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An Empirical Evaluation of Behavioral and Cognitive-Behavioral Group Marital Treatments with Discordant Couples Kimberly R. Montag & Gregory L. Wilson Published online: 14 Jan 2008.

To cite this article: Kimberly R. Montag & Gregory L. Wilson (1992) An Empirical Evaluation of Behavioral and Cognitive-Behavioral Group Marital Treatments with Discordant Couples, Journal of Sex & Marital Therapy, 18:4, 255-272, DOI: 10.1080/00926239208412851 To link to this article: http://dx.doi.org/10.1080/00926239208412851

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An Empirical Evaluation of Behavioral and Cognitive-Behavioral Group Marital Treatments with Discordant Couples

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KIMBERLY R. MONTAG and GREGORY L. WILSON

Previous research has revealed that group behavioral therapy for distressed couples provides an effective and efficient form of marital treatment. However, research comparing alternative group apfioaches is lacking. The current investigation evaluated group behavioral and cognitive-behavioral marital treatments across a variety of relationship dimensions and measures of individual functioning. Dysfunctional couples were randomly assigned to experimental conditions and demonstrated statistically and clinically significant improvement as contrasted with the waiting list control group. These results are discussed in terms of the differences between treatment conditions, potential advances in the field of marital therapy, and recommendationsfor further inquiry. Since Stuart’s’ initial use of an operant-interpersonal approach, various behavioral marital therapy (BMT)strategies have been utilized in the treatment of dysfunctional relationship^.^-^ Although BMT is considered an idiographic procedure tailored to meet the specific needs of each individual couple, its intervention strategies typically include three basic components: behavior exchange techniques designed to increase couples’ positive interactions, communication skills training emphasizing receptive and expressive skills, and problem-solving training composed of modeling, feedback, and behavioral rehearsal.jS6 In research and clinical settings alike, B M T has predominately been administered in a conjoint modality. However, given the growing need for cost- and time-efficient modes of treatment delivery, investigators have begun to systematically evaluate alternative therapy formats within the behavioral Of particular interest is the utility of group marital therapy intervention^.^- l 4 Unfortunately, there are few well-controlled studies designed to investigate the relative efficacy of group BMT approaches with dysfunctional couples. Address correspondence to: Gregory 1.. Wilson. Ph.D., Department of Psychology. Washington State University. Pullman, WA 99164-4820.

Journal of Sex & Marital Therapy, Vol. 18, No. 4, Winter 1992 0 Brunner/Mazel, Inc. 255

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.journal of Sex c3 Marital Therapy, Vol. 18, No. 4 , Winter 1992

To date, only three comparative outcome studies have systematically evaluated group behavioral interventions for distressed dyads. First, Hahlweg, Kevenstorf, and Schindler (9) conducted a major marital therapy study in the Federal Republic of Germany. Following therapy, conjoint and group-conjoint BMT, as well as a conjoint communication training condition, showed substantial improvements as compared to the control group. In Great Britain, Bennun" completed a comparative evaluation of conjoint, group, and one-partner treatment of marital discord and found no significant differences between the experimental conditions. Most recently, Wilson, Bornstein, and Wilson' I evaluated group BM'I' with distressed couples in the United States. Fifteen couples were randomly assigned to either a group, conjoint, or waiting list condition. Results revealed that couples in both the conjoint and group conditions, as contrasted with those in the waiting list condition, exhibited significant improvement in relationship satisfaction. In addition, treatment gains were maintained or enhanced over the six-month follow-up period. Minimal differences were detected between the two treatment modalities. However, couples in conjoint treatment reported improved affective communication and greater relationship harmony. Group therapy couples, on the other hand, demonstrated greater improvements in childrearing practices, sexual satisfaction, and positive verbal interactions.15 Although the effectiveness of BMT strategies in the treatment of marital disharmony has been established, various limitations have been reported in both its conceptual model and treatment t e ~ h n o l o g y . ' ~Also, -'~ because a substantial proportion of couples are not aided by BM'I'," it appears possible that a purely behavioral technology is inadequate in successfully treating dysfunctional relationships. In order to increase the effectiveness of BMT, a fruitful strategy may be to expand the behavioral technology to include alternative relationship components which could potentially influence the degree of marital satisfaction.','6,'8-20 Behavioral marital therapists have often employed some cognitive techniques, however ~ n s y s t e m a t i c a l l y . ~Several * ~ ~ * * ~recent investigations have shown empirically that cognitive components such as causal attributions and expectations are strongly related to current levels of satisfaction in 97 "4 the marriage.-. * - The realization that untreated dysfunctional cognitions may interfere with both the establishment and maintenance of positive behavior change has prompted researchers and practitioners alike to advocate a more systematic inclusion of co nitive-behavioral therapy (CBT) strategies within the BMT framework.F9.25 Although a variety of behavioral models and therapeutic strategies have been proposed which incorporate cognitions, a paucity of empirical research has been devoted to evaluating their effectiveness with distressed couples.2" A t present, three studies have been published in which the effectiveness of cognitive restructuring alone was i n v e ~ t i g a t e d . ~ ~ * * ~ * ' ~ T h e overall results of this research revealed that cognitive interventions were successful in modifying both dysfunctional attributions and problematic expectations.

