square, six differing sequences of randomly counterbalanced treatment descriptions were created. All subjects were randomly assigned to one of the experimental conditions. Assessment Demographic Data. A demographic questionnaire was used to gather such information as length o f marriage, format of any previous therapy experiences, and self-rating of the participant’s likelihood of seeking marital therapy. Dyadic Adjustment Scale (DAS).22T h e DAS is a widely used self-report questionnaire, which provides a global measurement of marital satisfaction. Subscales of the DAS measure four components of adjustment: dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression. In previous empirical research o n the DAS, SpanierZ2reports that the DAS has excellent reliability (Cronbach’s alpha = .Y6) and substantial criterion-related validity as well as construct validity. Individuals who score below 100 points were classified as being in a “distressed” relationship, while those scoring 100 points or more were classified as “nondistressed.” Prcccdence for the use of these cut-off scores has been set in previous researche9More recently, Crane, Allgood, Larson, and Griffinz3 employed multiple regression t o develop formulas t o establish cutoff scores for distressed and nondistressed subjects o n the Dyadic Adjustment Scale, the Marital Adjustment Test, and the Revised
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Marital Therapy Furmals
163
Marital Adjustment Test. They also recommended using 100 as a DAS cutoff score for nonclinical couples. Treatment Evaluation Inventory (TEZ).”724T h e T E I consists of 15 items on a seven-point Likert scale which asks subjects to evaluate such factors as the acceptability of treatment, suitability of procedures for the individuals, and the likely effectiveness of the procedures. T h e T E I was developed by Kazdin specifically to measure acceptability of alternative treatments. It was modified so as to conform with an evaluation of marital therapy. Research on the inventory”*24has shown that it is able to discriminate between alternative treatments. Items on the TEI were selected based upon previous factor analytic research from four separate samples. T h e 1 E I represents the single most common measure employed in treatment acceptability research. In a previous analysis of the TEI, Wilson and F l a m m a t ~ gfound ~ ~ the instrument to have high levels of reliability (Cronbach’s alpha = .96, split-half reliability = .96). Higher scores on the TEI are representative of greater acceptability. T h e SD has been employed extensively in Semantic Dflmential treatment acceptability re~earch.”,’”,’~,’~.’~ T h e form of the SD used in acceptability research consists of 15 bipolar adjectives, rated o n a one-toseven Likert scale. These 15 adjectives are divided into three subscales (Evaluative, Potency, and Activity), each of which consists of 5 adjective pairs. T h e adjectives that subjects used to rate treatment formats on the Evaluative subscale included good-bad, valuable-worthless. Adjectives comprising the Potency subscale include strong-weak, hard-soft. Adjectives such as active-passive, fast-slow are characteristic of the Activity subscale. Extensive research with the SD indicates that it is a psychometrically sound and reliable instrument. Osgood et aI.% reported a test-retest reliability coefficient of .85. Marshall and Merritt*’ also found that SD reliability coefficients ranged from .78 to .88 in their study using a 40-item SD scale designed to assess individuals’ learning styles. More recently, Wilson and F l a m m a r ~ gfound ~ ~ the SD to be highly reliable when used in acceptability research: Evaluative Scale (Cronbach’s alpha = .93; split-half reliability = .95), Potency Scale (Cronbach’s alpha = 3 5 ; split-half reliability = .go), Activity Scale (Cronbach’s alpha = .71; split-half reliability = 30). Across all subscales, higher scores are representative of greater endorsement of that particular construct (e.g., “high potency” versus “low potency”). Procedures Subjects were initially given instructions explaining the purpose of the study (i.e., to evaluate different methods of treating marital dysfunction). Each subject received a packet that began with the demographic questionnaire and a DAS. All subjects then received one of the two forms of educational information (i.e., descriptive information or group-oriented). Each packet also contained a written description of a marital couple
164
Iournal of Sex &f Manta1 Therapy, Vol. 18, No. 3 , Fall 1992
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
seeking treatment for relationship dysfunction. Following this information, descriptions of individual, conjoint, and group marital therapy were presented. After subjects read the first treatment description, the dependent measures for that vignette were completed. Each set of acceptability questionnaires served as the dependent variables. When dependent measures for the first treatment format were completed, subjects proceeded to read the next treatment description and complete the attached set of questionnaires for that format of intervention. This procedure was followed until all treatment formats had been evaluated by each subject.
Case Description A case description of a distressed marital couple was presented to subjects so that they could apply the various treatment formats to this specific case description. T h e case description was modified from material presented by Nadclson,‘” which was representative of actual clients and problems frequently seen in outpatient clinical settings. T h e specific case description employed in the present study was used previously by Bornstein et aI.l5 in an earlier treatment acceptability study comparing various marital therapy orientations and intervention packages. T h e case history described Mr.and Mrs. A who were requesting marital therapy because of frequent arguments and growing dissatisfaction with their two-year marriage. Since the birth of their child, Mrs. A had been forced to stay home and take care of their son, while Mr. A increased his work commitment to earn extra income. Mr.A complained that his wife frequently berated him, ordered him about the house, and failed to appreciate his work. Mr. and Mrs. A attempted to communicate but their discussions invariably deteriorated into “shouts” and “accusations.” Mr. and Mrs. A were considering separation a n d possible divorce.
Informational Materials
Either of t w o forms of educational information were presented to subjects in order to evaluate the relative influence of descriptive and grouporiented information on acceptability ratings. Descriptive information consisted of a definition of acceptability, a description of its importance in relation to the purpose of the study, and definitions of the three different treatment formats for marital therapy. T h e group-oriented information section included the descriptive information and a summary of research findings (as described earlier) that detailed the effectiveness of group marital therapy. Moreover, subjects were told that group treatment provides special opportunities for learning by working with other couples experiencing similar concerns; it also increases the availability and sources of helpful feedback from others; and it can promote positive expectations through witnessing improvements among other couples. T h e group-oriented informational section concluded by stating that group therapy is less costly for clients and more time efficient.
Marital Therapy Formals
165
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Treatment Conditions
In order to test the relative significance of the various treatment formats, all treatment descriptions included similar content (e.g., behavioral exchange, expressive and receptive communication skills, training in a ninestep problem-solving approach). However, the therapy process (e.g., talking directly to partner in conjoint sessions; sharing information a n d suggestions with other couples in group format) varied significantly depending upon the specific format being described. T h e therapy descri tions were based on the principles of behavioral marital therspy.*'. In all conditions, the therapist indicated that negative styles of communication and interaction (e.g., provoking one another, ignoring, complaining, criticizing) were being employed too frequently, and the couple seemed unable to effectively resolve these conflicts. T h e therapy descriptions were written in such a way as not t o identify whether thc therapist was male or female. Treatment sessions lasted for 90 minutes per week for a total of 8 weeks in all conditions. T h e specific focus of successive sessions paralleled the treatment outcome procedures employed by Wilson and his c 0 1 I e a g u e s . ~ ‘That ~ ~ ’ ~ is, ~~ initial sessions focused o n “caring” behaviors, decreasing negative interactions, and behavioral contracting. Middle sessions focused o n communication training and conflict resolution skills. Final sessions incorporated procedures for the maintenance and generalization of new skills. Furthermore, homework assignments were employed throughout the treatment period. Each treatment description was tailored to the couple’s difficulties as presented in the case description. A brief sample of the treatment description follows. Individuul Treatment. Following the initial interview, the therapist recommended that Mrs. A be treated individually to more directly address her underlying depression, which coexisted with the couple’s marital distress. Specifically, therapy addressed several causes of her depression. Treatment strategies included activity scheduling and increasing rates of pleasant events in her daily life. Moreover, the couple was told that Mrs. A would describe the complete package of relationship techniques and strategies that she learned in therapy to Mr. A at home. Conjoint Treatment. During conjoint sessions, the therapist was described as facilitating a dialogue between Mr. and Mrs. A. T h e therapist provided feedback concerning their use of communication and conflict resolution skills, which were exhibited in session, as well as encouraged continued practice of specific skills at home. Both partners met with the therapist for every session. Croup Treatment. Mr. and Mrs. A were described as participating in a group with four other couples who were working toward resolving their relationship difficulties. Group interactions incorporated feedback from participants and the therapist in communication tactics and problemsolving strategies. Couples learned by observing each other and by assisting one another in the generation of conflict resolution strategies.
