Journal of Marital and Family Therapy doi: 10.1111/jmft.12063 July 2015, Vol. 41, No. 3, 340–353

A BOWEN FAMILY SYSTEMS MODEL OF GENERALIZED ANXIETY DISORDER AND ROMANTIC RELATIONSHIP DISTRESS Jacob B. Priest The University of Iowa

Many individuals with generalized anxiety disorder (GAD) do not respond well to currently available treatments. Moreover, treatments are less effective when GAD is accompanied by romantic relationship distress. In order to develop effective treatments for GAD and relationship distress, it is necessary to conduct theory-based research to identify links common to both GAD and romantic relationship distress. Drawing on Bowen’s family systems theory, the roles of family abuse/violence and differentiation in GAD and romantic relationship distress were examined using existing data from the National Comorbidity Survey Replication (n = 2,312; 2005). As predicted, family abuse/violence was directly linked to both GAD and romantic relationship distress. Differentiation mediated the relationship between family abuse/violence and GAD, and partially mediated the relationship between family abuse/violence and romantic relationship distress. Findings suggest that current and past relationship processes may help maintain chronic anxiety and that Bowen’s theory may be a useful framework for developing couple therapy treatment of GAD and romantic relationship distress. Generalized anxiety disorder (GAD) affects approximately 3.1% of the U.S. adult population each year (Kessler, Chiu, Delmer, & Walters, 2005). Symptoms of GAD (e.g., uncontrollable worry, difficulty concentrating, and irritability) tend to be chronic (Kessler, Keller, & Wittchen, 2001) and cause considerable impairment. GAD is associated with an estimated 1.5–5.4 days of being impaired during a given month, which is comparable to the impairment seen in major depressive disorder, arthritis, diabetes, and autoimmune disease (Hoffman, Dukes, & Wittchen, 2008). Given the prevalence and impairment caused by GAD, treatments have been developed to address GAD symptoms. Though treatments have shown effectiveness, significant room for improvement exists (Newman et al., 2011). For example, Siev and Chambless (2007) conducted a meta-analysis exploring treatment outcomes for cognitive-behavioral treatment and relaxation treatment for GAD. They found that cognitive-behavioral therapy resulted in clinically significant change for 44% of people with GAD and relaxation treatment resulted in clinically significant change in 45% of individuals. However, when rates of dropout were included, clinically significant change resulted in only 29% of those receiving cognitive-behavioral treatment and in only 26% of those receiving relaxation treatment. Additionally, Hoffman and Smits (2008) found that cognitive-behavioral treatment was less effective for those with GAD than for those with posttraumatic stress disorder, social anxiety disorder, and obsessive-compulsive disorder. The results of these analyses suggest that many people with GAD still experience clinically significant symptoms after treatment with individual psychotherapy. One reason for poor outcomes in GAD treatment may be the presence of poor romantic relationship functioning. Romantic relationship distress is strongly correlated with GAD. For example, Whisman (2007) found that an increase in reported committed romantic relationship distress increased the odds of meeting diagnostic criteria for GAD increase by 2.54. Poor relationship functioning is also associated with longer duration of GAD symptoms (Yonkers, Dyck, Warshaw, & Keller, 2000). Moreover, romantic relationship processes play a role in response to cognitivebehavioral therapy treatment for GAD. The presence of marital discord at the beginning of treatment predicts a more negative response to cognitive behavioral therapy, higher treatment dropout Jacob B. Priest, PhD, The University of Iowa. Address correspondence to Jacob B. Priest, N338 Lindquist Center, Iowa City, Iowa 52242; E-mail: [email protected]