Group Marital Treatment A#roaches

25 7

Two recent investigations have explored whether the efficacy of BMT could be enhanced by the addition of a cognitive component. Baucom and Lesterl8 conducted the first controlled outcome investigation of marital therapy which combined cognitive treatments with established BMT strategies. Results revealed that, compared to the waiting list condition, couples receiving BMT alone and CBT + BMT showed substantial improvements in overall marital adjustment and behavioral change; only the CBT + BM'I' couples demonstrated consistent cognitive changes. N o significant differences were found between the two types of treatment on an of the dependent variables. Most recently, Baucom, Sayers, and Sher2 investigated whether the effectiveness of BMT could be increased by the addition of cognitive interventions and/or emotional expressiveness training. Once again, results showed few significant differences between the combined treatments and BM'I' presented alone. Both of these studies utilized a sequential presentation of cognitive and behavioral components. For example, couples in the Baucom and LAester18 investigation received six sessions of CBT followed by six sessions of BMT. Perhaps the reverse order would prove more beneficial to some couples, or it may even be that the consecutive format, in which the treatments are presented separately, is not the optimal strategy. It is possible that the combination of cognitive and behavioral therapies will demonstrate increased utility if the two components are presented together in a singular integrated treatment intervention. This approach would afford couples the opportunity to benefit from either one or both of the approaches, depending on their own unique needs, at any time during the course of treatment. Moreover, such an integration of cognitive and behavioral tactics would parallel effective appro ache^*^*^^ employed with depressed and anxious clients. Thus, the current study represents the first effort to investigate the potential efficacy of an integrated cognitive-behavioral marital therapy (CBMT) package. Moreover, since couples were treated in a group setting, this study serves to further extend the research base of group marital therapy formats. T w o primary hypotheses were advanced prior to the initiation of treatment. First, it was predicted that both BMT and CBMT would be more effective than the waiting list condition in improving relationship satisfaction and individual functioning. Second, CBMT, with its dual focus on both behavioral and cognitive change, was predicted to be superior to BMT alone. More specifically, cognitive measures of relationship and individual functioning were hypothesized to reveal the largest amount of change for couples in CBMT.

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.y

METHOD Subjects Fifteen couples (i.e., 30 clients) were recruited through media announcements offering a low-cost therapy program for distressed couples. This study was conducted as part of an ongoing investigation of differential

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journal of Sex U Marital Therapy, Vol. 18, No. 4 , Winkr 1992

effects among couples experiencing marital dysfunction. Each couple was randomly assigned to one of three experimental conditions (i.e., behavioral group treatment, cognitive-behavioral group treatment, or waiting list control). Couples who participated in the waiting list control group were offered marital treatment following the collection of posttreatment data. Spouses ranged in age from 22 to 55 years (BMT: Mean = 41.50 years, SD = 7.32 years; CBM'I': Mean = 37.70, SD = 11.46 years; Waiting list control: Mean = 34.60, SD = 7.03 years). Fourteen of the 15 couples were married. They ranged in length of marriage from 4 months to 32 years (BM'T: Mean = 18.40 years, SD = 12.10 years; CBMT: Mean = 10.06 years, SD = 11.58 years; Waiting list control: Mean = 15.82 years, SD = 5.57 years). Comparisons between experimental conditions on these preceding dimensions proved nonsignificant. T h e remaining couple had been cohabitating for t w o years with plans for marriage. T h e screening process began with a clinical interview designed to evaluate and delineate the nature of a couple's presenting problems. T h e Dyadic Adjustment Scale (DAS) was also administered in order to gather additional'information about each couple's level of dysfunction. Requirements for participation in the study included: 1) at least one spouse had to score in the distressed range on the DAS (i.e., less than 97); 2) the average score for both partners had to be 97 or less; 3) no current extramarital affairs; 4) no recent history of violence; and 5) no evidence of drug or alcohol abuse. T w o couples were disqualified due to scores following in the nondistressed range on the DAS. Another couple could riot be included because of the unwillingness of one partner to attend treatment sessions.