Y”
166
Journal of Sex
W
Marital Thrernpy, Vol. 18, No. 3 , Fall 1992
TABLE 1 Comparison of Mean Scores Across Treatment Formats o n Each Dependent Measure Conjoint ~~
Group
Individual
68.6gb 17.08
52.93‘ 19.16
24.30h 7.1 1
18.50‘ 7.47
22.53’ 5.72
18.1ab 6.54
22.46” 494
1 8.03b
~
Treatment Evaluation Inventory***
M SD
80.17’ 13.88
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Scmantic Dilferential-Evaluative***
M SD
28.73” 4.42
Semantic Differential-Potency***
M SD
22.33” 5.22
Scmanlic Differential-Activity***
M SD
22.88” 4.65
5.26
***
,001 l e d of significance. Mean scorcs that sharc a common superscript are not significantly different.
RESULTS An initial 2 x 3 (Gender x Treatment Format) series of univariate analyses of variance (ANOVAs) were conducted and failed to reveal significant findings for the Gender x Treatment Format interaction or the main effect o f Gender. Therefore, w e collapsed across gender of subject for all remaining analyses. Results were analyzed via a 2 X 2 x 2 x 3 (Information x Length of Marriage X Level of Distress X Treatment Format) multivariate analysis of variance (MANOVA), with repeated measures o n the final factor, across all dependent variables. Subjects were divided into long-term (over 6 years) and short-term (less than 6 years) length of marriage based o n a median split procedure. T h e MANOVA showed a significant main effect for treatment format, Wilks’s lambda = .34, F (8, 120) = 28.58, p < .001. In addition, a significant Length of Marriage X Treatment Format interaction was revealed, Wilks’s lambda = 3 4 , F (8,120) = 2.93, p < .01. Also, a significant Information X Level of Distress X Treatment Format interaction was also observed, Wilks’s lambda = .85,F (8, 120) = 2.71, p = .01. All other main effects and interactions proved nonsignificant. Summary data for each dependent variable across treatment format are presented in Table 1 . Subsequent ANOVAs o n dependent variables revealed significant ’I‘reatment Format main effects o n the T E I , F (2,254) = 83.03,p < .001; o n the SD-Evaluative Scale, F (2, 254) = 87.44, p < . O O l ; on the SDPotency Scale, F (2,254) = 28.42, p < .001; and on the SD-Activity Scale,
Marital Therapy Fonnak
167
TABLE 2 Comparison o f Mean Scores Across l r e a t m e n t Format as a Function of Length of Marriage Group
Individual
28.66a 4.40
25.12' 7.74
17.95' 7.72
28.7Y 4.47
23.49' 6.39
19.07' 7.23
22.46" 5.78
23.43' 5.94
1 7.37'
22.21" 4.64
2 1.65" 5.38
1 8.97b
Conjoint Semantic Differential-Evaluative* Longer term
M SD Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Shorter term
M
SD
Semantic Differential-Potency** Longer term
M SD
6.54
Shorter term
M
SD
* = .05;** = .01 level of significance. Mean scores that share a common superscript arc
not
6.49
significantly dfferent
F (2, 254) = 33.65, p < .001. Neuman-Keuls multiple comparison tests on the T E I and SD-Evaluative Scale revealed that all treatment formats were rated as significantly different from one another, with conjoint treatment format being evaluated as most acceptable, followed by group and individual treatment formats, respectively. Subsequent comparison tests conducted on the SD-Potency and Activity Scales revealed that conjoint and group were equal in acceptability and both were rated as more acceptable than individual treatment. Subsequent ANOVAs also demonstrated significant Length of Marriage x Treatment Format interactions on the SD-Evaluative Scale, F (2, 254) = 3.99, p < .05; and on the SD-Potency Scale, F (2, 254) = 5.03, p < .O 1. However, multiple comparison tests failed to reveal 2-way interactions. Specifically, Newman-Keuls analyses on the SD-Potency Scale demonstrated that regardless of length of marriage, subjects rated the group and conjoint treatment formats as equal in acceptability. Newman-Keuls analyses on the SD-Evaluative Scale revealed that conjoint treatment format was rated as most acceptable followed by group and individual treatment formats, respectively, regardless of length of marriage of participants. T h e individual treatment format was rated as least acceptable on all measures. Summary data for the Length of Marriage x Treatment Format interactions are presented in Table 2. ANOVAs also revealed a significant Information X Level of Distress x Treatment Format interactions on the TEI, F (2, 254) = 3.43, p = .05. Neuman-Keuls analyses showed that conjoint and group formats were found to be equivalent in all but one experimental condition (i.e., nondistressed subjects who received descriptive information and were
journul
I68
of SPX U Marital
Therapy, Vol. 18, No. 3. Fall I992
TABLE 3 Comparison of Mean Scores Across Treatment Format as a Function of Information and Level of Distress
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Distress
Conjoint Group Individual Nondistress Distress Nondistress Distress Nondistress
Treatment Evaluation Inventory* Descriptive Information M 79.05” 8 1.43’ 13.13 SI) 18.27
74.86” 14.76
62.35ih.‘ 17.22
53.24‘.d 19.10
5 20.7 1
Group-Oriented Information M 81.41” 78.83’ sn 10.3.5 14.07
70.45” 17.00
71.37’
53.64‘,d 19.15
53.57‘,d 18.13
16.51
1.w
* = .05 IcwI 0 1 signific-ance. Mean scores that share a common superscript are not significantly different.
rating group treatment). Specifically, nondistressed subjects who received only descriptive information rated group treatment as less acceptable than did either distressed or nondistressed subjects who received grouporiented information. In addition, nondistressed subjects who received only descriptive information rated group treatment lower than distressed subjects who received descriptive information. In general, nondistressed subjects who received only descriptive information tended to rate group treatment as equivalent to other subjects’ ratings of individual treatment. All other main effects and interactions proved nonsignificant. Summary data for the Information x Level of Distress X ‘I‘reatment Format interactions are presented in ‘Table 3. Subjects were also given the opportunity to indicate treatment format preference ratings. Once again, these results clearly indicated the superiority of conjoint ( t i = loo), followed by group (n = 30), and individual ( n = 5), Ch;‘ Square = 107.78, df = 2, p < .001. In ordcr to evaluate the relative influence of previous therapy experience on acceptability ratings of alternative marital formats, a series of 2 x 3 (Previous Therapy Experience x Treatment Format) posthoc ANOVAs were completed. N o interaction or main effect involving previous therapy was found. Subjects were also asked to rate themselves in terms of their likelihood to participate in marital therapy. Sixty-five percent rated themselves as being likely to participate, 16%rated themselves as unlikely, and 19% remained uncommitted. Finally, subjects’ ratings of each treatment on the 1 E I and SD-Evaluative Scale were found to be highly intercorrelated. Pearson product-moment correlation coefficients of these two dependent measures ranged from .66 t o .84 (ps < .001). Likewise, the SD-Activity and Potency Scales were highly related with correlation coefficients ranging from .48 t o .75 (/Is < .001).