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rates, and lower likelihood of anxiety symptom remission (Durham, Allan, & Hackett, 1997). Zinbarg, Lee, and Yoon (2007)found that baseline reports of a romantic partner’s hostility was associated with less favorable treatment outcomes, and that nonhostile criticism was associated with better treatment outcomes. When taken together, the variables of hostility and nonhostile criticism accounted for 41% of the variance in the treatment outcome. The findings of these studies have led for many to call for couple therapy treatment for GAD (Priest, 2013a; Whisman, 2007; Zinbarg et al., 2007); however, few models have been put forth. Bowen’s family systems theory (Kerr & Bowen, 1988) offers a potential theoretical link between GAD and romantic relationship distress. Specifically, this theory suggests that family abuse/violence and low differentiation can result in relationship distress and chronic anxiety (Kerr & Bowen, 1988). This theory could be the basis for developing and testing couple therapy treatments for GAD. However, before treatments can be developed, it is important to conduct theory based research in order to establish a framework for designing treatments. In particular, to develop a treatment model of GAD and romantic relationship distress from a Bowen’s family systems perspective, an understanding family abuse/violence, and differentiation are linked to romantic relationship distress and GAD is needed. Currently, there are no empirical tests of GAD and committed romantic relationships distress from a Bowen’s family systems theory perspective. The purpose of this article is to test a model based on Bowen’s family systems theory of GAD and romantic relationship distress. Specifically, this model proposes that experiencing family abuse/ violence results in lower differentiation, and those who are less differentiated are at greater risk of having GAD and committed romantic relationship distress. Bowen’s Family Systems Theory Bowen’s family system’s theory is rooted in differentiation (Kerr & Bowen, 1988). Bowen posits that an individual’s levels of differentiation stems from the ability to manage anxiety. Anxiety regulation occurs in two ways: emotional self-regulation, and balancing individuality and togetherness in relationships. For example, if individuals poorly manage anxiety, they may react to their emotions, leading them to act in ways that might conflict with their long-term goals (Werner & Gross, 2010). Poor anxiety management may also result in fusing with another person or cutting off from another person, which may lead to inflexible patterned behavior (Kerr & Bowen, 1988). Bowen also suggests that patterns of poor anxiety management may stem from family of origin experiences (Kerr & Bowen, 1988). In particular, Bowen suggests that family abuse/violence has negative effects on the emotional development of children, and that family abuse/violence are often symptoms of poor relationships process that occur in families. Therefore, if a person comes from a home where poor anxiety management results in children witnessing or experiencing violence, as adults, they may be more likely to have poor emotion regulation, difficulty balancing individuality and togetherness (Henry et al., 2011; Kerr & Bowen, 1988; Rellini, Vujanic, Gilbert, & Zvolensky, 2012), and may even perpetuate family violence in current relationships (Black, Sussman, & Unger, 2010; McWey, Pazdera, Vennum, & Wojciak, 2013). Generalized Anxiety Disorder and Relationship Functioning Poor emotion regulation, difficulty in interpersonal processes, and family abuse/violence have all been linked to GAD. Symptoms of GAD may stem from deficits in emotion regulation (Cisler & Olatunji, 2012; Mennin, Turk, Heimberg, & Carmin, 2004). For example, many with GAD may be intolerant of uncertainty. Intolerance of uncertainty refers to the cognitive and emotional reactions that come from uncertainty in the environment. This uncertainty can bias information processing and lead to poor threat appraisal and coping (McEvoy & Mahoney, 2012). Intolerance of uncertainty can lead to uncontrollable worry (McEvoy & Mahoney, 2012), which is the major symptom of GAD. The worry associated with GAD is found to be different from the worry of people who frequently worry, but do not have GAD (Ruscio & Borkovec, 2004). People with GAD perceive worry as more uncontrollable, harmful or dangerous than non-GAD frequent worriers, and people with GAD think that there will be negative consequences if worry or thoughts are not kept under control (Ruscio & Borkovec, 2004). Those with GAD also have relational processes marked by difficulty balancing individuality and togetherness. For example, Salzer et al. (2008) found four aggregate interpersonal style groups July 2015