A total of seven measures of relationship and individual functioning were employed as outcome measures. These measures assessed relationship dimensions, individual functioning, and consumer satisfaction. T h e relatioriship measures included assessments of overall marital satisfaction (i.e., Dyadic Adjustment Scale, Marital Happiness Scale), positive and negative verbal behavior (Marital Interaction Coding System), and dysfunctional cognitions about relationships (Relationship Beliefs Inven tory).

Kel~~tiort.ship Dimensions Dyadic Adjustment Scule (DAS).31T h e DAS is a widely used 32-item selfreport questionnaire which provides a global measure of tnarital satisfxtion. Reliability and validity studies on the DAS are consistently positive. I n fact, Spanier"' reports an internal consistency of r = .Y6. Marital Interaction Coding Syslem (MICS).'? T h e MICS is the most widely used direct observational coding system for the analysis of couples' interactions. Summary codes have been shown to be reliably predictive of

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259

either distress or satisfaction in individuals and c o ~ p l e s .Three ~ ~ , ~sepa~ rate 10-1 5-minute video recordings were evaluated (i.e., pretreatment, posttreatment, follow-up) using the Resick et al.33scoring modification of the MICS. Relatiomhip Beliefs Inventory T h e RBI is a 40-item self-report questionnaire designed to assess couples’ unrealistic beliefs about intimate relationships. T h e measure consists of five subscales: disagreement is destructive; mindreading is expected; partners cannot change; sexual perfectionism; and sex role rigidity. Higher total scores indicate greater endorsement of unrealistic relationship beliefs. T h e RBI has been demonstrated to differentiate distressed from nondistressed couples, and its subscales have been found to possess adequate internal consistency. Eidelson and E p ~ t e i nreported ~~ reliabilities for the scales, as measured by Cronbach’s alpha, ranging from .72 to 3 1 . Wilson and M ~ n t a further g ~ ~ evaluated the psychometric characteristics of the RBI with a sample of 62 couples seeking relationship therapy. Results revealed Cronbach’s alphas ranging from .43 (Partners cannot change) to .79 (Sex role rigidity). Split-half reliability estimates of each subscale ranged from .49 (Partners cannot change) to .86 (Sex role rigidity). Cronbach’s alpha and split-half reliabilities for the total scale score of the 40item RBI were .85 and 2 9 , respectively. In addition, the RBI demonstrated significant correlations with other marital assessment instruments (e.g., Marital Happiness Scale, Dyadic Adjustment Scale). In the present investigation, the total scale score of the RBI was employed as a primary dependent variable because evidence revealed that some of the individual scales revealed low reliability coefficients, whereas the total scale score demonstrated adequate psychometric rigor. Marital Happiness Scale (MHS).’ The MHS, as modified by Bornstein and his colleague^,^^^^^ provides a rapid assessment of common areas of marital interaction including, household responsibilities, sex, affection, and general happiness. Spouses rate their degree of marital happiness on a scale of 1-10 for each component of interaction. Higher scores indicate greater relationship happiness.

Measures of Indivzdual Functioning Irrational Beliefs Test (IBT).3gT h e IBT is a 100-item self-report inventory which measures irrational expectations. The content of these items corresponds to the 10 core irrational beliefs identified by Ellis.40Higher scores on the IBT indicate a greater number of irrational beliefs and expectations. Validity and reliability estimates of this instrument in predicting problematic emotionality and disturbed psychological functioning have been detailed p r e v i ~ u s l y . ~ ’ * ~ ~ Beck Depression Invento?y (BDI).43T h e BDI is a widely used 21-item self-report measure that assesses cognitive, affective, motivational, and physiological symptoms of depression. Studies of the internal consistency and stability of this instrument indicate a high degree of ~ - e l i a b i l i t y . ~ ~ , ~ ~

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T h e BDI's validity is similarly well established. Scores range from 0 to 63 with higher scores indicating greater depression. Symptom Check List 90-Revised (SCL-90-K).46T h e SCL-90-R is a selfreport inventory designed to assess current psychological symptom status along nine primary symptom dimension and three global indices of distress. T h e Global Severity Index (GSI) was chosen for use in this study because it represents the best single indicator of the level or depth of an individual's psychopathology. Higher T-scores a r e indicative of greater pathology. Previous research has documented the reliability and validity of the SCLA-90-R.47 Consumer Sntisfaction Consumer Satisfaclion Questionnaire (CSQ).48'The CSQ is a direct, practical, and highly cost-efficient means of evaluating clients' evaluation of services provided. Scores range from 8 to 32, with higher scores being indicative of greater treatment satisfaction. This instrument was administered at posttreatment to each individual who participated in the program. Treatment Procedure Treatment for all therapy groups consisted of eight weekly, lLk-hour group sessions. A week after the program terminated, all participants returned for a posttest evaluation. I n addition, the couples underwent a follow-up assessment six months after the end of treatment. All treatment sessions were conducted by a cotherapy team composed of the authors of the investigation. T h e first author was enrolled in the doctoral training program at Washington State University in clinical psychology. She had previously completed 1%months of clinical training emphasizing marital treatment modalities. In addition, she received 150 hours of training in behavioral-communications marital therapy and cognitive-behavioral marital therapy. T h e second author was a licensed clinical psychologist, director of the Marital Treatment Program at Washington State University, and had been investigating and conducting marital therapy programs from behavioral a n d cognitive-behavioral perspectives for 1 0 years. Behaziiorul Group Therupy This therapy program proceeded in accordance with the treatment guidelines in Hornstein and Bornstein.'" Specifically, treatment followed a sequential five-step procedure: 1 ) intake interviewing and assessment; 2) early treatment tactics; 3) communication skills acquisition; 4)problemsolving training; and 5) provisions for maintenance. T h e eight-session intervention had been developed and outlined by Wilson15 in a manual that was utilized by the therapists during each session.