169
Manta1 Therapy Fonnalc
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
DISCUSSION T h e results of this study clearly indicate that: (a) conjoint treatment format was generally rated as most acceptable and credible, followed by group and individual interventions; (b) similarly, when asked to choose between the three therapy formats, significantly more subjects chose the conjoint condition as the most preferred format; (c) on several analyses, group and conjoint treatment formats were found to be equal in acceptability; (d) the individual treatment format was generally rated as least acceptable; (e) educational inforniation appears to demonstrate some limited influence on acceptability ratings for nondistressed subjects. 'This study evaluated the relative acceptability ratings of three commonly used formats of marital therapy: conjoint, group, and individual. Because all subjects who participated in this study were currently married, these results provide valuable information, which may help clinicians decide which format of marital therapy to offer clients. In particular, our sample of distressed subjects parallels the characteristics (e.g., length of marriage, communication difficulties, frequent disagreements) of the majority of couples who have participated in marital therapy research studies. T h e majority of subjects found the conjoint treatment format to be most acceptable. Subjects who preferred the conjoint format often reported that they liked that the responsibility for treatment could be shared by both partners, and that more attention could be placed on the couple's particular problems. Many subjects rated conjoint and group treatment formats as equally acceptable. A representative sample of these subjects' comments can give insight into the reasons for their increased acceptability of the group format. Many of these subjects reported that they appreciated the increased opportunities for exchange of information, identification with others, and social support. T h e individual treatment format was rated as least acceptable. Although the individual treatment format was found by Bennun' to be as effective as the conjoint and group treatment formats, subjects expressed concerns about the greater responsibility that this format places on the one partner receiving treatment. However, subjects who preferred the individual format appreciated the increased focus on one partner's problems, especially if those problems affect the couple's relationship. T h e influence of educational information o n acce tability ratings has been debated. Kesults from various s t u d i e ~ ' ~ ~ ' ~have ~ ' ~been . ~ ~mixed. .~~. In this study, there is some evidence that group-oriented information may increase nondistressed subjects' acceptability ratings of the group treatment format. Nondistressed subjects who received group-oriented information found group treatment to be equivalent to conjoint treatment. Distressed subjects found group to be equal in acceptability to conjoint regardless of the type of information given. Thus, i t appears that level of distress and educational information interact to influence acceptability ratings. Results from this study indicate that educational
''
B
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
I70
Journal vf Sex
U Marital Tht-rapy.
Vol. 18. No. 3 , Fall 1992
information about nontraditional treatment formats (e.g. group) may be more important for clients seeking marital enrichment than it is for those seeking alleviation of distress. These results are similar to those of Von Brock a n d Elliott," Tingsand Singh a n d Katz." Each of these investigations found that educational information did increase acceptability ratings. In previous acceptability studies regarding marital treatment formats, educational information did not influence acceptability ratings.'"~'' However, these studies employed college students as subjects. Thus, it appears that married spouses may respond differently to educational information than do college students. 'The reason for this difference may be that a significant percentage of the subjects in this study were either (a) currently seeking marital therapy-25%, (b) had previously participated in relationship treatment-32%, or (c) rated themselves as being likely to participate in marital therapy-65%. It can be assumed that married subjects have higher levels of past, present, a n d anticipated involvement in marital therapy than do college students; therefore, educational information may be more salient for married subjects. Choice o f treatment format is an important consideration because it influences the outcome of treatment interventions.") O n e concern of clinicians has been their belief that the group format of marital therapy would not be acceptable to distressed couples. This study found evidence contrary to that belief. Perhaps this information will encourage clinicians and researchers to offer g r o u p marital therapy not only because it is lowcost, a highly efficient use of the therapist's time, a n d offers unique advantages such as increased sources of modeling a n d feedback from other clients, but also because it is acceptable to potential consumers of marital therapy. REFERENCES 1. Glick PC: H o w American families are changing. Amer. Demo 6 : 2 0 - 2 5 . 1984. 2. Imidon KA, Wilson GT: Criteria for evaluating psychotherapy. Arch Gen Psych 3 5 : 4 0 7 4 1 7 , 1988. 3 . National Center for Health Statistics: Births. marriages, divorces, arid deaths for 1983. Monlhly Vila1 Slat R e p , 3 2 : DHHS Pub. No. (PHS) 84-1 120. Hyattsville, MD,
U S Public Health Service, 1984. 4. Bloom Bl,, Asher SJ, White SW: Marital disruption as a stressor: A review and analysis. Psycho1 Bull 85:867-894. 1978. 5 . Slaier EJ, Calhoun KS: Familial conHict and marital dissolution: Effects on the social functioning of college students. J Social Clin Psycho1 65: 118-126, 1988. 6. Veroff J , Kulka RA. Douvan E: Mental health in America: Patterns vf help-seekingfrom 1957 to 1976. New York, Basic, 1981. 7. Herinun I : Behavioral marital therapy: An outcome evaluation of conjoint. group and one spouse treatment. S c a d J Behav Ther 14:169-176, 1985. 8. Kevenstorf D, Schindler 1.. Hahlweg K : Behavioral marital therapy applied in a c-on.joiritand conjoint-group modality: Short- and long-term effectiveness. t ? t ' h 7 l ThPr 1 4 % 14-62.5, 1983.
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Marital Therapy Formats
I71
9. Wilson GI,, Bornstein PH, Wilson 1.J: l r e a t m e n t of relationship dysfunction: An empirical evaluation of g r o u p a n d conjoint behavioral marital therapy.] Conruft Clin Psychol 56.929-931, 1988. 10. Wilson CL: T h e comparative efficacy of alternative treatments in the resolution of marital dysfunction. (Doctoral Dissertation, University of Montana). Dirs Abst Int 47:31298-31308. (University Microfilms No. 86-22, 350), 1987. 1 1 . Kazdin AE: Acceptability of alternative treatments for deviant child behavior.] Applied Rehuu Analysis 13:259-273, 1980. 12. Pickering D, Morgan SB. Houts AC, Rodrigue JR: Acceptability of treatments for self-abuse: Do risk-benefit information a n d being a parent make a difference?] Clin Child Psychol 17:209-216, 1988. 13. Wilson GL, Flammang MR: Treatment acceptability of alternative formats of marital therapy. S c a d J Behav Ther f9:87-99, 1990. 14. Wilson GL, Wilson LJ: 'I'reatment acceptability of alternative sex therapies: A comparative analysis. ] Sex Marital Ther 17:35-44, 1991. 15. Bornstein P H , Fox SG, Sturm CA, Ballweg BJ, Kirby KL, Wilson GL, Weisser CE, A n d r e JC, McLellarn RW: Treatment acceptability of alternative marital therapieu: A comparative analysis. ] Mantul Fam Ther 9:205-208, 1983. 16. Bornstein PH, Stube D. Wilson GL. Horstman AM, Sheets DR, Zulauf.JR, Brier KL, Cogswell KA: Egalitarian versus traditional behavioral marital therapy: A test o f preference. Rehav Ther 18:279-282, 1987. 17. Wilson GI.. Flammang MR, Dehle CM: Therapeutic formats in the resolution of relationship dysfunction: An acceptability investigation.] Sex Marital Ther f8:20-33, 1992. 18. Cross (Avert S, Johnston C: Acceptability of.treatments for child behavior problems: Issues a n d implications for future research. J Clin Child Psychol 19:61-74, 1990. 19. Kazdin AE: Acceptability of child treatment techniques: T h e influence of treatment efficacy a n d adverse side effects. Sehazl Ther 12:493-506, 1981. 20. Von Brock MB, Elliott SN: T h e inHuence of treatment effectiveness information on the acceptability of classroom intervention. J School Psychol 25: 131-144, 1987. 21. Singh N N , Katz RC: O n the modification of acceptability ratings for alternative child treatments. Rehav Mod 9:375-386, 1985. 22. Spanier GB: Measuring dyadic adjustment: New scales for assessing the quality of marriage a n d similar dyads. J M u m Family 38: 15-28, 1976. 23. Crane DR, Allgood SM, Larson J H , Griffin W: Assessing marital quality with distressed a n d nondistressed couples: A comparison a n d equivalency table for three frequently used measures. J M a v Family 52:87-93, 1990. 24. Kazdin AE: Acceptability of time o u t from reinforcement procedures for disruptive child behavior. Behav Ther 11:329-344. 1980. 25. Wilson GL., Flammang MR: Psychometric characteristics of acceptability measures: A comparison o f the Treatment Evaluation Inventory and the Semantic Differential. Unpublished manuscript, 1991. 26. Osgood CE. Suci GJ, l'annenbaum I'H: Meruuremenf of meaning. Urbana. University of' Illinois Press, 1957. 27. Marshall JC, Merritt SL: Reliability a n d construct validity of the learning style questionnaire. Ed Psychol Meas 46:257-262, 1986. 28. Kadelson C X : Marital therapy from a psychoanalytic perspective. In TJ Paolino, RS McCrady (eds). Mam'age and marital fherupy: Psychoanalyfic. behavioral, and systems theoty perspectives. New York, BrunnerlMazel, 1978. 29. Jacobson NS, Margolin G: Marital therapy: Slratepes based on social lparning and behauior exchange principles. N e w York, Bruiiner/Mazel. 1979. 30. Bornstein PH, Bornstein M T : M a r i h l therapy: A behavioral-communication, approach. New York, Pergamon, 1986.