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of GAD: intrusive, exploitable, cold and nonassertive. Salzer, Pincus, Winkelbach, Leichsenring, and Leibing (2011)found four groups, but with a slightly different clustering pattern: overly nurturant, modestly nurturant, socially avoidant, and nonassertive. Though the findings of these studies are not congruent, the similarities suggest that the anxiety people with GAD experience may lead to interpersonal over functioning (e.g., excessively trying to care for others, or being overly accommodating, or trying to be too close to others) or cutting off (e.g., higher levels of anger or hostility, or excessive submissiveness or nonassertion; Newman & Erickson, 2010). This idea was supported by Erickson and Newman (2007). They compared people with GAD to nonanxious controls to see if there would be differences in their amount of self-disclosure to a confederate who acted in a standardized way across groups. Compared to the nonanxious controls, some of those with GAD overestimated how much ridicule they expected during self-disclosure and they sought for increased levels of reassurance from the confederate. Others with GAD underestimated the negative impressions of the confederate, coming off as cold or socially avoidant. In romantic relationships, these processes may manifest themselves as either wanting to be closer to a romantic partner or being uncomfortable being too close to a romantic partner. Links have also been established between childhood experience of family abuse/violence and GAD. For example, Afifi, Boman, Fleisher, and Sareen (2009) found that those who reported being abused as children were 2.38 times more likely to be diagnosed with GAD. The magnitude of the association between GAD and abuse was larger than the association between child abuse and any other anxiety disorder except posttraumatic stress disorder. In a similar vein, Keyes et al. (2012) examined how different types of abuse were associated with psychopathology. Specifically, they examined reports of neglect, physical, emotional, and sexual abuse on internalizing disorders (e.g., major depressive disorder, GAD, social anxiety disorder, and posttraumatic stress disorder). Moreover, they wanted to examine whether there were different patterns of associations between men and women. Using a data set of over 36,000 individuals, they found that for women, reports of physical, emotional, and sexual abuse were all associated with a higher likelihood of have having an internalizing disorder. For men, emotional and sexual abuse was both associated with internalizing disorders. A Family Systems Model of Generalized Anxiety Disorder and Romantic Relationship Distress Research has suggested links between family abuse/violence, emotion regulation, interpersonal processes and GAD (Afifi et al., 2009; Cisler & Olatunji, 2012; Eng & Heimberg, 2006; Mennin et al., 2004; Wade, Bulik, & Kendler, 2001), and between family abuse/violence, emotion regulation, and romantic relationship functioning (Kim, Pears, Capaldi, & Owen, 2009; Rellini et al., 2012). Additionally, GAD and romantic relationship distress are also linked (Priest, 2013a; Whisman, 2007). These findings suggest that some of the same family of origin, emotion regulation, and interpersonal processes may underlie both GAD and romantic relationship distress. Given that GAD and romantic relationship distress often co-occur (Whisman, 2007), and that romantic relationships contribute to treatment response (Zinbarg et al., 2007), it would be important to develop couple therapy treatments that can address both problems. To develop such treatments, theory-based research is needed to identify links common to both GAD and romantic relationship distress. From a Bowen’s family systems theory perspective, the symptoms of GAD and romantic relationship distress stem from a person’s level of differentiation. This level of differentiation is affected by an individual’s family of origin experiences. Therefore, if a person comes from a home with violence or abuse, it is likely that they will have lower differentiation and by extension will have difficulty emotionally self-regulating and balancing individuality and togetherness in relationships. Low levels of differentiation may manifest itself as chronic anxiety and/or as a distressed romantic relationship. Therefore, Bowen’s family system theory (Kerr & Bowen, 1988) would suggest that family abuse/violence, balancing individuality and togetherness in relationships, and emotion regulation would contribute both to GAD and romantic relationship distress. If these hypotheses were confirmed, Bowen’s theory may be a useful framework for developing a couple therapy treatment for GAD and romantic relationship distress; however, these assertions have yet to be tested. The purpose of this study is to test these assertions. Figure 1 presents the hypothesized family systems model of GAD and romantic relationship distress. This model proposes that family abuse/ 342

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GAD

FA/V

DIFF

RRD

Figure 1. Proposed Model. FA/V, family abuse/violence; DIFF, differentiation; RRD, romantic relationship distress; GAD, generalized anxiety disorder. violence leads to both romantic relationship distress and GAD. However, this relationship is mediated through an individual’s level of differentiation. In other words, the presence of family abuse/ violence while growing up lowers an individual’s ability to emotionally self-regulate and to balance individuality and togetherness in relationships. The inability to self-regulate and balance individuality and togetherness in relationships leads to GAD and romantic relationship distress. Moreover, this model proposes that since GAD and romantic relationship distress are linked to family abuse/ violence and differentiation, GAD and romantic relationship distress will often occur together.

METHODS To test the proposed model, existing data from the National Comorbidity Survey Replication (NCS-R) were used. The NCS-R surveyed English-speaking adults in the United States aged 18 years old and older (Kessler et al., 2004). The NCS-R used a multistage clustered area probability sample to make the survey nationally representative. To gather responses, 13,054 addresses were obtained, and 10,622 of these addresses were valid and deemed eligible for the survey. From these addresses, 9,282 interviews were conducted between February 2001 and April 2003 (Kessler et al., 2004). The NCS-R included two parts. The first part consisted of a diagnostic assessment of psychiatric disorders. This part was administered to all respondents. This second part was given to those whose responses suggested that they had a psychiatric disorder during their lifetime and an additional probability sample of 5,692 people. The second part of the NCS-R assessed for disorders not screened for in the first part of the survey and correlates of mental illness (e.g., relationship satisfaction, physical health problems, etc.). Additionally, a subset of people who were married or cohabiting were randomly selected and asked about their romantic relationships. This sample included 2,321 people (Kessler et al., 2004). Of the original 9,282 respondents, a random sample of 10% were re-contacted. These respondents were asked a random sample of questions from the original survey and these responses were compared to the original responses to check that answers were being recorded correctly. Moreover, 554 individuals who were initially nonresponsive were also re-contacted and given short form interviews. These interviews were used in the development of weights used to account for nonresponsiveness. A complete description of the design and collection methods of the NCS-R is found in Kessler et al. (2004). Sample The subset of individuals (n = 2,321) who were asked about their marriages or cohabiting relationships are used in this data set. The sample was 52% of the sample; the average age was 46.18,