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Group Marital Treatment Approaches

26 I

T h e first session was designed to assess three primary areas of each couple’s relationship: 1) presenting complaints; 2) developmental history; and 3) cross-sectional history (i.e., daily patterns of interactions). ‘The initial interview, like other treatment sessions, concluded with specific homework assignments (e.g., “Tell me what you like”) designed to generalize treatment success to the natural environment. Continued emphasis on “positive tracking” and “positive control tactics” characterized sessions 2 and 3. Behavior exchange techniques, including “caring days,” behavioral contracting, and compromise were also presented during these sessions. Communication training was the primary focus of sessions 4 and 5. T h e targets of intervention included: the “basics” of communication, (e.g., respect, understanding, sensitivity); principles of communication (e.g., timeliness, manner, specification, “mindreading”); nonverbal behaviors; and molecular verbal behaviors (e.g., assertiveness, sidetracking, sarcasm). T h e actual training approach consisted of a sequence of seven primary clinical strategies: instructions; modeling; rehearsal; reinforcement; feedback/coaching; rehearsal; and homework. Sessions 6 and 7 focused on teaching and practicing effective problem solving. Couples received specific instruction on a nine-step conflict resolution approach. T h e final therapy session addressed maintenance and generalization of relationship improvements achieved as a result of treatment. Specific issues addressed during the final session included behavioral traps, fading of contingencies, self-control, and expanding stimulus control. Cognitive-Behavioral Group Therapy

For this treatment condition, elements of B a u c o m ’ ~cognitive ~~ restructuring program for couples and beck'^^^^^^ cognitive therapy were integrated into the behavioral-communications approach described above. Therapists followed a treatment manual constructed by Wilson and Montag5’ in implementing each session. T h e first session paralleled the initial session from the behavioral treatment condition. Sessions 2 and 3 emphasized positive tracking, positive control tactics, and behavioral exchange techniques. An additional goal of session 3 was to both identify and modify couples’ faulty attributional processes. Specifically, three attributional dimensions were examined: internal-external; global-specific, and stable-unstable. Therapists coached the couples in examining and challenging the validity of their attributions and assisted them in relabeling partners’ behaviors that they found to be distressing. As in the behavioral treatment, sessions 4 and 5 were devoted to teaching couples effective communication skills. In addition, session 5 also focused on irrational beliefs that couples may express about themselves or their partners as individuals. T h e therapists outlined various ways in which couples’ incongruent or rigidly extreme expectations could create

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difficulties in their relationship. Ellis’s4’ ABC(DE) strategy for disputing dysfunctional beliefs was also introduced and practiced in the group. Conflict-resolution training was implemented during sessions 6 and 7. Session 7 also emphasized unrealistic expectations about the nature of intimate relationships and the roles of its members. Five common extreme expectations, based on Epstein and E i d e l ~ o n ’ sunrealistic ~~ relationship beliefs, were discussed and examined by the group. Therapists encouraged the couples to generate more logical, adaptive statements. The final therapy session addressed maintenance and generalization of relationship improvements, including Behavioral Traps, Fading of Contingencies, Self-Control, Expanding Stimulus Control, Self-Talk, and Stress Inoculation. Ma?Li@lnlion Check

In order to evaluate the degree to which therapists adhered to the respective manuals in implementing the t w o treatments, videotaped sessions were rated by four research assistants who received 20-30 hours of training on observational coding procedures prior to conducting reliability checks. T h e raters reviewed 50% of the sessions for each of these therapy conditions. Each session was rated on the Treatment Protocol Adherence Scale52from 0 to 100% as t o the degree to which each treatment session followed the treatment manual. T h e formula used to calculate degree of adherence was: number of completed intervention strategies divided by number of‘ planned intervention strategies per session. Ratings for all sessions ranged from 80 to 100% with an average rating of 95%.

