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Booster sessions : a strategy for maintaining change in an emotionally-focused marital therapy Elbe, Norma-Jean 1991

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BOOSTER SESS IONS: A STRATEGY FOR MAINTAINING CHANGE IN AN EMOTIONALLY-FOCUSED MARITAL THERAPY by NORMA-JEAN ELBE B . S c , UNIVERSITY OF CALGARY, 1985 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of C o u n s e l l i n g Psychology We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1991 (r\ Norma-Jean Elbe In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of ^o-^as.|(vJ^-o^ /"^yc-Lcjl The University of British Columbia Vancouver, Canada at Date LAS If m i DE-6 (2/88) ABSTRACT The p r i m a r y p u r p o s e o f t h i s f o l l o w - u p s t u d y was t o was i n v e s t i g a t e w h e t h e r c o u p l e s who had r e g r e s s e d a f t e r r e c e i v i n g an E m o t i o n a l l y F o c u s e d c o u p l e s t h e r a p y c o m b i n e d w i t h a c o m m u n i c a t i o n s k i l l s t r a i n i n g c o m p o n e n t ( E F T + C T ) w o u l d i n c r e a s e i n s c o r e s on m e a s u r e s o f m a r i t a l a d j u s t m e n t , c o m m u n i c a t i o n , a n d t a r g e t c o m p l a i n t i m p r o v e m e n t a f t e r r e c e i v i n g f o u r b o o s t e r s e s s i o n s i n c o m m u n i c a t i o n s k i l l s t r a i n i n g . The s e c o n d a r y p u r p o s e was t o i n v e s t i g a t e w h e t h e r r e c e i v i n g t h e b o o s t e r s e s s i o n s w o u l d e n h a n c e t h e m a i n t e n a n c e o f t h e E F T + C T c o u p l e s ' g a i n s . A c o m p a r a t i v e c r o s s o v e r c o n t r o l d e s i g n was u s e d t o t e s t t h e h y p o t h e s e s i n t h i s s t u d y . T e n v o l u n t e e r c o u p l e s f r o m t h e E F T + C T c o n d i t i o n i n J a m e s ' (1988) s t u d y were r a n d o m l y a s s i g n e d e i t h e r t o a f i r s t - b o o s t e r g r o u p ( F B ) , or a d e l a y e d b o o s t e r g r o u p ( D B ) . B o t h g r o u p s were m e a s u r e d a t p r e - t e s t a n d t h e n t h e b o o s t e r s e s s i o n s were a d m i n i s t e r e d t o t h e F B g r o u p w h i l e t h e DB g r o u p s e r v e d as a n u n t r e a t e d w a i t - l i s t c o n t r o l . B o t h g r o u p s were m e a s u r e d a g a i n a t p o s t - t e s t . N e x t , a t r e a t m e n t c r o s s o v e r o c c u r r e d a t w h i c h t i m e t h e b o o s t e r s e s s i o n s were a d m i n i s t e r e d t o t h e DB g r o u p a n d t h e F B g r o u p e n t e r e d a f o u r month f o l l o w -up p e r i o d . F i n a l m e a s u r e s were t a k e n f o r b o t h g r o u p s a t t h e end o f t h e f o l l o w - u p p e r i o d . The b o o s t e r s e s s i o n s were a d m i n i s t e r e d by f o u r t h e r a p i s t s who were r a n d o m l y a s s i g n e d t o c o u p l e s i n e a c h g r o u p . R a t i n g s o f t h e r a p i s t s ' i n t e r v e n t i o n s i l c o n f i r m e d t h e t r e a t m e n t i n t e g r i t y o f t h e CT b o o s t e r s e s s i o n s i n b o t h g r o u p s . T e s t s o f e q u i v a l e n c e showed no s i g n i f i c a n t d i f f e r e n c e s b e t w e e n t h e FB and DB g r o u p s a t p r e - t e s t on t h e m e a s u r e o f m a r i t a l a d j u s t m e n t . The r e s u l t s i n d i c a t e d t h a t t h e p r i m a r y h y p o t h e s i s was p a r t i a l l y s u p p o r t e d . A s t a t i s t i c a l l y s i g n i f i c a n t T ime m a i n e f f e c t was f o u n d on m e a s u r e s o f m a r i t a l a d j u s t m e n t and t a r g e t c o m p l a i n t i m p r o v e m e n t when t h e c o l l a p s e d p r e - t e s t a n d p o s t -t e s t s c o r e s f o r t h e FB and DB g r o u p s were c o m p a r e d . The r e s u l t s s u p p o r t e d t h e s e c o n d a r y h y p o t h e s i s . No s i g n i f i c a n t d i f f e r e n c e s were f o u n d on t h e d e p e n d e n t m e a s u r e s , f o r t h e F B g r o u p , b e t w e e n t h e b o o s t e r p o s t - t e s t a n d f o l l o w - u p o c c a s i o n s or b e t w e e n b o o s t e r p o s t - t e s t a n d E F T + C T p o s t - t e s t o c c a s i o n s . As a n e x p l o r a t o r y s t u d y , t h i s i n v e s t i g a t i o n p r o v i d e s p r o v i s i o n a l s u p p o r t f o r t h e e f f i c a c y o f b o o s t e r s e s s i o n s i n i n c r e a s i n g a n d m a i n t a i n i n g m o d e r a t e l y d i s t r e s s e d c o u p l e s ' t r e a t m e n t g a i n s f o l l o w i n g a n E m o t i o n a l l y F o c u s e d m a r i t a l t h e r a p y . i i i TABLE OF CONTENTS A b s t r a c t . i i T a b l e of Contents.. i v L i s t of T a b l e s . . . v i L i s t of F i g u r e s v i i CHAPTER I: INTRODUCTION 1 Background 1 The Problem 5 Purpose and Hypotheses 9 CHAPTER I I : REVIEW OF THE LITERATURE 11 Follow-up Research i n M a r i t a l Therapy 11 Follow-up S t u d i e s i n B e h a v i o r a l M a r i t a l Therapy 12 Follow-up S t u d i e s i n Non-Behavioral M a r i t a l Therapy ....15 Booster S e s s i o n s as a Maintenance S t r a t e g y 19 R a t i o n a l e Research on Booster S e s s i o n s A l c o h o l i s m A s s e r t i v e n e s s D e p r e s s i o n H y e r t e n s i o n Smoking Weight Loss M a r i t a l Therapy Fading as a Maintenance S t r a t e g y 28 Communication S k i l l s T r a i n i n g 31 Background 31 The Need f o r Communication S k i l l s T r a i n i n g . . 