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
172
lournal o/ Sex C9 Marital Therapv, Vol. 18, No. 3 , Fall I992
3 I . Wilson GL: T h e empirical status of alternative treatment formats in behavioral marital therapy. In N S Jacobson (Chair), New developmenlr in the behavioral prevention and treatment of manta1 ducmd. Symposium presented at the annual convention of the Association for the Advancement of Behavior Therapy, Washington, DC, November 1989. 32. Montag K , Wilson GL: An empirical evaluation of behavioral and cognitive-behavioral group marital treatments with rural couples. Submitted for publication, 1991. 33. Hahlweg K, Markman HJ: Effectiveness of behavioral marital therapy: Empirical status of behavioral techniques in preventing and alleviating marital distress.J Consult Clin Psycho ?6:440-447, 1988. 34. Tingstrom DH: Increasing acceptability of alternative behavioral interventions through education. Psycho1 SchooCc 26: 188-194, 1989. 35. Reutler LE, Clarkin JF: Systematic treatment sekctlon: Toward targeted therapeutic interurntiom. New York, Rrunner/Mazel, 1990.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Marital therapy formats: An analysis of acceptability ratings with married spouses a
Marian R. Flammang & Gregory L. Wilson
a
a
Department of Psychology , Washington State University , Pullman, WA, 99164-4820 Published online: 14 Jan 2008.
To cite this article: Marian R. Flammang & Gregory L. Wilson (1992) Marital therapy formats: An analysis of acceptability ratings with married spouses, Journal of Sex & Marital Therapy, 18:3, 159-172, DOI: 10.1080/00926239208403405 To link to this article: http://dx.doi.org/10.1080/00926239208403405
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Marital Therapy Formats: An Analysis of Acceptability Ratings with Married Spouses Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
M A R I A N R. F L A M M A N G and GREGORY L. W I L S O N
One hundred thirty-five married individuals evaluated the accepubility of alternative therapeutic formats commonly employed in murital thera p y Distressed and nondistressed spouses were randomly assigned to experimental conditions including two types of educational information (descriptive and group-oriented) presented across three treatment formats (i.e., individual, conjoint, und group). Primary dependent variables included the Treatment Evaluation Inventory and the Semantic Differential. Results revealed that conjoint format was most acceptable, followed by group and individual, respectively. However, distressed spouses rated the group and conjoint formats as equal i n acceptability. Group-oriented information increased nondistressed subjects’ ratings of group format. The implications of these results f o r clinicians and researchers offering marital therapy are discussed. Marriage is exceedingly common in the United States. In fact, it is estimated that over 90% of Americans will marry at least once in their lifetimes.’ However, nearly 50% of those who marry will eventually divorce.2 Moreover, the average length of a first marriage is only five to seven years3 Previous research has found evidence that links divorce and marital distress to a wide variety of emotional disorders in spouses and their children.4~~ Marital distress is also one of the most common complaints for patients seeking psychological help in the United States.6 Whereas demands for marital treatment services have expanded over the last t w o decades, few investigations have systematically evaluated the efficacy and acceptability of alternative marital therapy formats. Comparative investigations have revealed minimal differences in terms of efficacy across alternative marital treatment format^.^-^ Bennun7 documented the effectiveness of marital therapy regardless of whether the Marian R. Flammang, M.S., and Gregory L. Wilson, Ph.D., are at the Department of Psychology. Washington State University, Pullman. WA 99164-4820. Address correspondence to the first author.
Journal of Sex & Marital Therapy, Vol. 18, No. 3, Fall 1992 0 Brunner/Mazel, Inc.