RESULTS Treatment data were analyzed in two distinct manners: 1) statistical significance between groups was evaluated over time (i.e., pre-post and pre-post follow-up); and 2) a n analysis of clinical significance was performed. In addition, consumer satisfaction data are provided. All videotaped observational measures of couples’ interactions (i.e., MICS data) were rated by trained research assistants using a 10-category coding system. These raters required a total of 15 hours training prior to attaining acceptable levels of interrator agreement across target behaviors ( r > 70%).Raters recorded the occurrence of each of the codes in consecutive 30-second intervals. T h e order of tapes (i.e., pretest, posttest, follow-up) was scrambled so as to keep raters unaware of assessment period. Twenty percent of the tapes were rated by the trained coders for reliability purposes. Reliability for behavioral codes was calculated by using the following formula: agreements/agreements plus disagreements. Reliability quotients ranged from 72 to 97% with a mean reliability quotient o f 87%. Data were initially analyzed via a 3 X 2 (Treatment x Sex) multivariate analysis of variance (MANOVA) on pretest scores for coriirnon dependent variables. N o significant differences were revealed, thus indicating successful randomization.

Croup Manhl Treahent A#xoaches

263

Pre-Post

Two types of de endent variables were included in the present study: assessments of re ationship functioning and measures of individual funcTherefore, two separate MANOVAs were completed. As detailed ionin y Baucom, Sayers, and Sher,22all data were analyzed separately for husbands and wives because previous research has documented emp i r i ~ a l l yas~ well ~ as argued c ~ n c e p t u a l l ythat , ~ ~ calculating couple scores distorts differences between responses to treatment by husbands and wives. Analyses conducted on male and female partners in the current investigation further revealed low correlations among scores on some of the primary marital measures (e.g., MHS, RBI) as well as individual functionin measures. Relations ip Functioning. Pre-post data were first analyzed via a mixed model 3 X 2 x 2 (Treatment X Sex x Time) MANOVA with repeated measures on the final factor across relationship dependent variables. T h e MANOVA showed a significant main effect of Time, Wilks’s lambda = .28, F (5,20) = 10.06,p < .001. In addition, significance was revealed on the Treatment X Time interaction, Wilks’s lambda = .3 1, F (10,40) = 3.18, p < .005. All other main effects and interactions proved nonsignificant. Summary data for each relationship measure across treatment and time (i.e., pre-post follow-up) are presented in Table 1. Subsequent mixed model 3 x 2 x 2 (Treatment x Sex x Time) ANOVAS with repeated measures on the final factor revealed a significant Time effect on the DAS, F ( 1 2 7 ) = 19.83, p < .OO 1, wherein higher relationship satisfaction scores were found at posttesting than at pretesting. A significant Treatment X Time interaction was also obtained on the DAS, F (2,27) = 4.32, p < .05. A subsequent Newman-Keuls analysis of this interaction indicated greater improvement in the scores of behavioral clients as contrasted with the cognitive-behavioral clients and wait list controls. On the MHS, statistical significance was obtained over time with higher means found at the conclusion of the treatment intervention, F (1,27) = 8.23, p < .008. In addition, a significant Treatment X Time interaction was found, F (2,27) = 5.33, p < .02. Multiple comparison analysis yielded evidence of significant improvement for clients in cognitive-behavioral treatment, whereas behavioral and wait list clients’ scores remained essentially unchanged. O n the KBI, the Treatment x Time interaction approached significance, F (2,27) = 2.78, p = .078. However, subsequent Newman-Keuls analysis revealed no significant pairwise differences. Results from the MICS revealed significant main effects of Time for ositive verbal behaviors, F (1,27) = 6.64, p < .02, and negative verbal gehaviors, F (1,27) = 19.32, p < .001. In both instances, significant improvement was evident from pretesting to posttesting. In addition, a marginally significant Treatment X Time interaction was obtained for negative verbal behavior, F (2,27) = 2.53, p = . l o . Subsequent multiple comparison analysis revealed that clients in behavioral and cognitivebehavioral treatment significantly decreased their negative verbal behavior and demonstrated greater improvement than wait list subjects at posttreatment.