3 3 The C o m p a t i b i l i t y of EFT and RE ...35 i v 19 , 20 21 ,21 ,25 27 The E f f e c t i v e n e s s of RE 38 James' (1988:) CT Component 41 The CT Booster Component 45 Conceptual Hypothesis 47 CHAPTER I I I : METHODOLOGY 49 Method of James' (1988) Study 49 Design 49 S u b j e c t s 50 T h e r a p i s t s 51 T h e r a p i s t T r a i n i n g .....52 Research Measures 52 Implementation Check 53 Method of the Booster Study .53 Research Design 52 R a t i o n a l e of the Crossover Design ...55 S u b j e c t s 59 T h e r a p i s t s 60 Experimental Procedures 61 Research Measures 63 Dyadic Adjustment S c a l e 63 Communication S c a l e 64 Target Complaints 65 Post-treatment S t r u c t u r e d Interview 66 Implementation Check ...66 Data A n a l y s i s Procedures 68 P r e l i m i n a r y A n a l y s i s 68 Design C o n s i d e r a t i o n s i n the A n a l y s i s of Booster E f f e c t s 70 S t a t i s t i c a l Treatment of Data 73 Designs Used To Test the Research Hypotheses 74 CHAPTER IV: RESULTS 7B Implementation Check 78 T e s t s of Group E q u i v a l e n c e 79 R e s u l t s of P r e l i m i n a r y A n a l y s e s 80 Treatment E f f e c t s of Booster S e s s i o n s 92 v [ Hypothesis 1(a) 92 Hypothesis 1(b) 95 Hypothesis 1(c) 96 W a i t - l i s t E f f e c t s 99 Hypothesis 2 99 Maitenance E f f e c t s 99 Hypothesis 3 99 Hypothesis 4 100 E f f e c t S i z e s 101 Summary of Q u a n t i t a t i v e R e s u l t s 102 Q u a l i t a t i v e R e s u l t s 104 CHAPTER V: DISCUSSION AND CONCLUSIONS 109 Review of The Maintenance Problem 109 Regr e s s i o n i n Non-behavioral M a r i t a l Therapy 110 D i s c u s s i o n of the P r e l i m i n a r y Analyses 112 D i s c u s s i o n of Booster Treatment E f f e c t s 115 D i s c u s s i o n of W a i t - l i s t E f f e c t s 121 D i s c u s s i o n of Maintenance E f f e c t s 121 C o n c l u s i o n s 123 L i m i t a t i o n s 126 I m p l i c a t i o n s 130 Future Research 132 REFERENCES 138 APPENDICES 147 Appendix A: Demogragpic Data ....147 Appendix B: S t r u c t u r e d Interview 148 v i LIST OF TABLES TABLE 1 Repeated Measures Analysis of Variance of DAS Mean Scores Accross Four Occasions... 83 2 Student Newman-Keuls Analysis of DAS Mean Scores Across Four Occasions 83 3 Trend Analysis of DAS Mean Scores Across Four Occasions 83 4 Table of Means and Standard Deviations For Dependent Measures 84 5 Analyses of Variance for Each Dependent Variable for Hypothesis 1 (a) 85 6 Analyses of Variance for Each Dependent Variable for Hypothesis 1 (b) 86 7 Analyses of Variance for Each Dependent Variable for Hypothesis 1 (c) 88 8 Results of Paired t-Tests for Short-term Maintenance and Wait-List Effects 90 9 Results of Paired t-Tests for Hypothesis 4: Long-term Maintenance Effects 91 10 Ef f e c t Sizes for Dependent Measures 91 11 Results at Follow-up of EFT Outcome Studies: Mean Couple DAS scores 110 v i i LIST OF FIGURES FIGURE 1 Design of the Six C e l l Means Used to Test The Research Hypotheses 72 2 Mean Scores on the Dyadic Adjustment Scale...81 3 Mean Scores on the Communication Scale 81 4 Mean Scores on Target Complaints 82 v i i i CHAPTER I: INTRODUCTION BACKGROUND OF THE PROBLEM The r e s u l t s of r e s e a r c h on t h e r e l a t i o n s h i p between m a r i t a l s t a t u s and p e r s o n a l w e l l - b e i n g i n d i c a t e t h a t b e i n g m a r r i e d i s a s s o c i a t e d w i t h t h r e e f u n d a m e n t a l a s p e c t s of w e l l n e s s : p h y s i c a l h e a l t h and l o n g e v i t y , m e n t a l h e a l t h , and l i f e s a t i s f a c t i o n ( F e h r & P e r l m a n , 1985; S e g r a v e s , 1 9 8 2 ) . T h a t i s , m a r r i e d i n d i v i d u a l s t e n d t o r e m a i n h e a l t h i e r , l i v e l o n g e r , and e n j o y l i f e more t h a n t h e widowed, d i v o r c e d or n e v e r -m a r r i e d . L o w e n t h a l and Haven (1968) s u g g e s t t h a t h a v i n g c l o s e p e r s o n a l r e l a t i o n s h i p s h e l p s t o a l l e v i a t e t h e n e g a t i v e e f f e c t s of s t r e s s and promote h e a l t h y p e r s o n a l d e v e l o p m e n t t h r o u g h o u t t h e l i f e c y c l e . A c c o r d i n g t o Bowlby ( 1 9 6 9 ) , a t t a c h m e n t , or t h e e s t a b l i s h m e n t o f i n t i m a t e r e l a t i o n s h i p s , i s a b a s i c human need. T h i s n o t i o n i s a f f i r m e d by t h e u n i v e r s a l i t y of m a r r i a g e as a p r i m a r y human c o n t e x t f o r i n t i m a t e a d u l t r e l a t i o n s h i p s . I n t i m a c y has been d e f i n e d as t h e s h a r i n g of f e a r s or h u r t f e e l i n g s w i t h someone who c a n be t r u s t e d , u s u a l l y a mate ( L ' A b a t e , 1 9 7 7 ) . D e s p i t e t h e s i g n i f i c a n c e o£ a h e a l t h y m a r i t a l r e l a t i o n s h i p i n m e e t i n g a d u l t i n t i m a c y needs and e n h a n c i n g p e r s o n a l w e l l - b e i n g , a s a t i s f y i n g u n i o n i s d i f f i c u l t f o r many 1 c o u p l e s t o s u s t a i n . In Canada, a p p r o x i m a t e l y one m a r r i a g e i n t h r e e c u r r e n t l y ends i n d i v o r c e (Adams and Nagnur, 1989). A s a t i s f y i n g r e m a r r i a g e a l s o seems d i f f i c u l t f o r s p o u s e s t o s u s t a i n . The r e s u l t s o f a r e c e n t r e p o r t on m a r r y i n g and d i v o r c i n g b e h a v i o r i n d i c a t e t h a t a p p r o x i m a t e l y 13 p e r c e n t of t h e m a r r i a g e s of C a n a d i a n men and women who were d i v o r c e d a t t h e t i m e of m a r r i a g e a l s o end i n d i v o r c e (Adams and Nagnur, 1 9 8 9 ) . The t r a u m a t i c e f f e c t s o f d i v o r c e on c h i l d r e n and s p o u s e s have been w e l l documented and r e c e n t l o n g i t u d i n a l i n v e s t i g a t i o n s r e p o r t t h a t t h e s e e f f e c t s c a n p e r s i s t a d ecade l a t e r ( L a n d i s , 1960; L e s l i e , 1979; W a l l e r s t e i n , 1 9 88). T h e r e i s some e v i d e n c e t h a t b e i n g u n h a p p i l y m a r r i e d may have e v e n more damaging c o n s e q u e n c e s t h a n d i v o r c e . In a s t u d y o f t h e r e l a t i o n s h i p between h e a l t h and m a r i t a l e x p e r i e n c e , Renne (1971) f o u n d t h a t p e o p l e i n t r o u b l e d m a r r i a g e s were l e s s p h y s i c a l l y and p s y c h o l o g i c a l l y h e a l t h y t h a n t h o s e who were d i v o r c e d . C h r o n i c m a r i t a l d i s t r e s s has been a s s o c i a t e d w i t h symptoms of d y s f u n c t i o n i n one or b o t h s p o u s e s s u c h a s : a l c o h o l i s m , i l l n e s s , n e u r o t i c or p s y c h o t i c , b e h a v i o u r , o c c u p a t i o n a l p r o b l e m s , e x t r a m a r i t a l a f f a i r s , and d e p r e s s i o n (Le M a s t e r s , 1959; Coyne, 1 9 8 4 ) . M a r i t a l c o n f l i c t i s a l s o I m p l i c a t e d i n a d j u s t m e n t d i s o r d e r s o f c h i l d h o o d and a d o l e s c e n c e ( M i