159
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
160
Journal oJSex k3 Manta1 Therapy, Vol. 18, No. 3 , Fall 1992
format was individual, conjoint, or group. Likewise, other investigations”’ comparing group and conjoint treatment formats of marital therapy have demonstrated that couples in both formats showed significant improvements in targeted areas as compared to wait-list couples. Moreover, Wilson” showed some evidence that dysfunctional couples in conjoint treatment improved more in learning to share feelings with each other than did couples in group treatment. However, this same study found group marital therapy to be more effective than conjoint treatment in teaching couples improved communication strategies, as well as in maintaining improvements in sexual relations and childrearing practiccs. T h e choice o f which treatment format to offer clients seeking marital therapy is based on a host of factors including documented effectiveness, differential advantages for meeting treatment goals, and the clients’ perceived acceptability of treatment formats. Acceptability refers to the fairness, appropriateness, and intrusiveness of treatment procedures as judged by patients, lay persons, and professionals.” Acceptability is a n important criterion for evaluating treatment formats because it offers a mcans to discriminate among equally viable treatment formats, and because highly acceptable treatment formats may be more fre uently selected and adhered to than those rated as less acceptable.’*Only four previous studies have examined the acceptability of marital therapy procedures. Bornstein et al.I5 evaluated the acceptability of alternative marital therapy “schools” (ix.. analytic, behavioral, systems, and eclectic) and found the behavioral and systems approaches to be rated consistently superior to alternative approaches. In a later study examining the “politics and values” associated with behavioral marital therapy, Bornstein et al.16 revealed that traditional behavioral marital therapists were rated as more acceptable and credible than “egalitarian” behavioral marital therapists. More recently, Wilson and Flammang“ examined the acceptability of four alternative treatment formats used in the resolution of marital dysfunction: individual, concurrent, conjoint, a n d group. O n e hundred subjects were randomly assigned to experimental conditions which included two forms of information (ie., descriptive versus research-oriented). Results revealed that conjoint treatment was consistently rated as most acceptable, followed by concurrent, group, and individual, respectively. It was also found that providing efficacy information about alternative formats did not alter acceptability ratin s. Later, Wilson, Flammang, and D e h l J 7 expanded the above study to include 356 college students who rated the four treatment formats. Additionally, three forms of information (i.e., descriptive, research-oriented, and group-oriented) and t w o differing case histories were presented across the treatment formats. Again, conjoint treatment format was rated as most acceptable followed by concurrent, group, and individual, rcspectively. T h e type of information given to subjects did not affect acccptability ratings, neither did varying case histories. O n e limitation o f all the previous marital acceptability studies is that college students were employed as subjects. T h e r e has been considerable
’1
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Marital TherapV Formu&
161
controversy over the use of nonclinical populations in acceptability studies. Pickering et al.“ found that parents and nonparents differed in acceptability ratings. Cross Calvert and JohnstonIR also reported that parents and college students significantly differed in acceptability ratings, By using distressed and nondistressed married individuals as subjects, this study surveyed the population that is most likely to seek marital therapy for purposes of marital enrichment or the alleviation of distress. In addition, this study also evaluates whether length of marriage influences ratings of acceptability. Based on a median-split procedure, partners who have been married less than six years are contrasted with partners who have been married over six years. Since the average length of first marriages is between five to seven years, six years is representative of the national average for first marriage^.^ Another important question in acceptability research concerns whether the use of educational information influences acceptability ratings. Educational information includes reports on the efficacy of various treatments and the comparative advantages or disadvantages of each treatment. Research has produced mixed results, with some studies showing that educational information did little to alter subjects’ acceptability ratings, 12.13.I7,l9 while other studies found that educational information did increase acceptability ratings.20,21I n a n attempt to examine the relative influence of educational information presented to married subjects, t w o types of educational information were used in this study: I ) descriptive, which defined the three different formats of marital therapy; and 2) group-oriented, which summarized the advantages of group marital therapy. Group-oriented information was developed in a n attempt to systematically influence ratings of group marital treatment. Because research has consistently shown group marital therapy to be as effective as conjoint marital therapy,’-’ and group marital treatment generally has the added advantage of costing less than con-joint treatment, it seems important to examine which variables may improve acceptability ratings of group marital therapy. Thus, the current investigation compared the acceptability ratings of distressed and nondistressed married subjects involved in short- and long-term marriages who received different forms of information across three common therapeutic formats. Specifically, it was hypothesized that subjects would rate group treatment as a more acceptable option following the presentation of group-oriented information. Moreover, it was hypothesized that conjoint and group treatment would be consistently rated as more acceptable than individual therapy of one spouse. Finally, this investigation represents the first acceptability study to employ married spouses as subjects.
METHODS Subjects
One hundred and thirty-five married spouses (63 males and 72 females) were recruited through media announcements. A raffle of t w o $50 cash
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
162
Journal of Sex &f Manta1 Thnapy, Vol. 18, No. 3 , Fall 1992
prizes was offered in exchange for participation. Approximately 25% of the subjects were prospective clients seeking marital therapy at mental health agencies. These subjects participated in this study prior to beginning marital treatment. Length of marriage ranged from 2 months to 37 years (M = 8.16 years, SD = 7.46 years). T h e median length of marriage across subjects was 6 years. These subjects ranged in age from 19 to 6 3 years (M = 33.13, SD = 9.28). Forty-three subjects (32%) scored in the distressed range on the Dyadic Adjustment Scale. Scores o n the Dyadic Adjustment Scale ranged from 21 t o 147 points (M = 109.19. SD = 21.32). Fiftyfour percent of the subjects had previously participated in therapy. Of those subjects who had previous therapy experience, individual treatment was most common (44%), followed by relationship treatment (32%). Twenty-five couples (i.e., 50 subjects) were included in the total sample of 135 participants. Data were analyzed to determine whether there were significant correlations in the acceptability ratings of thcse married partners. Only t w o significant correlations were revealed. Specifically, married couples scored similarly o n SD-Potency Scale ratings of conjoint treatment (correlation coefficient = .42, p = .05), a n d o n SD-Evaluative Scale ratings of group treatment (correlation coefficient = .48, p = .05). Therefore, w e concluded that married spouses revealed limited similarity across experimental conditions o n the various dependent variables. Thus, all married partners were evaluated as independent subjects. Using a completely crossed Latin square, six differing sequences of randomly counterbalanced treatment descriptions were created. All subjects were randomly assigned to one of the experimental conditions. Assessment Demographic Data. A demographic questionnaire was used to gather such information as length o f marriage, format of any previous therapy experiences, and self-rating of the participant’s likelihood of seeking marital therapy. Dyadic Adjustment Scale (DAS).22T h e DAS is a widely used self-report questionnaire, which provides a global measurement of marital satisfaction. Subscales of the DAS measure four components of adjustment: dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression. In previous empirical research o n the DAS, SpanierZ2reports that the DAS has excellent reliability (Cronbach’s alpha = .Y6) and substantial criterion-related validity as well as construct validity. Individuals who score below 100 points were classified as being in a “distressed” relationship, while those scoring 100 points or more were classified as “nondistressed.” Prcccdence for the use of these cut-off scores has been set in previous researche9More recently, Crane, Allgood, Larson, and Griffinz3 employed multiple regression t o develop formulas t o establish cutoff scores for distressed and nondistressed subjects o n the Dyadic Adjustment Scale, the Marital Adjustment Test, and the Revised
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Marital Therapy Furmals
163
Marital Adjustment Test. They also recommended using 100 as a DAS cutoff score for nonclinical couples. Treatment Evaluation Inventory (TEZ).”724T h e T E I consists of 15 items on a seven-point Likert scale which asks subjects to evaluate such factors as the acceptability of treatment, suitability of procedures for the individuals, and the likely effectiveness of the procedures. T h e T E I was developed by Kazdin specifically to measure acceptability of alternative treatments. It was modified so as to conform with an evaluation of marital therapy. Research on the inventory”*24has shown that it is able to discriminate between alternative treatments. Items on the TEI were selected based upon previous factor analytic research from four separate samples. T h e 1 E I represents the single most common measure employed in treatment acceptability research. In a previous analysis of the TEI, Wilson and F l a m m a t ~ gfound ~ ~ the instrument to have high levels of reliability (Cronbach’s alpha = .96, split-half reliability = .96). Higher scores on the TEI are representative of greater acceptability. T h e SD has been employed extensively in Semantic Dflmential treatment acceptability re~earch.”,’”,’~,’~.’~ T h e form of the SD used in acceptability research consists of 15 bipolar adjectives, rated o n a one-toseven Likert scale. These 15 adjectives are divided into three subscales (Evaluative, Potency, and Activity), each of which consists of 5 adjective pairs. T h e adjectives that subjects used to rate treatment formats on the Evaluative subscale included good-bad, valuable-worthless. Adjectives comprising the Potency subscale include strong-weak, hard-soft. Adjectives such as active-passive, fast-slow are characteristic of the Activity subscale. Extensive research with the SD indicates that it is a psychometrically sound and reliable instrument. Osgood et aI.% reported a test-retest reliability coefficient of .85. Marshall and Merritt*’ also found that SD reliability coefficients ranged from .78 to .88 in their study using a 40-item SD scale designed to assess individuals’ learning styles. More recently, Wilson and F l a m m a r ~ gfound ~ ~ the SD to be highly reliable when used in acceptability research: Evaluative Scale (Cronbach’s alpha = .93; split-half reliability = .95), Potency Scale (Cronbach’s alpha = 3 5 ; split-half reliability = .go), Activity Scale (Cronbach’s alpha = .71; split-half reliability = 30). Across all subscales, higher scores are representative of greater endorsement of that particular construct (e.g., “high potency” versus “low potency”). Procedures Subjects were initially given instructions explaining the purpose of the study (i.e., to evaluate different methods of treating marital dysfunction). Each subject received a packet that began with the demographic questionnaire and a DAS. All subjects then received one of the two forms of educational information (i.e., descriptive information or group-oriented). Each packet also contained a written description of a marital couple
164
Iournal of Sex &f Manta1 Therapy, Vol. 18, No. 3 , Fall 1992
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
seeking treatment for relationship dysfunction. Following this information, descriptions of individual, conjoint, and group marital therapy were presented. After subjects read the first treatment description, the dependent measures for that vignette were completed. Each set of acceptability questionnaires served as the dependent variables. When dependent measures for the first treatment format were completed, subjects proceeded to read the next treatment description and complete the attached set of questionnaires for that format of intervention. This procedure was followed until all treatment formats had been evaluated by each subject.