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and the median income was $65,000. The vast majority of the sample was White (79.5%), 8% were African American, 7.3% were Latino, and 5.2% were other. This sample also included 76 respondents (3.3%) who met diagnostic criteria for GAD within the past 12 months. For the entire NCS-R sample, the 12 month prevalence of GAD was 3.1% (Kessler et al., 2005). Variables Family abuse/violence. The NCS-R included a section about the presence of family abuse/violence. Two of the questions asked about violence. Specifically, the first questions asked how frequently someone in the household pushed, grabbed, shoved, threw something, slapped, hit or spanked them as a child. The second questions asked how often their parents or the people who raised them pushed, grabbed, shoved, threw something or slapped each other while growing up. Responses for both questions ranged from “1 – Never” to “4 – Often”. Additionally, the NCS-R included five questions that asked about childhood neglect. These questions asked 1) “How often were you made to do chores that were too difficult or dangerous for someone your age?” 2) “How frequently were you left alone or unsupervised when you were too young to be alone?” 3) “How often did you go without things you needed like clothes, shoes, or school supplies because your parents or caregivers spent the money on themselves?” 4) “How often did your parents or caregivers make you go hungry or not prepare regular meals?” 5) “How often did your parents or caregivers ignore or fail to get medical treatment when you were sick or hurt?” Responses for these questions also ranged from “1 – Never” to “4 – Often”. Differentiation. Two sets of questions were used to measure differentiation. The first group of questions asked about emotion regulation and included four questions. The emotion regulation questions asked respondents to say whether the following statements were true or false about them: “I’m very moody;” “I give in to urges;” “I have tantrums or angry outbursts;” and “My feelings are like the weather, they’re always changing.” Answers were coded as 1 for “true” and 0 for “false”. The second group of questions asked about balance in relationships and included two questions. Specifically, the first question asking about balance in relationships asked: “How much does this sound like you – I am somewhat uncomfortable being close to others; I find it difficult to trust them completely and difficult to depend on them. I am nervous when anyone gets too close to me.” The second question “How much does this sound like you – I find that others are reluctant to get as close as I would like. I often worry that people who I care about do not love me or won’t want to stay with me. I want to merge completely with another person, and this desire sometimes scares people away.” Responses ranged from “1 – not at all” to “4 – a lot.” Romantic relationship distress. Two questions were used to assess romantic relationship distress. The first question asked, “How often do you regret ever getting married/living together?” The second question asked, “How often do you think about getting a divorce or ending your relationship?” Responses ranged from “1 – Never” to “5 – All of the time.” Generalized anxiety disorder. The presence of GAD was determined making use of the World Health Organization’s Composite Interactional Diagnostic Interview (CIDI; Kessler & Üstün, 2004). The CIDI generates 12-month and lifetime diagnoses based on DSM-IV criteria. Twelve month diagnoses were used in this study. Data Analysis Data analysis was conducted in three steps. First, all variables in the data were screened for missing data and outliers. Second, confirmatory factor analysis (CFA) was used to construct latent variables of family abuse/violence and differentiation. Specifically, questions from the NCS-R that asked about family abuse/violence and differentiation were pooled into separate groups. Then, CFAs were run to find the best fitting measurement model for each construct. Though this was done for the family abuse/violence measure and differentiation, CFAs were not conducted for the romantic relationship distress variable since only two items were used. Finally, structural equation modeling was used to test the hypothesized model with the latent variables and mediation. All analysis were conducted in Mplus (Muth
en & Muth
en, 2012) using TYPE = COMPLEX method. The COMPLEX analysis can incorporate the stratification, clustering, and sampling weights of the NCS-R to compute standard errors and v2 test of model fit. Maximum likelihood with robust standard errors and v2 (MLR) was used as the estimator. MLR can used to with 344