P

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t

f

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Journal of Sex k3 Maritnl Therapy, Vol. 18, N o . 4 , Winler 1992

'I'ABIX 1 Mean Scores and Standard Deviations o n Measures of Relationship and Individual Functioning Across Treatment a n d T i m e (i-e., Pre-Post Follow-up)

Measure

Pre

B M T Group F- U POSL

Pre

C R M T Group Post F-U

Waiting List Pre Post

DAS

89.30 8.03

1 0 1.70

SD

8.86

95.67 8.57

87.30 16.88

92.80 16.59

83.90 19.46

88.30 14.71

90.20 20.27

M SD

56.60 6.92

67.10 15.16

66.00 12.65

56.40 10.90

7 I .60 13.0I

60.70 14.09

66.70 10.55

62.60 11.55

M

69.50 18.89

58.60 8.8 1

70.30 12.61

72.30 17.77

58.00 19.48

59.70 20.63

58.60 16.47

65.00

6.77 3.03

6.55 4.24

7.34 1.34

7.46 1.03

5.10 1.78

7.22 5.32

.13 .16

.40 .53

.26 .39

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M

MHS

KB I SI) M1CS-P

M SI)

3.7 1 1.30

MI(25-N M SD

.70 .75

.I2 20

.o 1

.o 1

.90 .98

23 .27

275.00 20.63

264.00 27.23

266.30 33.08

29 1.30 29.90

278.60 24.27

34.30 7.24

30.00 8.0 1

30.67 5.09

38.50 10.84

32.70

5.30 6.13

3.40

3.67 3.67

8.30 6.82

4.40

1'3.67

I B'l' M

SD

280.50 291.30 289.20 22.16 14.82 25.42

GSI M

sI)

11.01

33.40 8.57

34.50 6.93

32.10 4.31

6.90 5.51

9.60 5.08

6.30 4.52

RDI M

s1)

3.10

4.86

Note: DAS = Dyadic Adjustment Scale; MHS = Marital Happiness Scale; RBI = Relationship Reliefs Inventory; MICS-P = Marital Interaction Coding System-Positive; MICS-N = Marital Interaction Coding System-Negative; IKI' = Irrational Beliefs Test; GSI = Global Severity Index; BDI = Hrck Depression Inventory.

Individual Functioning. A mixed model 3 X 2 X 2 (Treatment X Sex x Time) MANOVA conducted o n dependent variables assessing individual functioning revealed a significant main effect of Time, Wilks's lambda = .48,F (3.22) = 8.02, p < .01. Summary data for each individual measure across treatment a n d time (i.e., pre-post follow-up) are also presented in Table 1. Subsequent ANOVAs o n dependent variables revealed significant Time effects on the BDI, F (1,27) = 1 1.47, p < .003, a n d o n the Global Severity Index of the SCL-gO-K, F ( 1 2 7 ) = 21.05, p < .001. I n addition, a marginally significant T i m e effect was revealed on the IBT, F (1,27) = 3.46, p = .07. Consistently, couples demonstrated significant improvement from pretreatment to post-treatment.

Group Marital Trealmnl Approaches

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TABLE 2 Tabulations of Clinical Significance for Couples in Behavioral, CognitiveBehavioral, and Waiting List Conditions as Measured by the DAS UnImprovechanged ment

Dcterioration

Nondysfunctional

Alleviation

(n=5) (n=5) (n=5)

5(100%) 3(60%) 2(40%)

O(070) 2(40%) 2(40%)

O(%)

O(O%) 1(20%)

4(80%) 3(60%) 3(60%)

4(80%) 3(60%) 2(40%)

(11=3) (n=5)

1(33%) O(O%)

1(33%) 2(40%)

1(33%) S(607c)

1(33%) 1(20%)

1(33%) O(O%)

(n=3) (n=5)

2(67%) 1(20%)

1(33%) 2(40%)

O(O%) 2(40%)

1(33%) 1(20%)

1(33%) 1(20%)

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Pre-Putt

BMT CBMT WL Post-Follow-up

BMT CRMT Pie-Follow-up

BMT CBMT

Pre-Post-Follow- Up

Data from the waiting list controls were excluded because these subjects were offered active treatment following the posttreatment assessment, and therefore, no longer represented a time-matched comparison control group. All clients completed pre-, post- and follow-up testing except two couples in the behavioral treatment who did not complete the follow-up assessments (i.e., both couples could not be located at follow-up). Reluliomhzp Functioning. Pre-Post-Follow-up data were initially analyzed via a mixed model 2 X 2 X 3 (Treatment x Sex X Time) MANOVA with repeated measures on the final factor across relationship dependent variables. T h e MANOVA showed a significant main effect for Time, Wilks’s lambda = .014, F (10,3) = 20.2, p < .02. All other main effects and interactions proved nonsignificant. Subsequent mixed model 2 X 2 X 3 (Treatment x Sex X Time) ANOVAs on dependent variables revealed a significant Time effect on the DAS, F (2,30) = 4.89, p < .02; on the MHS, F (2,30) = 5.69, p < .008; on the RBI, F (2,30) = 5.75, p < .008; and on the MICS-Negative, F (2,30) = 10.25, p < .001. All subsequent Newman-Keuls analyses revealed significant improvements at posttesting for behavioral and cognitive-behavioral couples which were maintained at follow-up, except on the DAS wherein a return to pretreatment levels of functioning was revealed at follow-up. Individual Functioning. A mixed model 2 x 2 x 3 (Treatment x Sex x Time) MANOVA conducted on measures of individual functioning revealed a significant main effect of Time, Wilks’s lambda = .12, F (6,7)