n u c h i n , Rosman & Baker 1978, ) and c o n d u c t d i s o r d e r s ( S h a p i r o & G a r f i n k e l , 1 9 86). A r e v i e w o f s t u d i e s c o r r e l a t i n g m a r i t a l s t a t u s w i t h w e l l - b e i n g r e p o r t s a n e g a t i v e 2 r e l a t i o n s h i p between m a r i t a l d i s t r e s s and p s y c h o l o g i c a l h e a l t h of spouses and t h e i r c h i l d r e n (Seagraves, 1982). The powerful impact of the m a r i t a l r e l a t i o n s h i p on the l i v e s of spouses and t h e i r c h i l d r e n underscores the need for e f f e c t i v e methods to a l l e v i a t e m a r i t a l d i s t r e s s and promote l a s t i n g m a r i t a l adjustment. The recent and r a p i d advancement of the f i e l d of m a r i t a l therapy suggests that t h i s need has been r e c o g n i z e d . To date, the overwhelming m a j o r i t y of r e s e a r c h on m a r i t a l therapy has i n v e s t i g a t e d r e l a t i o n a l d i f f i c u l t i e s w i t h i n the couple (Gurman, Kniskern & P i n s o f , 1986) . Research on the outcomes of m a r i t a l therapy has increased c o n s i d e r a b l y over the l a s t ten y e a r s . In t h e i r e x tensive review of t h i s l i t e r a t u r e , Gurman et a l . (1986) conclude that both b e h a v i o u r a l and non-behavioural approaches i n couples therapy are s i g n i f i c a n t l y more e f f e c t i v e than no treatment. Each of these approaches achieve p o s i t i v e gains at outcome about two-thirds of the time. The achievement of d e s i r e d changes a t outcome i s only one i n d i c a t i o n of t h e r a p e u t i c e f f e c t i v e n e s s , however. R e s u l t s of a 20-year l o n g i t u d i n a l follow-up i n v e s t i g a t i o n of psychotherapy p a t i e n t s suggest that p s y c h o t h e r a p e u t i c change i n v o l v e s two pr o c e s s e s : the process producing change and the process of m a i n t a i n i n g the achieved changes or treatment gains (Liberman, 1978). Jacobson and Holtzworth-Munroe (1986) support t h i s view i n t h e i r a s s e r t i o n t h a t " the u l t i m a t e goals of ( m a r i t a l ) 3 t h e r a p y i n v o l v e c h a n g e s i n t h e r e l a t i o n s h i p t h a t p e r s i s t i n d e p e n d e n t l y o f t h e t h e r a p i s t " (p. 3 6 ) . In a d d i t i o n t o e v a l u a t i n g m a r i t a l t h e r a p y a t outcome, p o s t - t r e a t m e n t f o l l o w -up s t u d i e s a r e needed t o d e t e r m i n e whether t r e a t m e n t e f f e c t s a r e s u s t a i n e d o v e r t i m e . To d a t e , f o l l o w - u p s t u d i e s a r e l a c k i n g i n r e s e a r c h on m a r i t a l t h e r a p y (Gurman e t a l . , 1 9 86). C l i n i c a l and e m p i r i c a l s t u d y o f t h e p r o c e s s of m a i n t a i n i n g change has been n e g l e c t e d d e s p i t e t h e o b s e r v a t i o n t h a t few s t u d i e s d e m o n s t r a t e d u r a b i l i t y o f t r e a t m e n t e f f e c t s . G o l d s t e i n , L o p e z and G r e e n l e a f (1979) r e v i e w e d 192 c o n t r o l l e d s t u d i e s o f v a r i o u s p s y c h o t h e r a p e u t i c t r e a t m e n t s r a n g i n g o v e r a v a r i e t y o f d i s o r d e r s and f o u n d t h a t 85% o f t h e s t u d i e s r e p o r t e d p o s i t i v e outcomes a t t e r m i n a t i o n but o n l y 14% r e p o r t e d m a i n t e n a n c e o f t r e a t m e n t e f f e c t s . The a u t h o r s d o u b t t h a t t h e a b s e n c e o f f o l l o w - u p e v a l u a t i o n i n many of t h e s e s t u d i e s c o u l d have r e s u l t e d i n an a r t i f i c i a l l y low r a t e of o b s e r v e d m a i n t e n a n c e e f f e c t s , c i t i n g o t h e r r e v i e w e r s who r e p o r t s i m i l a r c o n c l u s i o n s . F o r i n s t a n c e , K e e l e y , Shemberg, and C a r b o n e l l (1976) examined 146 c l i n i c a l i n v e s t i g a t i o n s o f b e h a v i o r t h e r a p y and f o u n d r e p o r t s o f m a i n t e n a n c e e f f e c t s i n o n l y 3% o f t h e s t u d i e s . O n l y e i g h t o f t h e s e s t u d i e s p r e s e n t e d d a t a c o l l e c t e d a t l e a s t s i x months a f t e r t e r m i n a t i o n o f t r e a t m e n t and s h o r t t e r m f o l l o w - u p d a t a were a l s o a b s e n t . In t h e i r r e v i e w o f t h e r e s e a r c h on t h e m a i n t e n a n c e of change i n p s y c h o t h e r a p y , Imber, P i l k o n i s , Harway, K l e i n , and R u b i n s k y (1982) c o n f i r m t h a t l i t t l e e v i d e n c e e x i s t s t h a t g a i n s a c h i e v e d 4 in psychotherapy persist over time in the absence of planned maintenance techniques. The two main conclusions of these extensive reviews are that: (1) the maintenance of therapeutic gain is "more the exception than the rule" (Goldstien et a l . , 1979).(p.4) and (2) the maintenance problem has not been serious l y addressed in the research on c l i n i c a l psychotherapy and behavior therapy (Keeley et a l . , 1976). Only recently have researchers attended to the problem of maintaining gains achieved in marital therapy (Jacobson, 1986). A small but growing base of follow-up research provides evidence of the maintenance problem in behavioral (Jacobson, F o l l e t t e , Revenstorf, Baucom, Hawleg & Margolin, 1984) and non-behavioural domains of marital therapy (Johnson & Greenberg, 1985; Goldman, 1978,; James, 1988). Gurman et a l . (1986) contend that p a r t i t i o n i n g the research into these domains "does r e f l e c t the r e a l i t y that there are two quite d i s t i n c t marital therapy l i t e r a t u r e s , the l i t e r a t u r e dealing with behavioral marital therapy (BMT) which contains dozens of outcome studies, and that dealing with a l l other "brands" of couples therapy (e.g., psychodynamic, st r a t e g i c , systemic), which i s almost a n u l l set" (p.582). THE PROBLEM Most marital therapy research has focused on improvement within or at the termination of treatment. Both behavioral and 5 n o n - b e h a v i o r a l s c h o o l s o f m a r i t a l t h e r a p y have d e m o n s t r a t e d e f f i c a c y i n p r o d u c i n g change a t outcome (Gurman e t a l . , 1986), however, t h e d