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categorical variables and has been shown to be robust to nonnormality and nonindependence of observations, (Asparouhoc, 2005). Confirmatory Factor Analysis In CFA, a hypothesized model is used to estimate a population covariance matrix which is then compared to the observed covariance matrix (Schreiber, Nora, Stage, Barlow, & King, 2006). A good fitting model will have minimal difference between the observed and estimate matrices (Schreiber et al., 2006). To find a good fitting measurement model of family violence, two CFAs were conducted. The first measurement model had all of the questions asking about childhood abuse or neglect loading onto a single factor. The second measurement model included two distinct but correlated latent variables. The first latent variable had the two family violence and abuse questions as indicators and the second latent variable had the five neglect items as indicators. The results of the two CFAs were then compared to determine which provided better measurement. The model providing the best measurement was used in the SEM. The same processed was used to find a good fitting measurement model of differentiation. Two CFAs were conducted to compare two different measurement models. The first model included all of the differentiation questions as indicators on a single latent variable. The second measurement model included two distinct but correlated latent variables. The first latent variable included all of the emotion regulation variables as indicators, and the second latent variable included all of the questions asking about balance in relationships. As with the family violence latent variable, the best fitting measurement model of differentiation was used in the SEM. To assess the best fitting measurement model, the chi-square test, the comparative fit index (CFI), and the root mean square of error approximation (RMSEA) were evaluated. Additionally, the standardized root mean square residual (SRMR), and the weighted root mean square residual (WRMR) were used. WRMR can be used for categorical indicators, and was used to assess model fit for the differentiation measurement models. SRMR is used for continuous indicators, and was used to assess model fit for the family abuse/violence measurement model. Based on these statistics, the best fitting model will have small, nonsignificant chi-square, a RMSEA less than 0.05, a CFI greater than 0.95, and a SRMR or WRMR value less than 1. Structural Equation Modeling Following the creation of latent variables using CFA, SEM was used to test the hypothesized model and mediation. SEM can be seen as a combination of factor analysis and multiple regressions (Schreiber et al., 2006). Specifically, SEM can “test theoretical propositions regarding how constructs are theoretically linked and the directionality of significant relationships” (Schreiber et al., 2006, p. 326). In this analysis the best fitting measurement model of family abuse/violence was used as a variable to predict GAD and romantic relationship distress. The best fitting measurement model of differentiation was used as a mediator between family abuse/violence and GAD and romantic relationship distress. Mediation was tested using the MODEL INDIRECT statement in Mplus. Mplus uses the delta method to test for indirect effects; this method has shown to be similar to the Sobel test (MacKinnon, 2008). Similarly to the CFA, model fit for SEM was assessed using the chi-square test, CFI, RMSEA, and, because of the categorical variables, WRMR. In order to find the best fitting, most parsimonious model, model trimming was applied. Model trimming is commonly used in structural equation modeling (e.g. Driver & Gottman, 2004; Gallagher, Ting, & Palmer, 2008; Sidora-Arcoleo, Feldman, & Spray, 2012), and is normally done by removing variables or pathways that are small or nonsignificant.

RESULTS Descriptive Statistics and Correlations The mean, standard deviation, and skewness and kurtosis along with the correlations with other variables are presented in Table 1. The response rate for each of the variables used in the analysis was greater than 98%. As mentioned above, MLR was used as the estimator, so all missing data was estimated using maximum likelihood estimation. July 2015

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Note. **p < .01 *p < .05.

1. Frequency you were pushed, etc. 2. Frequency parents pushed, etc. 3. Frequency made to do chores too dangerous 4. Frequency left unsupervised as a child 5. Frequency went without 6. Frequency went hungry in childhood 7. Frequency parents failed to get treatment 8. I’m very moody. 9. I give in to urges 10. I have angry outbursts 11. Feelings are always changing 12. Uncomfortable getting close 13. I worry people will leave me. 14. How often do you regret getting married? 15. How often do you think about ending the relationship? 16. Generalized anxiety disorder Mean SD Skewness Kurtosis 1 .33** .34** .35** .32** .26** .19** .10** .15** .14** .14** .08** .14** .15** .09** 1.32 0.76 2.42 4.83

.07** 1.70 0.95 1.08 0.07

2

1 .42** .34** .30** .28** .27** .26** .13** .14** .15** .16** .16** .07** .11** .14**

1

.13** 1.26 0.69 2.84 7.32

1 .43** .36** .33** .31** .14** .17** .15** .12** .18** .17** .09** .10**

3

.09** 1.27 0.73 2.80 6.83

1 .46** .47** .37** .10** .14** .07** .07** .09** .11** .09** .11**

4

.11** 1.13 0.52 4.32 18.58

1 .68** .50** .11** .10** .10** .08** .12** .10** .05* .07**

5

.10** 1.10 0.44 5.07 26.32

1 .51** .07** .12** .09** .05* .13** .07** .07** .08**

6

.14** 1.09 0.40 5.30 29.78

1 .09** .13** .09** .07** .15** .07** .09** .09**

7

.22** 0.23 0.42 1.30 0.30

1 .24** .37** .47** .25** .18** .18** .21**

8

Table 1 Correlations, Means, Standard Deviations, Skewness and Kurtosis Table for All Variables