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= 8.35, p < .008. Subsequent ANOVAs o n dependent variables revealed significant Time effects o n the BDI, F (2,30) = 5.40, p < .01, o n the IB‘T, F (2,28) = 3.37, p < .05, and o n the GSI scale of the SCL-90-R, F (230) = 12.0, p < .003. I n each instance, Newman-Keuls analysis revealed significant improvement for both behavioral and cognitive-behavioral clients during treatment which was maintained at follow-up.

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Clinical S i < pzficance T h e present investigation examined clinical significance via tabulational analyses of improvement, deterioration, and alleviation employing the reliable change (RC) index55as modified by Christensen a n d M e n d o ~ a . ~ ~ T h e K C index is equivalent to the difference score divided by the standard error of the difference score: KC = (X, - X1/Sdifl) where Sdirl= standard error of difference between two test scores; X2 = the posttest score for each couple; and X , = that couple’s pretest score. Any KC larger than 2 1.96 would be unlikely to occur ( p < .05) without actual change. Tabulational analyses of clinical significance for couples in each treatment condition o n the DAS are presented in Table 2. Five sets of empirical criteria were employed to evaluate clinical significance: 1) Zmprovemenl-couples were classified as improved if the RC index was 1.96 o r RC scores between + 1.96 a n d - 1.96 were larger; 2) unchanged-ouple labeled as unchanged; 3) de~m’oration+ouples were identified as deteriorated if the difference score was less than - 1.96; 4) nondysfunctionnf-couples who surpassed the clinical cut-off o f 97 o n the DAS were classified as nondysfunctional; 5) alleviafion-clinically significant alleviation was defined as statistically reliable movement from the dysfunctional range into the nondysfunctional range on the DAS. This classification involved a two-fold criterion: clinical “improvement” (as defined earlier) and movement out of the clinically dysfunctional range of marital adjustment. Tabulational analyses of DAS scores revealed that all couples in behavioral treatment improved “reliably” from pre- to posttesting. In addition, three couples in cognitive-behavioral treatment a n d two couples from the waiting list condition “reliably” improved. Two cognitive-behavioral and two waiting list couples remained unchanged during treatment, and one waiting list couple showed deterioration. A majority of couples in behavioral and cognitive-behavioral treatment demonstrated alleviation o f marital dysfunction. Following active intervention, most of the behavioral a n d cognitivebehavioral couples demonstrated maintenance of improvement (ix., “unchanged”). Over the entire course of treatment (pre-follow-up), behavioral couples either demonstrated clinically significant improvement or remained unchanged, whereas cognitive-behavioral couples showed only limited improvement and some evidence of deterioration.

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Consumer Satisfaction

Results from the CSQ revealed a mean satisfaction score of 28.10 for clients in behavioral treatment and a mean satisfaction score of 27.60 for cognitive-behavioral clients. Both scores were indicative of considerable satisfaction with the treatment program. No significant differences were found between these scores.

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DISCUSSION T h e results of the present investigation revealed that couples in BMT and CBMT exhibited statistical and clinical improvement. Specifically, during active intervention, both group approaches were effective in improving relationship satisfaction. Moreover, as compared to waiting list controls, couples in active treatment demonstrated greater improvement in overall functioning. Follow-up assessments further indicated that many of the treatment gains were maintained six-months later. This study sought to provide effective group treatment for couples experiencing relationship distress. T h e current results confirm the earlier findings of Wilson, Bornstein, and Wilson" and provide continued support for the efficacy of group marital modalities in the treatment of relationship dysfunction. As the first evaluation of an integrated cognitive-behavioral treatment for couples, it was found that the relative differences in effectiveness between the behavioral and cognitive-behavioral interventions were minimal. Statistical analyses revealed differences between the two therapy formats on only two dependent variables. BMT couples demonstrated greater improvements than CRMT couples on overall marital adjustment as measured by the DAS. However, results on the MHS revealed that cognitive-behavioral treatment produced greater marital happiness than did the behavioral intervention. Although both of these scales provide a global measure of relationship Satisfaction, the DAS contains more items pertaining directly to aspects of couples' communication (e.g., degree of dyadic consensus, level of affectional expression). It seems probable that the added emphasis on communication training in the behavioral condition may have promoted greater improvement on the DAS in that group. Couples in both active treatments tended to reveal greater improvement than did waiting list couples on the MICS-Negative scale. However, both treatment and control clients showed an increase in positive verbal behaviors as measured by the MICS from pre- to posttesting. These results are congruent with those found in other BMT studies, in which treatment-specific gains are seen for negative verbal behaviors but not for positive communication skill^.^'^^^ T h e clinical results demonstrate the superiority of the behavioral condition during active treatment, with 100% of the couples showing clinically significant improvement from pre- to posttesting. T h e majority of these couples also improved throughout the investigation, from pretest to follow-up. In contrast, the cognitive-behavioral group showed more