u r a b i l i t y o f t r e a t m e n t g a i n s beyond t h e f o r m a l t r e a t m e n t p e r i o d r e m a i n s u n c l e a r . T h e r e i s an a p p a r e n t need f o r r e s e a r c h i n v e s t i g a t i n g t h e m a i n t e n a n c e o f t r e a t m e n t -i n d u c e d change o v e r t i m e . T h i s need i s p a r t i c u l a r l y e v i d e n t i n n o n - b e h a v i o r a l m a r i t a l t h e r a p y , t h e l e a s t s t u d i e d o f t h e two s c h o o l s . One o f t h e f i r s t i n v e s t i g a t i o n s o f a c o n t e m p o r a r y n o n - b e h a v i o r a l t h e r a p y named E m o t i o n a l l y F o c u s e d C o u p l e s T h e r a p y (EFT) ( G r e e n b e r g & J o h n s o n , 1986) was c o n d u c t e d by J o h n s o n and G r e e n b e r g ( 1 9 8 5 ) . In t h i s c o m p a r a t i v e e x p e r i m e n t , 45 c o u p l e s were r a n d o m l y a s s i g n e d t o e i t h e r o f two t r e a t m e n t c o n d i t i o n s or a w a i t - l i s t c o n t r o l c o n d i t i o n . The two t r e a t m e n t c o n d i t i o n s c o n s i s t e d o f e i g h t s e s s i o n s o f e i t h e r EFT or C o g n i t i v e - B e h a v i o r a l m a r i t a l t h e r a p y (CBMT). A t p o s t - t e s t , b o t h t r e a t m e n t g r o u p s showed s i g n i f i c a n t g a i n s o v e r u n t r e a t e d c o n t r o l s on measures o f g o a l a t t a i n m e n t , m a r i t a l a d j u s t m e n t , i n t i m a c y , and r e s o l v i n g t a r g e t c o m p l a i n t s . EFT s u r p a s s e d CBMT on m a r i t a l a d j u s t m e n t , i n t i m a c y , and r e s o l v i n g t a r g e t c o m p l a i n t s . A t e i g h t - w e e k f o l l o w - u p , EFT was s u p e r i o r t o CBMT on m a r i t a l a d j u s t m e n t o n l y , i n d i c a t i n g r e g r e s s i o n on measures o f i n t i m a c y and t a r g e t c o m p l a i n t s . In a r e c e n t s t u d y , James (1988) r a n d o m l y a s s i g n e d 42 c o u p l e s t o t h r e e g r o u p s : an e x p e r i e n t i a l - s y s t e m i c t r e a t m e n t c a l l e d E m o t i o n a l l y F o c u s e d T h e r a p y ( E F T ) , EFT p l u s a Co m m u n i c a t i o n S k i l l s T r a i n i n g component (EFT+CT) and a w a i t -6 l i s t c o n t r o l . The c o u p l e s i n t h e EFT c o n d i t i o n r e c e i v e d 12 one-hour s e s s i o n s o f EFT and t h e c o u p l e s i n t h e EFT+CT c o n d i t i o n r e c e i v e d e i g h t one-hour s e s s i o n s o f EFT and f o u r one-hour s e s s i o n s o f CT. Data were c o l l e c t e d a t p r e - t e s t , e i g h t weeks, p o s t - t e s t , and f o u r - m o n t h f o l l o w - u p on measures of m a r i t a l a d j u s t m e n t , c o m m u n i c a t i o n , i n t i m a c y , and r e s o l v i n g t a r g e t c o m p l a i n t s . The p r i m a r y p u r p o s e o f t h e i n v e s t i g a t i o n was t o t e s t whether t h e a d d i t i o n o f a c o m m u n i c a t i o n s k i l l s t r a i n i n g (CT) component would enhance t h e e f f e c t i v e n e s s o f EFT. In c o m p a r i s o n t o t h e c o n t r o l g r o u p , b o t h t r e a t m e n t g r o u p s showed s t a t i s t i c a l l y s i g n i f i c a n t g a i n s on t h e f o u r outcome measures a t p o s t - t e s t . However, r e g r e s s i o n o f t r e a t m e n t g a i n s was f o u n d i n b o t h t r e a t m e n t g r o u p s a t t h e f o u r - m o n t h f o l l o w - u p . R e s u l t s o f t h e s t r u c t u r e d i n t e r v i e w James (1988) c o n d u c t e d a f t e r c o u p l e s ' f i n a l t h e r a p y s e s s i o n s , r e v e a l e d t h a t t h e EFT+CT c o u p l e s would , have l i k e d more s e s s i o n s o f CT. C o u p l e s r e p o r t e d t h a t t h e y had n o t s u f f i c i e n t l y m a s t e r e d t h e s k i l l s t o f e e l c o n f i d e n t i n u s i n g them o u t s i d e o f t h e r a p y . The e m p i r i c a l f i n d i n g s o f d e t e r i o r a t i o n i n t h e EFT+CT t r e a t m e n t g r o u p , t o g e t h e r w i t h c l i e n t r e s p o n s e s f a v o u r i n g more c o m m u n i c a t i o n t r a i n i n g , r a i s e d t h e q u e s t i o n of whether a d d i t i o n a l CT s e s s i o n s would enhance t h e m a i n t e n a n c e o f t r e a t m e n t g a i n s . C l e a r l y , t h e f a i l u r e o f c o u p l e s t o m a i n t a i n g a i n s a c h i e v e d i n m a r i t a l t h e r a p y i s an i m p o r t a n t c l i n i c a l c o n c e r n 7 and an i s s u e d e s e r v i n g e m p i r i c a l s t u d y . T h i s s t u d y a d d r e s s e s t h e m a i n t e n a n c e p r o b l e m by i n v e s t i g a t i n g t h e e f f i c a c y of b o o s t e r s e s s i o n s as a s t r a t e g y f o r e n h a n c i n g t h e d u r a b i l i t y of t r e a t m e n t g a i n s i n a n o n - b e h a v i o r a l m a r i t a l t h e r a p y . B o o s t e r s e s s i o n s have been a d v o c a t e d as a p r o m i s i n g t e c h n i q u e f o r p r o m o t i n g m a i n t e n a n c e a f t e r b e h a v i o u r t h e r a p y (Whisman, 1990). B o o s t e r m a i n t e n a n c e s e s s i o n s a r e t y p i c a l l y d e s c r i b e d as b r i e f v e r s i o n s of t h e t r e a t m e n t a d m i n i s t e r e d a f t e r t e r m i n a t i o n o f t h e f o r m a l t r e a t m e n t p e r i o d . Most o f t h e l i t e r a t u r e s u p p o r t i n g t h e e f f e c t i v e n e s s o f b o o s t e r s e s s i o n s emanates from b e h a v i o r a l r e s e a r c h on t h e t r e a t m e n t o f a d d i c t i v e d i s o r d e r s s u c h as a l c o h o l i s m , o b e s i t y , and s m o k i n g . C o n t e m p o r a r y r e s e a r c h e r s have recommended t h e use o f b o o s t e r s e s s i o n s as a s t r a t e g y f o r e n h a n c i n g t h e m a i n t e n a n c e o f t r e a t m e n t g a i n s a c h i e v e d i n m a r i t a l t h e r a p y (Bogner & Z i e l e n b a c h - C o e n e n , 1984; J a c o b s o n & H o l t z w o r t h - M u n r o e , 1986; James, 1988), a l t h o u g h no s u c h i n v e s t i g a t i o n has been r e p o r t e d t o d a t e . As a f o l l o w - u p o f James' (1988) s t u d y , t h i s s t u d y i n v e s t i g a t e s t h e e f f e c t s o f f o u r CT b o o s t e r s e s s i o n s on measures o f m a r i t a l a d j u s t m e n t , c o m m u n i c a t i o n , and t a r g e t c o m p l a i n t improvement, f o r c o u p l e s who p r e v i o u s l y had r e c e i v e d t h e EFT+CT t r e a t m e n t . 