.12** 0.32 0.47 0.75 1.43

1 .26** .24** .21** .11** .14** .15**

9

.12** 0.19 0.40 1.54 0.38

1 .30** .17** .15** .10** .13**

10

.17** 0.22 0.42 1.33 0.23

1 .23** .19** .17** .18**

11

.19** 1.64 0.90 1.20 0.35

1 .36** .15** .18**

12

.14** 3.79 0.562 2.86 8.02

1 .11** .13**

13

.13** 1.43 0.74 2.00 4.44

1 .70**

14

.17** 1.33 0.682 2.42 6.55

1

15

1 0.04 0.187 4.70 22.71

16

Variables regarding family abuse/violence, marital quality, and GAD are often not normally distributed. People often report very high levels of marital quality, and a smaller percentage of the population report abuse or neglect and GAD. Therefore, these variables are often skewed. Since it is assumed that these findings represent the true distributions of these variables, the variables were not transformed. Moreover, the MLR estimator used in all analysis is robust not non-normality and can be used with categorical variables (Asparouhoc, 2005). Confirmatory Factor Analysis Model fit statistics for all CFAs are reported in Table 2. For the family abuse/violence variables, the two factor measurement model provided better fit than the one factor model. Specifically, measuring neglect and family violence as two separate but related construct provided better fit than measuring these as these measures as one latent variable. Similarly, the two factor measurement model of differentiation provided better fit than the one factor model. Measuring differentiation as two separate but related constructs, one of emotion regulation and one of balance in relationship, provided better fit than measuring differentation as a single factor. Factor loadings from the CFAs for each of the variables are reported in Table 3. Though both two factor models provided better fit than the one factor model, the chi-square statitics in all cases suggests poor model fit. However, the chi-square statistic often preforms poorly with large data sets and assumes normal distribution (Klien, 2011). This model had a sample of n = 2,321 and included nonnormally distributed constructs and dichotomous constructs. Structural Equation Modeling Since the results of the CFAs suggested that both family abuse/violence and differentiation provide better measurement for this sample as two factor measures, the two factor measure of each construct was used in the SEM. This model was identified based on the two idicator rule (Kline, 2011), in other words, each latent construct was associated with at least two measures, and each construct was correlated with at least one other construct. Model fit statistic indicated that this model provided poor fit (v2 = 244.083, df = 90, p < .001; RMSEA = 0.027; CFI = 0.949; WRMR = 1.254); specifically, the v2, CFI, and WRMR values all demonstrated poor model fit. For this model, the latent variable with the five neglect items was not significantly related to the emotion regulation variable or GAD and had only very small significant associations with balance

Table 2 Results of Confirmatory Factor Analyses comparing Multiple Measurement Models of Family Abuse/Violence and Differentiation Family abuse/violence Model

v2

df

p

Factor Factor

153.878 32.824

14 8

.00 .00

Model

v2

df

p

Factor Factor

121.895 29.912

14 8

.00 .00

RMSEA

CFI

SRMR

0.066 0.037

0.853 0.966

0.059 0.028

RMSEA

CFI

WRMR

0.074 0.034

0.924 0.985

1.738 0.835

Differentiation

Note. CFI = comparative fit index; RMSEA = root mean square of error approximation; SRMR = standardized root mean square residual; WRMR = weighted root mean square residual.

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Table 3 Factor Loadings and Variance for Family Abuse/Violence and Two Factor Differentiation Factor loadings B (SE) Family violence How frequently did someone in your household hit, shove, etc. as a child? How frequently did your parents/caregivers hit, shove, etc. each other? Neglect How often were you made to do chores that were too difficult or dangerous for someone your age? How frequently were you left alone or unsupervised when you were too young to be alone? How often did you go without things you needed like clothes, shoes, or school supplies? How often did your parent or caregivers make you go hungry or not prepare regular meals? Emotion regulation I’m very moody I give in to urges I have tantrums or angry outbursts My feelings are like the weather, they’re always changing Balance in relationships I find that others are reluctant to get as close as I would like I am comfortable depending on others and having them depend on me.

b (SE)

R2

1.000 (–)

0.594 (0.033) .35

0.933 (0.097)

0.718 (0.041) .52

1.000 (–)

0.603 (0.037) .36

1.002 (0.078)

0.823 (0.037) .68

0.840 (0.068)

0.817 (0.034) .67

0.544 (0.064)

0.612 (0.070) .37

1.000 (–) 0.592 (0.037) 0.781 (0.038) 0.928 (0.042)

0.866 (0.023) 0.513 (0.030) 0.677 (0.026) 0.804 (0.025)

1.000 (–)

0.725 (0.051) .53

0.422 (0.067)

0.493 (0.039) .24

.75 .26 .46 .65

in relationsihps and romantic relationship distress. Therefore this variable was removed from the anaylsis. The model was then run without the neglect variable and model fit improved (v2 = 57.516, df = 35, p = .001; RMSEA = 0.017; CFI = 0.990; WRMR = 0.703). This model was also identified based on the two indicator rule. The final full model with standardized results is presented in Figure 2. As with the CFAs, the chi-square for the final model indicated poor model fit. However, the remaining three fit statistics suggest good model fit. This model accounted for 13% of the variance of the romantic relationship distress variable, and 34% of the variance of GAD. The results of the mediation analysis are presented in Table 4. As mentioned above, Mplus uses the delta method to test the indirect or mediating effects. The total effect between family abuse/violence and romantic relationship distress was significant. When emotion regulation and balance in relationship were added as mediators, the direct effect was reduced but still significant. The total effect between family abuse/violence and GAD was also significant. When emotion regulation and balance in relationships were added as mediators for this relationship, the total effect was reduced and no longer significant.