Case Description A case description of a distressed marital couple was presented to subjects so that they could apply the various treatment formats to this specific case description. T h e case description was modified from material presented by Nadclson,‘” which was representative of actual clients and problems frequently seen in outpatient clinical settings. T h e specific case description employed in the present study was used previously by Bornstein et aI.l5 in an earlier treatment acceptability study comparing various marital therapy orientations and intervention packages. T h e case history described Mr.and Mrs. A who were requesting marital therapy because of frequent arguments and growing dissatisfaction with their two-year marriage. Since the birth of their child, Mrs. A had been forced to stay home and take care of their son, while Mr. A increased his work commitment to earn extra income. Mr.A complained that his wife frequently berated him, ordered him about the house, and failed to appreciate his work. Mr. and Mrs. A attempted to communicate but their discussions invariably deteriorated into “shouts” and “accusations.” Mr. and Mrs. A were considering separation a n d possible divorce.
Informational Materials
Either of t w o forms of educational information were presented to subjects in order to evaluate the relative influence of descriptive and grouporiented information on acceptability ratings. Descriptive information consisted of a definition of acceptability, a description of its importance in relation to the purpose of the study, and definitions of the three different treatment formats for marital therapy. T h e group-oriented information section included the descriptive information and a summary of research findings (as described earlier) that detailed the effectiveness of group marital therapy. Moreover, subjects were told that group treatment provides special opportunities for learning by working with other couples experiencing similar concerns; it also increases the availability and sources of helpful feedback from others; and it can promote positive expectations through witnessing improvements among other couples. T h e group-oriented informational section concluded by stating that group therapy is less costly for clients and more time efficient.
Marital Therapy Formals
165
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Treatment Conditions
In order to test the relative significance of the various treatment formats, all treatment descriptions included similar content (e.g., behavioral exchange, expressive and receptive communication skills, training in a ninestep problem-solving approach). However, the therapy process (e.g., talking directly to partner in conjoint sessions; sharing information a n d suggestions with other couples in group format) varied significantly depending upon the specific format being described. T h e therapy descri tions were based on the principles of behavioral marital therspy.*'. In all conditions, the therapist indicated that negative styles of communication and interaction (e.g., provoking one another, ignoring, complaining, criticizing) were being employed too frequently, and the couple seemed unable to effectively resolve these conflicts. T h e therapy descriptions were written in such a way as not t o identify whether thc therapist was male or female. Treatment sessions lasted for 90 minutes per week for a total of 8 weeks in all conditions. T h e specific focus of successive sessions paralleled the treatment outcome procedures employed by Wilson and his c 0 1 I e a g u e s . ~ ‘That ~ ~ ’ ~ is, ~~ initial sessions focused o n “caring” behaviors, decreasing negative interactions, and behavioral contracting. Middle sessions focused o n communication training and conflict resolution skills. Final sessions incorporated procedures for the maintenance and generalization of new skills. Furthermore, homework assignments were employed throughout the treatment period. Each treatment description was tailored to the couple’s difficulties as presented in the case description. A brief sample of the treatment description follows. Individuul Treatment. Following the initial interview, the therapist recommended that Mrs. A be treated individually to more directly address her underlying depression, which coexisted with the couple’s marital distress. Specifically, therapy addressed several causes of her depression. Treatment strategies included activity scheduling and increasing rates of pleasant events in her daily life. Moreover, the couple was told that Mrs. A would describe the complete package of relationship techniques and strategies that she learned in therapy to Mr. A at home. Conjoint Treatment. During conjoint sessions, the therapist was described as facilitating a dialogue between Mr. and Mrs. A. T h e therapist provided feedback concerning their use of communication and conflict resolution skills, which were exhibited in session, as well as encouraged continued practice of specific skills at home. Both partners met with the therapist for every session. Croup Treatment. Mr. and Mrs. A were described as participating in a group with four other couples who were working toward resolving their relationship difficulties. Group interactions incorporated feedback from participants and the therapist in communication tactics and problemsolving strategies. Couples learned by observing each other and by assisting one another in the generation of conflict resolution strategies.
Y”
166
Journal of Sex
W
Marital Thrernpy, Vol. 18, No. 3 , Fall 1992
TABLE 1 Comparison of Mean Scores Across Treatment Formats o n Each Dependent Measure Conjoint ~~
Group
Individual
68.6gb 17.08
52.93‘ 19.16
24.30h 7.1 1
18.50‘ 7.47
22.53’ 5.72
18.1ab 6.54
22.46” 494
1 8.03b
~
Treatment Evaluation Inventory***
M SD
80.17’ 13.88
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Scmantic Dilferential-Evaluative***
M SD
28.73” 4.42
Semantic Differential-Potency***
M SD
22.33” 5.22
Scmanlic Differential-Activity***
M SD
22.88” 4.65
5.26
***
,001 l e d of significance. Mean scorcs that sharc a common superscript are not significantly different.