8 P U R P O S E A N D H Y P O T H E S E S The primary purpose of the proposed study is to investigate whether booster sessions in communication s k i l l s t r a i n i n g (CT) are more ef f e c t i v e than no treatment in increasing regressed couples scores on measures of marital adjustment, and communication, and in resolving target complaints. The secondary purpose of the study i s to investigate whether couples receiving (CT) booster sessions maintain their gains on the dependent measures. The hypotheses under investigation in this-study are: Hl(a): Couples who are in the fir s t - b o o s t e r group, w i l l demonstrate s t a t i s t i c a l l y s i g n i f i c a n t l y higher scores at the booster post-test occasion on measures of marital adjustment (DAS), communication (CS), and s p e c i f i c problem resolution (TC) than w i l l w a i t i n g - l i s t couples in the delayed-booster group. Hl(b): Couples who are in the first-booster group w i l l demonstrate s t a t i s t i c a l l y s i g n i f i c a n t l y higher scores on the DAS, CS, and TC on the booster post-test and booster follow-up occasions than w i l l w a i t i n g - l i s t couples in the delayed-booster group. Hl(c ) : Couples in the first-booster and delayed-booster groups who receive booster sessions at d i f f e r e n t times w i l l demonstrate a s t a t i s t i c a l l y s i g n i f i c a n t increase in scores on 9 the DAS, CS, and TC between booster pre-test and post-test occas ions. H2: Couples who are in the delayed-booster group w i l l not increase in scores on the DAS, CS, and TC during the w a i t - l i s t per iod. H3: Couples who are in the fir s t - b o o s t e r group w i l l maintain scores on the DAS, CS, and TC between the booster post-test and follow-up occasions. H4: Couples in the first-booster group, who receive CT booster sessions after termination of EFT+CT w i l l not d i f f e r in scores on the DAS, CS, and TC at the booster post-test occasion and the post-test occasion in the James (1988) study. 10 CHAPTER I I : LITERATURE REVIEW In t h i s chapter, follow-up studies in behavioral and non-behavioral marital therapy are discussed with emphasis on the problem of maintaining treatment-induced change. Research on the use of booster sessions and fading as strategies for maintaining treatment gains is also presented. The chapter ends with a description of the theory and contents of the CT booster treatment administered in this study. F O L L O W - U P R E S E A R C H I N M A R I T A L T H E R A P Y Over the la s t decade there has been a marked increase in outcome research in the f i e l d of marital therapy. From their extensive reviews of th i s research, Gurman et a l . , (1986) and Gurman and Kniskern (1981) conclude that both non-behavioural and behavioural schools of marital therapy are s i g n i f i c a n t l y more e f f e c t i v e than no treatment with improvement reported in about two-thirds of the t r i a l s . Whereas the e f f i c a c y of marital therapy in producing change at outcome is empirically validated, the related guestion of whether the achieved changes pe r s i s t over time remains unanswered. Adequate systematic longitudinal research has not been conducted to answer this question. To date, most studies have focused on improvement at outcome and even short-term follow-up studies are r a r e l y undertaken. E m p i r i c a l n e g l e c t o f f o l l o w - u p r e s e a r c h may owe t o v a r i o u s p r o b l e m s o f d e s i g n and d a t a i n t e r p r e t a t i o n . S h o r t - t e r m f o l l o w - u p s may have poor v a l i d i t y . A v e r y b r i e f f o l l o w - u p can d e m o n s t r a t e t r e a t m e n t e f f e c t s t h a t d i s a p p e a r o v e r l o n g e r p e r i o d s o f t i m e w h i l e more moderate d u r a t i o n s c a n undermine t h e d e t e c t i o n o f t r e a t m e n t e f f e c t s t h a t emerge i n t h e l o n g e r t e r m (Gurman e t a l . , 1986 e t . a l 1 9 8 6 ) . L o n g - t e r m f o l l o w - u p s a r e d i f f i c u l t t o c o n d u c t due t o c o n f o u n d s from sample a t t r i t i o n and t h e I n c r e a s e d number of i n t e r v e n i n g v a r i a b l e s t h a t compete w i t h t r e a t m e n t e f f e c t s o v e r t i m e . R e s e a r c h e r s r e c o g n i z e t h a t t h e f i n d i n g s o b t a i n e d i n f o l l o w - u p o f p s y c h o t h e r a p y s t u d i e s a r e i n f l u e n c e d by t h e t i m i n g o f t h e f o l l o w - u p . Lebow (1981) s t a t e s t h a t " outcome i s b e s t e v a l u a t e d a t more t h a n one p o i n t i n t i m e " ( p . 1 8 0 ) . Follov-up Studies in Behavioral Marital Therapy The b u l k o f outcome r e s e a r c h i n m a r i t a l t h e r a p y emanates f r o m t h e b e h a v i o u r a l m a r i t a l t h e r a p y s c h o o l (BMT). In t h i s r e s e a r c h , t h e l o s s o f t r e a t m e n t g a i n s a f t e r t r e a t m e n t t e r m i n a t i o n p r e s e n t s a s i g n i f i c a n t c o n c e r n . I n a r e a n a l y s i s o f d a t a t a k e n f r o m f o u r p r e v i o u s s t u d i e s , J a c o b s o n , F o l l e t t e , R e v e n s t o r f , Baucom, Hawleg, and M a r g o l i n (1984) u s e d a r e l i a b l e change i n d e x ( b a s e d on t h e s t a n d a r d e r r o r o f measurement) t o c l a s s i f y 148 t r e a t e d c o u p l e s i n t o c a t e g o r i e s o f i m p r o v e d , u n i m p r o v e d , and d e t e r i o r a t e d . R e s u l t s b a s e d on t h i s c r i t e r i a f o r a s s e s s i n g c l i n i c a l l y s i g n i f i c a n t change showed t h a t 54.7% o f t h e c o u p l e s i m p roved s i g n i f i c a n t l y a t outcome. At t h e s i x - m o n t h f o l l o w - u p a b o u t 72% o f t h e improved c o u p l e s had m a i n t a i n e d t h e i r t r e a t m e n t g a i n s whereas 28%, ( n e a r l y o n e - t h i r d ) showed d e t e r i o r a t i o n . S i m i l a r r e l a p s e r a t e s were fo u n d a t t h e o n e - y e a r and two-y