DISCUSSION Current treatments of GAD have been effective at reducing symptoms for some people with GAD (Garfinkle & Behar, 2012); however, a large proportion of individuals who received

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Urges

Moody

Angry

.67

.53

.87

Change

.79

ER .46**

GAD .34** Hit as Child

.19**

.63

.02

FA/V

.11*

.43** .13**

Parent Hit

.19** Regret

.67 .29**

.79

RRD BR

.15** .89

.74 Too Close

Divorce

-.47 Not Close

Figure 2. Full model with standardized results. FA/V, Family Abuse/Violence; ER, emotion regulation; BR, balance in relationships; RRD, romantic relationship distress; GAD, generalized anxiety disorder; ** p < .01; *p < .05.

Table 4 Results of Mediation Analysis Estimate Family abuse/violence ? Romantic relationship distress Total 0.240 Total indirect 0.105 Specific indirect Violence ? Emotion ? RRD 0.063 Violence ? Balance ? RRD 0.043 Direct Violence ? RRD 0.134 Family abuse/violence ? Generalized anxiety disorder Total 0.232 Total Indirect 0.208 Specific Indirect Violence ? Emotion ? GAD 0.152 Violence ? Balance ? GAD 0.055 Direct Violence ? GAD 0.024

SE

p-value

0.022 0.016

.000 .000

0.014 0.011

.000 .000

0.021

.000

0.056 0.023

.000 .000

0.037 0.026

.000 .036

0.058

.675

Note. GAD = generalized anxiety disorder; RRD = romantic relationship distress.

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individual psychotherapy treatment for GAD did not report clinically significant gains (Siev & Chambless, 2007). Moreover, when GAD co-occurs with committed romantic relationship distress, the gains for individual psychotherapy are reduced (Durham et al., 1997; Zinbarg et al., 2007).To develop treatments that can improve outcomes for those with GAD and committed romantic relationship distress, it is important to conduct theory-based research that could identify common links of GAD and romantic relationship distress. This study tested a model of GAD and committed romantic relationship distress from Bowen’s family systems perspective. Specifically, it tested links between family abuse/violence, differentiation, and the presence of GAD and committed romantic relationship distress. It predicted that the relationship between family abuse/violence and romantic relationship distress and family abuse/violence and GAD would be mediated by a person’s differentiation. As predicted, associations were found between family abuse/violence and committed romantic relationship distress and between family abuse/violence and GAD. Those who reported being pushed, slapped, or spanked frequently as children and who reported that their parents or caregivers pushed or hit each other frequently, reported romantic relationship distress more frequently and where more likely to meet diagnostic criteria for GAD. The finding tying abuse to GAD supports the findings of Afifi et al. (2009)and Keyes et al. (2012) which also suggest that abuse and family violence are associated with an increased risk of having GAD. Similarly, the findings tying abuse to committed romantic relationship distress support the findings of Kim et al. (2009). The mediations pathways between family abuse/violence and the two outcome variables were somewhat different. Specifically, the association between family violence and GAD was mediated by emotion regulation and balance in relationships. In other words, family abuse/violence was associated with GAD through differentiation. This finding supports some of the assertions of Bowen’s theory (Kerr & Bowen, 1988). Bowen posited that a person’s level of differentiation is related to the relationship processes that occur in a person’s family of origin, and that poor differentiation can lead to chronic anxiety. The results reported here support this assertion and suggest that if a person is exposed to violence or is a victim of abuse during childhood, that person is likely to have poorer emotion regulation and difficulty balancing individuality and togetherness in relationships. This poor differentiation puts this person at greater risk of having diagnosable chronic anxiety (e.g. GAD). The relationship between family abuse/violence and committed romantic relationship distress was only partially mediated by differentiation. Even when emotion regulation and balance in relationship were used as mediators, the direct effect between family abuse/violence and committed romantic relationship distress remained significant. In other words, the findings here suggest that family/abuse violence is directly associated with committed romantic relationship distress. This finding does not support the hypotheses of this study, which suggested that the relationship between family abuse/violence and romantic relationship distress would be mediated through a person’s differentiation. This contrary finding could result from the measure of differentiation used in this study. Other measures of differentiation are more comprehensive and multifaceted than the one used in this study (e.g. Schnarch & Regas, 2012; Skowron & Friedlander, 1998) and include parts of Bowen’s theory that were not accounted for in this study. Additionally, it may be that those who say their parents/caregivers were violent with each other, may not have been learned meaningful ways to deal with conflict in relationships and therefore continue to replicate patterns that increase relationship distress (McWey et al., 2013). It was also hypothesized that since GAD and romantic relationship distress would be linked to family abuse/violence and differentiation, GAD and romantic relationship distress would co-occur. The results of the final model suggest that GAD and romantic relationship distress are significantly correlated. Though many studies have shown that GAD and romantic relationship distress are related (e.g. Priest, 2013a; Whisman, 2007), the results of this study help shed light on some possible reasons behind the frequent co-occurrence. Bowen (Kerr & Bowen, 1988) suggesting that the symptoms of chronic anxiety and relationship distress stem from poor differentiation which may result from the experience of family abuse/violence, and these findings support that assertion. However, given that the data is cross-sectional, the temporal ordering of these findings is unclear. Future research could address the temporal ordering of the variables tested in this study by examining them longitudinally. 350