RESULTS An initial 2 x 3 (Gender x Treatment Format) series of univariate analyses of variance (ANOVAs) were conducted and failed to reveal significant findings for the Gender x Treatment Format interaction or the main effect o f Gender. Therefore, w e collapsed across gender of subject for all remaining analyses. Results were analyzed via a 2 X 2 x 2 x 3 (Information x Length of Marriage X Level of Distress X Treatment Format) multivariate analysis of variance (MANOVA), with repeated measures o n the final factor, across all dependent variables. Subjects were divided into long-term (over 6 years) and short-term (less than 6 years) length of marriage based o n a median split procedure. T h e MANOVA showed a significant main effect for treatment format, Wilks’s lambda = .34, F (8, 120) = 28.58, p < .001. In addition, a significant Length of Marriage X Treatment Format interaction was revealed, Wilks’s lambda = 3 4 , F (8,120) = 2.93, p < .01. Also, a significant Information X Level of Distress X Treatment Format interaction was also observed, Wilks’s lambda = .85,F (8, 120) = 2.71, p = .01. All other main effects and interactions proved nonsignificant. Summary data for each dependent variable across treatment format are presented in Table 1 . Subsequent ANOVAs o n dependent variables revealed significant ’I‘reatment Format main effects o n the T E I , F (2,254) = 83.03,p < .001; o n the SD-Evaluative Scale, F (2, 254) = 87.44, p < . O O l ; on the SDPotency Scale, F (2,254) = 28.42, p < .001; and on the SD-Activity Scale,
Marital Therapy Fonnak
167
TABLE 2 Comparison o f Mean Scores Across l r e a t m e n t Format as a Function of Length of Marriage Group
Individual
28.66a 4.40
25.12' 7.74
17.95' 7.72
28.7Y 4.47
23.49' 6.39
19.07' 7.23
22.46" 5.78
23.43' 5.94
1 7.37'
22.21" 4.64
2 1.65" 5.38
1 8.97b
Conjoint Semantic Differential-Evaluative* Longer term
M SD Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Shorter term
M
SD
Semantic Differential-Potency** Longer term
M SD
6.54
Shorter term
M
SD
* = .05;** = .01 level of significance. Mean scores that share a common superscript arc
not
6.49
significantly dfferent
F (2, 254) = 33.65, p < .001. Neuman-Keuls multiple comparison tests on the T E I and SD-Evaluative Scale revealed that all treatment formats were rated as significantly different from one another, with conjoint treatment format being evaluated as most acceptable, followed by group and individual treatment formats, respectively. Subsequent comparison tests conducted on the SD-Potency and Activity Scales revealed that conjoint and group were equal in acceptability and both were rated as more acceptable than individual treatment. Subsequent ANOVAs also demonstrated significant Length of Marriage x Treatment Format interactions on the SD-Evaluative Scale, F (2, 254) = 3.99, p < .05; and on the SD-Potency Scale, F (2, 254) = 5.03, p < .O 1. However, multiple comparison tests failed to reveal 2-way interactions. Specifically, Newman-Keuls analyses on the SD-Potency Scale demonstrated that regardless of length of marriage, subjects rated the group and conjoint treatment formats as equal in acceptability. Newman-Keuls analyses on the SD-Evaluative Scale revealed that conjoint treatment format was rated as most acceptable followed by group and individual treatment formats, respectively, regardless of length of marriage of participants. T h e individual treatment format was rated as least acceptable on all measures. Summary data for the Length of Marriage x Treatment Format interactions are presented in Table 2. ANOVAs also revealed a significant Information X Level of Distress x Treatment Format interactions on the TEI, F (2, 254) = 3.43, p = .05. Neuman-Keuls analyses showed that conjoint and group formats were found to be equivalent in all but one experimental condition (i.e., nondistressed subjects who received descriptive information and were
journul
I68
of SPX U Marital
Therapy, Vol. 18, No. 3. Fall I992
TABLE 3 Comparison of Mean Scores Across Treatment Format as a Function of Information and Level of Distress
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Distress
Conjoint Group Individual Nondistress Distress Nondistress Distress Nondistress
Treatment Evaluation Inventory* Descriptive Information M 79.05” 8 1.43’ 13.13 SI) 18.27
74.86” 14.76
62.35ih.‘ 17.22
53.24‘.d 19.10
5 20.7 1
Group-Oriented Information M 81.41” 78.83’ sn 10.3.5 14.07
70.45” 17.00
71.37’
53.64‘,d 19.15
53.57‘,d 18.13
16.51
1.w
* = .05 IcwI 0 1 signific-ance. Mean scores that share a common superscript are not significantly different.
rating group treatment). Specifically, nondistressed subjects who received only descriptive information rated group treatment as less acceptable than did either distressed or nondistressed subjects who received grouporiented information. In addition, nondistressed subjects who received only descriptive information rated group treatment lower than distressed subjects who received descriptive information. In general, nondistressed subjects who received only descriptive information tended to rate group treatment as equivalent to other subjects’ ratings of individual treatment. All other main effects and interactions proved nonsignificant. Summary data for the Information x Level of Distress X ‘I‘reatment Format interactions are presented in ‘Table 3. Subjects were also given the opportunity to indicate treatment format preference ratings. Once again, these results clearly indicated the superiority of conjoint ( t i = loo), followed by group (n = 30), and individual ( n = 5), Ch;‘ Square = 107.78, df = 2, p < .001. In ordcr to evaluate the relative influence of previous therapy experience on acceptability ratings of alternative marital formats, a series of 2 x 3 (Previous Therapy Experience x Treatment Format) posthoc ANOVAs were completed. N o interaction or main effect involving previous therapy was found. Subjects were also asked to rate themselves in terms of their likelihood to participate in marital therapy. Sixty-five percent rated themselves as being likely to participate, 16%rated themselves as unlikely, and 19% remained uncommitted. Finally, subjects’ ratings of each treatment on the 1 E I and SD-Evaluative Scale were found to be highly intercorrelated. Pearson product-moment correlation coefficients of these two dependent measures ranged from .66 t o .84 (ps < .001). Likewise, the SD-Activity and Potency Scales were highly related with correlation coefficients ranging from .48 t o .75 (/Is < .001).
169
Manta1 Therapy Fonnalc
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
DISCUSSION T h e results of this study clearly indicate that: (a) conjoint treatment format was generally rated as most acceptable and credible, followed by group and individual interventions; (b) similarly, when asked to choose between the three therapy formats, significantly more subjects chose the conjoint condition as the most preferred format; (c) on several analyses, group and conjoint treatment formats were found to be equal in acceptability; (d) the individual treatment format was generally rated as least acceptable; (e) educational inforniation appears to demonstrate some limited influence on acceptability ratings for nondistressed subjects. 'This study evaluated the relative acceptability ratings of three commonly used formats of marital therapy: conjoint, group, and individual. Because all subjects who participated in this study were currently married, these results provide valuable information, which may help clinicians decide which format of marital therapy to offer clients. In particular, our sample of distressed subjects parallels the characteristics (e.g., length of marriage, communication difficulties, frequent disagreements) of the majority of couples who have participated in marital therapy research studies. T h e majority of subjects found the conjoint treatment format to be most acceptable. Subjects who preferred the conjoint format often reported that they liked that the responsibility for treatment could be shared by both partners, and that more attention could be placed on the couple's particular problems. Many subjects rated conjoint and group treatment formats as equally acceptable. A representative sample of these subjects' comments can give insight into the reasons for their increased acceptability of the group format. Many of these subjects reported that they appreciated the increased opportunities for exchange of information, identification with others, and social support. T h e individual treatment format was rated as least acceptable. Although the individual treatment format was found by Bennun' to be as effective as the conjoint and group treatment formats, subjects expressed concerns about the greater responsibility that this format places on the one partner receiving treatment. However, subjects who preferred the individual format appreciated the increased focus on one partner's problems, especially if those problems affect the couple's relationship. T h e influence of educational information o n acce tability ratings has been debated. Kesults from various s t u d i e ~ ' ~ ~ ' ~have ~ ' ~been . ~ ~mixed. .~~. In this study, there is some evidence that group-oriented information may increase nondistressed subjects' acceptability ratings of the group treatment format. Nondistressed subjects who received group-oriented information found group treatment to be equivalent to conjoint treatment. Distressed subjects found group to be equal in acceptability to conjoint regardless of the type of information given. Thus, i t appears that level of distress and educational information interact to influence acceptability ratings. Results from this study indicate that educational
''
B
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
I70
Journal vf Sex
U Marital Tht-rapy.