e a r f o l l o w - u p s o f a s t u d y c o m p a r i n g t h e e f f e c t i v e n e s s o f a c o m p l e t e BMT t r e a t m e n t p a ckage (CO) w i t h i t s major components; b e h a v i o u r exchange t r a i n i n g (BE) and c o m m u n i c a t i o n / p r o b l e m -s o l v i n g t r a i n i n g (CPT) ( J a c o b s o n & F o l l e t t e , 1 9 8 5 ) . In t h i s s t u d y , no d i f f e r e n t i a l t r e a t m e n t e f f e c t s were fo u n d a t p o s t -t e s t , a l t h o u g h t h e r e s u l t s s u p p o r t e d t h e h y p o t h e s i s t h a t t h e CO c o n d i t i o n would p r o d u c e b e t t e r l o n g - t e r m outcomes t h a n e i t h e r o f t h e components a l o n e . In t h e i r o n e - y e a r f o l l o w - u p o f J a c o b s o n e t . a l . ( 1 9 8 5 ) , J a c o b s o n , F o l l e t t e , F o l l e t t e , H o l t z w o r t h - M u n r o e , K a t t , and S c h m a l l i n g , (1985) u s e d p r e v i o u s l y d e s c r i b e d c r i t e r i a t o a s s e s s c l i n i c a l l y s i g n i f i c a n t change i n t h e 43 o r i g i n a l l y t r e a t e d c o u p l e s . The r e s u l t s were t h a t a p p r o x i m a t e l y 30% o f t h e c o u p l e s i n e a c h o f t h e t h r e e t r e a t m e n t c o n d i t i o n s showed s i g n i f i c a n t d e t e r i o r a t i o n between s i x months and one y e a r . I n t h e t w o - y e a r f o l l o w - u p s t u d y , J a c o b s o n , S c h m a l i n g , and H o l t z w o r t h - M u n r o e (1987) c l a s s i f i e d t h e r e m a i n i n g 34 o f t h e o r i g i n a l 43 c o u p l e s on a s c a l e r a n g i n g from " i m p r o v e d " t o " r e l a p s e d " . The r e l a p s e d r a t i n g r e f e r r e d t o c o u p l e s who had been c l a s s i f i e d as " h a p p i l y - m a r r i e d " a t e i t h e r p o s t - t e s t , s i x -month, o r o n e - y e a r f o l l o w - u p , b u t whose DAS s c o r e s a t t wo-year 13 f o l l o w - u p were s i g n i f i c a n t l y d e t e r i o r a t e d and below 97. The r e s u l t s a t two y e a r s showed t h a t 30% o f t h e 34 CO c o u p l e s had r e l a p s e d . A s s u m i n g t h a t a t t r i t i o n i n t h e o r i g i n a l sample o f 43 had e l i m i n a t e d t h e most d i s t r e s s e d c o u p l e s ( l e a v i n g t h e most improved among t h e r e m a i n i n g 3 4 ) , t h e a c t u a l r e l a p s e r a t e c o u l d be even h i g h e r . T hese r e l a p s e r a t e s s u g g e s t t h a t t r e a t m e n t g a i n s f o r many c o u p l e s r e c e i v i n g BMT a r e t e m p o r a r y . W i t h r e s p e c t t o e s t i m a t e s o f t r e a t m e n t s u c c e s s , J a c o b s o n e t a l . (1984) a s s e r t t h a t " t h e a b s e n c e o f c o n v e n t i o n s f o r d e s i g n a t i n g a c o u p l e as i m p roved has l e d t o an i n f l a t e d e s t i m a t e o f (BMT) s u c c e s s r a t e s . I t i s a l m o s t i n e v i t a b l e t h a t t h e same i s t r u e o f o t h e r a p p r o a c h e s " (p.503) i n m a r i t a l t h e r a p y . I t f o l l o w s t h a t , i f s u c c e s s r a t e s i n m a r i t a l t h e r a p y a r e p r o n e t o o v e r e s t i m a t i o n b e c a u s e o f i l l - d e f i n e d c r i t e r i a , t h e n i t i s a l s o l i k e l y t h a t d e t e r i o r a t i o n or r e l a p s e r a t e s have been u n d e r e s t i m a t e d f o r s i m i l a r r e a s o n s . Even a t t h e c u r r e n t l y r e p o r t e d r a t e s , r e l a p s e i s a bona f i d e c o n c e r n t o r e s e a r c h e r s , c l i n i c i a n s and c l i e n t s i n v o l v e d i n m a r i t a l t h e r a p y . A t t h e t w o - y e a r f o l l o w - u p , J a c o b s o n e t a l . (1987) a l s o compared " m a i n t a i n e r s " and " r e l a p s e r s " r e s p o n s e s t o a s t r u c t u r e d i n t e r v i e w . The a u t h o r s f o u n d t h a t r e l a p s e seemed u n r e l a t e d t o f a c t o r s a s s o c i a t e d w i t h BMT b u t r a t h e r had more t o do w i t h n e g a t i v e l i f e e v e n t s t h a t had o c c u r r e d a f t e r t h e t e r m i n a t i o n o f t h e r a p y . One I n t e r p r e t a t i o n o f t h i s f i n d i n g i s t h a t t h e r a p y g r a d u a l l y t e n d s t o l o s e i t s i m p a c t on m a r i t a l 14 r e l a t i o n s h i p s as n e g a t i v e e v e n t s i n t e r v e n e . A n o t h e r f i n d i n g from t h e s t r u c t u r e d i n t e r v i e w was t h a t 20% o f t h e c o u p l e s s p o n t a n e o u s l y s u g g e s t e d b o o s t e r s e s s i o n s as a way t o m a i n t a i n c h a n g e s i n t h e i r r e l a t i o n s h i p s . Some 90% r e s p o n d e d p o s i t i v e l y when t h e i n t e r v i e w e r q u e s t i o n e d them as t o t h e p o t e n t i a l u s e f u l n e s s b o o s t e r s e s s i o n s . S e v e r a l o t h e r a u t h o r s s u p p o r t t h e n o t i o n t h a t i n t e r v e n i n g l i f e e v e n t s i n e v i t a b l y a t t e n u a t e t h e i m p a c t o f b r i e f t h e r a p y programs and undermine t h e m a i n t e n a n c e o f a c h i e v e d t r e a t m e n t g a i n s . J a c o b s o n e t a l . (1987) s u g g e s t an a l t e r n a t e way o f o r g a n i z i n g m a r i t a l t h e r a p y p r o g r a m s , namely t h a t , f o l l o w i n g t h e i n i t i a l t r e a t m e n t p e r i o d , " f o l l o w - u p and b o o s t e r s e s s i o n s a r e o f f e r e d as an e x p e c t e d and r e g u l a r p a r t o f t h e m a r i t a l t h e r a p y c o n t r a c t " ( p . 