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Though not part of the hypotheses of the study, the results of the CFAs support findings of other studies. The two factor measure of family abuse/violence provided better measurement than when violence and neglect were measured together. Moreover, the neglect latent variable was trimmed from the final model. These findings support the findings of Keyes et al. (2012), which measured types of abuse separately, and did not find associations between neglect and internalizing disorders for men or women. The two factor measure of differentiation also provided better model fit than the one factor measure. Other measures of differentiation (e.g. Schnarch & Regas, 2012; Skowron & Friedlander, 1998) have also been multidimensional; however, it should be noted that the items used to measure differentiation in this study had different response categories. It may be that the two factor measurement model provided a better fit due to this difference.

CLINICAL IMPLICATIONS Treatment outcomes for those with GAD may improve by screening for past abuse, and if there is a history of abuse, addressing it in therapy. Though there have been calls for universal screening of domestic violence in couples presenting for relationship and mental health issues (e.g. Bograd & Mederos, 1999; Todahl & Walters, 2011), the findings of this study suggest the need for screening of past experiences of violence and abuse, especially when distressed relationships and chronic anxiety are present. Moreover, those who do not respond to current psychotherapy treatments of GAD may benefit from therapy that focuses on past abuse and trauma. This might be particularly useful when GAD co-occurs with romantic or other relationship distress (Priest, 2013b). In addition to a focus on trauma and abuse, it may also be beneficial for treatments to focus on interpersonal processes for those with GAD and romantic relationship distress. It may be that by tracking inflexible cycles of interaction, partners may be able to express emotions that underlie their behaviors, and be better able to regulate their emotions and thereby ease symptoms of GAD and alleviate romantic relationship distress. Many researchers have shown that those with GAD often have unique interpersonal styles (Erickson & Newman, 2007; Salzer et al., 2008, 2011). This has led to studies that augment cognitive behavioral therapy with interpersonal therapies; however, this addition has not always improved treatment outcomes (Newman et al., 2011). These interpersonal therapies may not have improved treatment outcomes due to a lack of focus on balancing individuality and togetherness in relationships.

LIMITATIONS In interpreting these findings, some of the limitations of this study should be highlighted. First, the question used in this study to create the latent differentiation variables were a limitation. Also noted above, other measures of differentiation are multifaceted and more comprehensive (e.g. Schnarch & Regas, 2012; Skowron & Friedlander, 1998). The variables used here did not examine all of the facets of differentiation. Additionally, since the questions were taken from a nationally representative data set, the questions were not originally designed to measure differentiation. These questions were chosen based on being the most similar in the data sets to Bowen’s concept of differentiation. Though the questions used in this study do address some of the components of differentiation, future research would benefit from using established measures of differentiation to test whether the associations found here can be replicated using established measures. Second, though this study was based on tenets of Bowen’s family systems theory, it did not include many important tenets of the theory. For example, triangulation is a major tenet of Bowen’s theory (Kerr & Bowen, 1988). Bowen suggested that when conflict arises between two people, those who were poorly differentiated are likely to bring in an outside person to help diffuse the tension. Though this may diffuse tension in the short term, it may actually bind anxiety that can lead to chronic anxiety and dysfunctional relationship patterns. This assertion was not tested due to the single report data used in this study. Future research exploring processes associated with GAD and romantic relationship distress would benefit by exploring how triangulation occurs in family of origin relationships and in romantic relationships by using dyadic or triadic data.

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