Vol. 18. No. 3 , Fall 1992
information about nontraditional treatment formats (e.g. group) may be more important for clients seeking marital enrichment than it is for those seeking alleviation of distress. These results are similar to those of Von Brock a n d Elliott," Tingsand Singh a n d Katz." Each of these investigations found that educational information did increase acceptability ratings. In previous acceptability studies regarding marital treatment formats, educational information did not influence acceptability ratings.'"~'' However, these studies employed college students as subjects. Thus, it appears that married spouses may respond differently to educational information than do college students. 'The reason for this difference may be that a significant percentage of the subjects in this study were either (a) currently seeking marital therapy-25%, (b) had previously participated in relationship treatment-32%, or (c) rated themselves as being likely to participate in marital therapy-65%. It can be assumed that married subjects have higher levels of past, present, a n d anticipated involvement in marital therapy than do college students; therefore, educational information may be more salient for married subjects. Choice o f treatment format is an important consideration because it influences the outcome of treatment interventions.") O n e concern of clinicians has been their belief that the group format of marital therapy would not be acceptable to distressed couples. This study found evidence contrary to that belief. Perhaps this information will encourage clinicians and researchers to offer g r o u p marital therapy not only because it is lowcost, a highly efficient use of the therapist's time, a n d offers unique advantages such as increased sources of modeling a n d feedback from other clients, but also because it is acceptable to potential consumers of marital therapy. REFERENCES 1. Glick PC: H o w American families are changing. Amer. Demo 6 : 2 0 - 2 5 . 1984. 2. Imidon KA, Wilson GT: Criteria for evaluating psychotherapy. Arch Gen Psych 3 5 : 4 0 7 4 1 7 , 1988. 3 . National Center for Health Statistics: Births. marriages, divorces, arid deaths for 1983. Monlhly Vila1 Slat R e p , 3 2 : DHHS Pub. No. (PHS) 84-1 120. Hyattsville, MD,
U S Public Health Service, 1984. 4. Bloom Bl,, Asher SJ, White SW: Marital disruption as a stressor: A review and analysis. Psycho1 Bull 85:867-894. 1978. 5 . Slaier EJ, Calhoun KS: Familial conHict and marital dissolution: Effects on the social functioning of college students. J Social Clin Psycho1 65: 118-126, 1988. 6. Veroff J , Kulka RA. Douvan E: Mental health in America: Patterns vf help-seekingfrom 1957 to 1976. New York, Basic, 1981. 7. Herinun I : Behavioral marital therapy: An outcome evaluation of conjoint. group and one spouse treatment. S c a d J Behav Ther 14:169-176, 1985. 8. Kevenstorf D, Schindler 1.. Hahlweg K : Behavioral marital therapy applied in a c-on.joiritand conjoint-group modality: Short- and long-term effectiveness. t ? t ' h 7 l ThPr 1 4 % 14-62.5, 1983.
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
Marital Therapy Formats
I71
9. Wilson GI,, Bornstein PH, Wilson 1.J: l r e a t m e n t of relationship dysfunction: An empirical evaluation of g r o u p a n d conjoint behavioral marital therapy.] Conruft Clin Psychol 56.929-931, 1988. 10. Wilson CL: T h e comparative efficacy of alternative treatments in the resolution of marital dysfunction. (Doctoral Dissertation, University of Montana). Dirs Abst Int 47:31298-31308. (University Microfilms No. 86-22, 350), 1987. 1 1 . Kazdin AE: Acceptability of alternative treatments for deviant child behavior.] Applied Rehuu Analysis 13:259-273, 1980. 12. Pickering D, Morgan SB. Houts AC, Rodrigue JR: Acceptability of treatments for self-abuse: Do risk-benefit information a n d being a parent make a difference?] Clin Child Psychol 17:209-216, 1988. 13. Wilson GL, Flammang MR: Treatment acceptability of alternative formats of marital therapy. S c a d J Behav Ther f9:87-99, 1990. 14. Wilson GL, Wilson LJ: 'I'reatment acceptability of alternative sex therapies: A comparative analysis. ] Sex Marital Ther 17:35-44, 1991. 15. Bornstein P H , Fox SG, Sturm CA, Ballweg BJ, Kirby KL, Wilson GL, Weisser CE, A n d r e JC, McLellarn RW: Treatment acceptability of alternative marital therapieu: A comparative analysis. ] Mantul Fam Ther 9:205-208, 1983. 16. Bornstein PH, Stube D. Wilson GL. Horstman AM, Sheets DR, Zulauf.JR, Brier KL, Cogswell KA: Egalitarian versus traditional behavioral marital therapy: A test o f preference. Rehav Ther 18:279-282, 1987. 17. Wilson GI.. Flammang MR, Dehle CM: Therapeutic formats in the resolution of relationship dysfunction: An acceptability investigation.] Sex Marital Ther f8:20-33, 1992. 18. Cross (Avert S, Johnston C: Acceptability of.treatments for child behavior problems: Issues a n d implications for future research. J Clin Child Psychol 19:61-74, 1990. 19. Kazdin AE: Acceptability of child treatment techniques: T h e influence of treatment efficacy a n d adverse side effects. Sehazl Ther 12:493-506, 1981. 20. Von Brock MB, Elliott SN: T h e inHuence of treatment effectiveness information on the acceptability of classroom intervention. J School Psychol 25: 131-144, 1987. 21. Singh N N , Katz RC: O n the modification of acceptability ratings for alternative child treatments. Rehav Mod 9:375-386, 1985. 22. Spanier GB: Measuring dyadic adjustment: New scales for assessing the quality of marriage a n d similar dyads. J M u m Family 38: 15-28, 1976. 23. Crane DR, Allgood SM, Larson J H , Griffin W: Assessing marital quality with distressed a n d nondistressed couples: A comparison a n d equivalency table for three frequently used measures. J M a v Family 52:87-93, 1990. 24. Kazdin AE: Acceptability of time o u t from reinforcement procedures for disruptive child behavior. Behav Ther 11:329-344. 1980. 25. Wilson GL., Flammang MR: Psychometric characteristics of acceptability measures: A comparison o f the Treatment Evaluation Inventory and the Semantic Differential. Unpublished manuscript, 1991. 26. Osgood CE. Suci GJ, l'annenbaum I'H: Meruuremenf of meaning. Urbana. University of' Illinois Press, 1957. 27. Marshall JC, Merritt SL: Reliability a n d construct validity of the learning style questionnaire. Ed Psychol Meas 46:257-262, 1986. 28. Kadelson C X : Marital therapy from a psychoanalytic perspective. In TJ Paolino, RS McCrady (eds). Mam'age and marital fherupy: Psychoanalyfic. behavioral, and systems theoty perspectives. New York, BrunnerlMazel, 1978. 29. Jacobson NS, Margolin G: Marital therapy: Slratepes based on social lparning and behauior exchange principles. N e w York, Bruiiner/Mazel. 1979. 30. Bornstein PH, Bornstein M T : M a r i h l therapy: A behavioral-communication, approach. New York, Pergamon, 1986.
Downloaded by [Carnegie Mellon University] at 17:05 21 November 2014
172
lournal o/ Sex C9 Marital Therapv, Vol. 18, No. 3 , Fall I992
3 I . Wilson GL: T h e empirical status of alternative treatment formats in behavioral marital therapy. In N S Jacobson (Chair), New developmenlr in the behavioral prevention and treatment of manta1 ducmd. Symposium presented at the annual convention of the Association for the Advancement of Behavior Therapy, Washington, DC, November 1989. 32. Montag K , Wilson GL: An empirical evaluation of behavioral and cognitive-behavioral group marital treatments with rural couples. Submitted for publication, 1991. 33. Hahlweg K, Markman HJ: Effectiveness of behavioral marital therapy: Empirical status of behavioral techniques in preventing and alleviating marital distress.J Consult Clin Psycho ?6:440-447, 1988. 34. Tingstrom DH: Increasing acceptability of alternative behavioral interventions through education. Psycho1 SchooCc 26: 188-194, 1989. 35. Reutler LE, Clarkin JF: Systematic treatment sekctlon: Toward targeted therapeutic interurntiom. New York, Rrunner/Mazel, 1990.