1 9 4 ) . F o l l o w - u p S t u d i e s i n N o n - b e h a v i o r a l M a r i t a l T h e r a p y F o l l o w - u p s t u d i e s , and f o r t h a t m a t t e r c o n t r o l l e d s t u d i e s i n g e n e r a l , a r e r a r e i n t h e n o n - b e h a v i o u r a l m a r i t a l t h e r a p y l i t e r a t u r e (Gurman e t a l . , 1 9 8 6 ) . F o u r o f t h e f o l l o w i n g s t u d i e s p r o v i d e e v i d e n c e o f p o s t - t r e a t m e n t r e g r e s s i o n o f g a i n s a c h i e v e d In n o n - b e h a v i o r a l m a r i t a l t h e r a p y . C o n t r a r y t o t h e s e f i n d i n g s , t h e f i f t h s t u d y p r o v i d e s e v i d e n c e o f m a i n t e n a n c e one y e a r a f t e r t r e a t m e n t . In t h e f i r s t s t u d y , d e s c r i b e d e a r l i e r i n t h i s p a p e r , J o h n s o n and G r e e n b e r g (1985) compared 45 c o u p l e s who were r a n d o m l y a s s i g n e d t o e i t h e r o f two t r e a t m e n t c o n d i t i o n s or t o 15 a w a i t - l i s t c o n t r o l c o n d i t i o n . The two t r e a t m e n t s were a c o g n i t i v e - b e h a v i o u r a l m a r i t a l t h e r a p y (CBMT) and E m o t i o n a l l y F o c u s e d T h e r a p y ( E F T ) . A f t e r e i g h t w e e k l y t r e a t m e n t s e s s i o n s b o t h t r e a t m e n t g r o u p s made s i g n i f i c a n t g a i n s o v e r t h e c o n t r o l g r o u p on measures o f m a r i t a l a d j u s t m e n t , i n t i m a c y , g o a l a t t a i n m e n t , and t a r g e t c o m p l a i n t r e d u c t i o n . EFT was s u p e r i o r t o CMBT a t p o s t - t r e a t m e n t on a l l measures e x c e p t g o a l a t t a i n m e n t . By t h e e i g h t week f o l l o w - u p EFT had m a i n t a i n e d s u p e r i o r i t y o v e r CBMT on m a r i t a l a d j u s t m e n t o n l y , h a v i n g r e g r e s s e d on t h e o t h e r m e a s u r e s . P o s t - t r e a t m e n t r e g r e s s i o n was e v i d e n t i n b o t h t r e a t m e n t g r o u p s a t t h e f o l l o w - u p . No f u r t h e r d a t a were a v a i l a b l e t o d e t e r m i n e t h e p e r s i s t e n c e o f change beyond t h e e i g h t weeks. In a p a r t i a l r e p l i c a t i o n o f t h e J o h n s o n and G r e e n b e r g (1985) s t u d y , Goldman (1987) compared EFT w i t h an I n t e g r a t e d S y s t e m i c ( I S ) a p p r o a c h t o m a r i t a l t h e r a p y and a w a i t - l i s t c o n t r o l . B o t h t r e a t m e n t g r o u p s showed s i g n i f i c a n t g a i n s a t p o s t - t e s t o v e r t h e c o n t r o l g r o u p on measures of m a r i t a l a d j u s t m e n t , c o n f l i c t r e s o l u t i o n , g o a l a t t a i n m e n t , and t a r g e t c o m p l a i n t r e d u c t i o n . T h e r e were no d i f f e r e n t i a l outcome e f f e c t s between t r e a t m e n t g r o u p s a t p o s t - t e s t . At t h e f o u r -month f o l l o w - u p , t h e IS g r o u p had m a i n t a i n e d t r e a t m e n t g a i n s whereas t h e EFT g r o u p had e x p e r i e n c e d s i g n i f i c a n t d e t e r i o r a t i o n on a l l measures e x c e p t c o n f l i c t r e s o l u t i o n . Remple (1987) c o n d u c t e d a o n e - y e a r f o l l o w - u p of Goldman's (1987) s t u d y and f o u n d t h a t t h e EFT g r o u p had improved t o 16 post-treatment levels between four months and one year, and that the IS group had maintained their treatment gains. No s i g n i f i c a n t differences were found between the EFT and IS groups at one year. Remple attributed the increase in EFT scores over time to a "sleeper e f f e c t " operating as a function of the treatment. These results oppose those reported in other studies of EFT and c a l l for further research on the long-term treatment e f f e c t s . James (1988) reported the familiar pattern of post-treatment regression of treatment gains in a later comparative outcome study. In t h i s experiment, 42 moderately distressed couples were randomly assigned to one of two treatment groups or to a control condition. Couples in the Emotionally Focused Couples Therapy (EFT) group received 12 one-hour sessions; couples in the EFT plus Communication S k i l l s Training (CT) group received eight sessions of EFT and four sessions of CT. The dependent measures were; the Dyadic Adjustment Scale (DAS), the Psychosocial Intimacy Questionnaire (PIQ), the Passionate Love Scale (PLS), the Communication Scale (CS), and Target Complaints (TC). The results at post-test showed both the EFT and EFT+CT treatments to be superior to the control condition on measures of marital adjustment (DAS), and target complaints (TC). Only the EFT+CT group achieved s i g n i f i c a n t l y higher post-test scores than the control group on the measure of communication (CS) . 17 No d i f f e r e n t i a l treatment effects were found between the groups at post-test. By the four month follow-up, both the EFT and EFT+CT groups had regressed. In p a r t i c u l a r , the EFT+CT group had regressed more than the EFT group which is perplexing because CT component was hypothesized to enhance the effects of the EFT and expected to serve a maintenance function. Results of a structured interview of the couples administered after treatment indicated that couples would have liked a few additional CT sessions because they thought they had not s u f f i c i e n t l y mastered the s k i l l s to use them with confidence. James suggested that CT booster sessions could be useful in promoting the maintenance of gains achieved in marital therapy. Replicating Remple's (1987) study, Hansen (1990) conducted a one year follow-up of nine couples from James' (1988) EFT treatment group. Outcome was assessed on measures of marital adjustment (DAS), communication (CS), intimacy (PIQ) , and target complaints (TC). Results indicated no s i g n i f i c a n t differences in couples' mean scores between four-month follow-up and one year follow-up on any of the measures. Trend analysis revealed a s i g n i f i c a n t cubic trend in the data which was interpreted to r e f l e c t a decline in post-treatment regression (from four-months to one year) as couples' mean scores s t a b i l i z e d . While i t appears that the regression of scores had slowed, one year later couples had not regained 18 t h e i r p o s t - t r e a t m e n t g a i n s b u t r e m a i n e d a t t h e same d i m i n i s h e d l e v e l r e p o r t e d a t t h e f o u r - m o n t h f o l l o w - u p . I n s u p p o r t o f t h i s o b s e r v a t i o n , r e s u l t s o f t h e Neuman-Keuls p a i r w i s e c o m p a r i s o n s showed a s i g n i f i c a n t d e c r e a s e i n s c o r e s between p o s t - t e s t and f o u r - m o n t h s , and p o s t - t e s t and one y e a r on t h e DAS, CS, and TC. I t seems t h a t , f r o m p o s t - t e s t t o o n e - y e a r c o u p l e s had e x p e r i e n c e d a marked l o s s i n t h e i r t r e a t m e n t g a i