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modest improvements during treatment, although the majority of couples still revealed improvement. T h e finding that t w o couples from the waiting list condition demonstrated improvement is rather unusual when compared to previous marital research. However, these two couples were the least distressed dyads in the waiting list condition and may have benefited from the extensive assessment and feedback provided during the screening process. T h e results of the present study compare favorably with the clinical significance findings reported by Jacobson et aL5' in their reanalysis of BMT outcome studies using the KC Index. In fact, the improvement rate seen in this study's behavioral couples (i.e., 100%) exceeds the reanalysis results, and the present study's alleviation rates are similar to those reported in the reanalysis. Results also revealed that clients in all three experimental conditions showed a general pattern of improvement from pretreatment to posttreatment on individual functioning measures (i.e., IBT, BDI, and GSI). These gains were maintained at follow-up testing. I t is possible that the improvement seen in the waiting list group in individual functioning is d u e simply to the passage of time. However, it also appears likely that nonspecific treatment factors may be associated with such improvement. That is, although the waiting list group did not participate in formal treatment during the eight-week intervention period, they did receive potent treatment benefits (e.g., assured entrance into the treatment program, instillation of hope, increased positive expectations, face-to-face meetings with treatment staff) which are considered curative in most forms of psychotherapy.60*61Although nonspecific therapeutic factors have been shown by many studies to facilitate improvements in individual functioning, relationshi? satisfaction does not typically increase without active i n t e r v e n t i ~ n . ~ . ' T h e present results are consistent with those of Baucom and Lester'* and Baucom, Sayers, a n d Sher,22 who found behavioral and cognitivebehavioral treatments to be generally equal in effectiveness. T h e fact that the current study revealed no consistent differences between treatments may indicate that behaviorally oriented strategies alone are sufficient and that the addition of cognitive tactics is not necessary to strengthen their effectiveness. It is possible that the components common to both interventions, including behavioral exchange, communication skills training, and conflict resolution tactics, as well as group support and cohesiveness, were the most integral ingredients in therapeutic change. However, the relatively small sample size in the current investigation is a distinct limitation. It also seems reasonable that the cognitive-behavioral couples were presented with too many interventions in the treatment period, which, in turn, may have hindered their ability to learn and successfully employ the treatment strategies. Future investigations in this area should examine the effect of providing an extended cognitive-behavioral intervention package with additional therapy sessions. Another factor that may be contributing to the lack of differential effectiveness is that measures designed to assess cognitions are only in their early stages of development. Specifically, it has been noted that the

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RBI, this study’s primary cognitive measure, was not intended to provide comprehensive coverage of the entire gamut of unrealistic relationship beliefs.63 In addition, the current study was unable to rigorously assess the attributional style of couples due to the lack of appropriate measures. Cognitive intervention studies are clearly dependent upon appropriate cognitive assessment strategies in order to evaluate intervention-specific effects, and cognitive marital researchers are eager to address such limitations.64An additional concern has been raised by previous researchers in that random assignment does not take into consideration the specific issues relevant to each ~ o u p l e . ’ ~The , * ~results of ongoing research that matches treatment to specific client dysfunctions (e.g., behavioral deficits, cognitive excesses) by employing cross-over designs may yield differential improvement rates between behavioral and cognitive-behavioral tactics. A final limitation found in this study is its reliance on only one cotherapist team. While keeping therapists constant across groups reduces the possibility of differential therapist characteristics influencing the study’s outcome, it also introduces the risk of experimenter bias. Efforts were taken in an attempt to control for the possibility of experimenter bias, including the use of specific, detailed session outlines for each treatment and videotaping of all sessions for rating by independent observers on the degree to which therapists adhered to treatment protocols. Moreover, the manipulation check revealed compliance with treatment protocols. Further research contrasting cognitive and behavioral treatment approaches with distressed dyads is clearly needed. We encourage research that employs larger sample sizes and longer treatment phases (i.e., 12-16 sessions) in order to highlight potential treatment-specific effects. As a first step, the current investigation has examined the utility of an integrated cognitive-behavioral approach in a nontraditional format (i.e., group) with dysfunctional couples. REFERENCES 1. Stuart GB: Operant-interpersonal treatment of marital disc0rd.J Comiclf Clin Psychol

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