n s . B O O S T E R S E S S I O N S A N D T H E M A I N T E N A N C E O F C H A N G E R a t i o n a l e A d v o c a t e d i n b e h a v i o u r t h e r a p y r e s e a r c h f o r o v e r two d e c a d e s , b o o s t e r s e s s i o n s a r e t h e most commonly s t u d i e d m a i n t e n a n c e t e c h n i q u e . B o o s t e r s e s s i o n s have been d e s c r i b e d a s b r i e f v e r s i o n s of th e t r e a t m e n t s e s s i o n s d e s i g n e d t o p r o v i d e a d d i t i o n a l s u p p o r t b u t n o t i n t r o d u c e new t r e a t m e n t t e c h n i q u e s ( H a l l & H a l l , 1 9 8 0 ) . In o t h e r words, t h e y a r e a l i m i t e d e x t e n s i o n o f r o u t i n e t h e r a p y p r o c e d u r e s s p a c e d o v e r l o n g e r i n t e r v a l s t h a n t h e i n t e n s i v e t r e a t m e n t p e r i o d i t s e l f . The s e s s i o n s a r e t y p i c a l l y a d m i n i s t e r e d i n t h e f o l l o w - u p phase a f t e r t r e a t m e n t t e r m i n a t i o n . The r a t i o n a l e f o r b o o s t e r s e s s i o n s i s b a s e d on t h e n o t i o n t h a t e x t e n d e d c o n t a c t w i t h t h e t h e r a p i s t w i l l enhance t h e m a i n t e n a n c e o f t r e a t m e n t g a i n s ( E y s e n c k , 1 9 6 3 ) . M a i n t e n a n c e i s d e f i n e d a s t h e c o n t i n u a t i o n o f c h a n g e s i n s t i g a t e d i n t h e r a p y beyond t h e f o r m a l t e r m i n a t i o n o f t r e a t m e n t ( K a r o l y & S t e f f e n , 1 9 8 0 ) . G o l d s t e i n e t a l . (1979) have i d e n t i f i e d m a i n t e n a n c e e n h a n c i n g e v e n t s as t h o s e w h i c h i n c r e a s e t h e r e a l - 1 i f e n e s s of t h e t r e a t m e n t c o n t e x t , maximize r e s p o n s e a v a i l a b i l i t y , and maximize s t i m u l u s v a r i a b i l i t y . More s i m p l y p u t , a b e h a v i o u r l e a r n e d i n t r e a t m e n t i s s a i d t o have been m a i n t a i n e d when i t i s r e a d i l y a v a i l a b l e t o t h e c l i e n t f o r use i n h i s d a i l y l i f e w i t h h i s s i g n i f i c a n t o t h e r s . In t h i s s t u d y m a i n t e n a n c e o f t r e a t m e n t g a i n s i s s a i d t o be a c h i e v e d when c o u p l e s mean s c o r e s a t t h e p o s t - t r e a t m e n t a s s e s s m e n t a r e n o t s i g n i f i c a n t l y d i f f e r e n t f r o m t h e i r mean s c o r e s a t s u b s e q u e n t f o l l o w - u p a s s e s s m e n t s . R e s e a r c h on B o o s t e r S e s s i o n s In a r e c e n t r e v i e w o f t h e e f f i c a c y o f b o o s t e r s e s s i o n s , Whlsman (1990) i d e n t i f i e d 30 c l i n i c a l t r i a l s i n t h e l i t e r a t u r e o f t h e p a s t 18 y e a r s i n w h i c h b o o s t e r s e s s i o n s were employed w i t h a r a n g e o f t a r g e t b e h a v i o u r s . I n t h e 26 s t u d i e s w h i c h e v a l u a t e d a d d i n g b o o s t e r m a i n t e n a n c e s e s s i o n s t o s t a n d a r d t r e a t m e n t s , t h e s e s s i o n s " s i g n i f i c a n t l y enhance b e h a v i o u r change i n 15 (58%) o f t h e s t u d i e s " (Whisman, 1990, p.165) and augmented change i n s e v e r a l o t h e r s . The f o l l o w i n g i s a r e v i e w by s u b j e c t o f t h e r e l e v a n t s t u d i e s o f t h e e f f i c a c y of b o o s t e r m a i n t e n a n c e s e s s i o n s . 20 An early study of aversion therapy with chronic al c o h o l i c s ( Vogler, Lunde, Johnson, & Martin, 1970), compared subjects assigned to either a conditioning-only group, a booster group, or to a control group. Shocks were administered to both treatment groups with the booster group receiving extra aversion sessions. The booster group was superior to the conditioning-only group and the control group in the median number of days to relapse. Although no difference was reported between the two treatment groups in the proportion of relapses, there were less relapses in both these groups compared to the control group. A major problem of this study was that subjects from the conditioning only group were also requested to attend booster sessions to offset drop-outs from the booster group. As a r e s u l t , the booster group may have consisted of individuals who were highly motivated for treatment while the conditioning group contained those who did not return for their boosters. Of the eight scheduled booster sessions, the median number kept was three. Assert iveness: The effects of booster sessions in maintaining treatment gains for subjects who participated in a six-week group assertiveness t r a i n i n g program were recently investigated (Ridel, Fenwich, & J i l l i n g s , 1986). Booster sessions consisting of role-playing, instruction and review, cognitive 21 r e s t r u c t u r i n g , p r o b l e m s o l v i n g , and encouragement were h e l d once per month from two t o s i x months p o s t - t r e a t m e n t . The b o o s t e r s u b j e c t s e x h i b i t e d s u p e r i o r m a i n t e n a n c e of t r e a t m e n t g a i n s on measures o f d e p r e s s i o n but were n o t s i g n i f i c a n t l y d i f f e r e n t from t h e n o - b o o s t e r g r o u p on measures o f a s s e r t i v e n e s s and a n x i e t y . D e p r e s s i o n : B aker and W i l s o n (1985) examined t h e e f f e c t s of group b o o s t e r s e s s i o n s i n m a i n t a i n i n g t r e a t m e n t g a i n s i n c l i n i c a l l y d e p r e s s e d i n d i v i d u a l s who had r e c e i v e d c o g n i t i v e - b e h a v i o r a l t h e r a p y . S u b j e c t s were r a n d o m l y a s s i g n e d t o one o f t h r e e g r o u p s a f t e r t r e a t m e n t ; c o g n i t i v e - b e h a v i o r a l b o o s t e r , non-s p e c i f i c or no b o o s t e r . B o o s t e r s e s s i o n s f o r t h e two b o o s t e r g r o u p s were h e l d a t two weeks, and t h e n once m o n t h l y f o r t h r e e months p o s t - t r e a t m e n t . A l t h o u g h t h e r e s u l t s a t p o s t - t e s t , and f o u r and f i v e month f o l l o w - u p d i d n o t show b o o s t e r s t o be s i g n i f i c a n t l y b e t t e r i n p r e v e n t i n g r e l a p s e , t h e r e was a t r e n d s u p p o r t i n g m a i n t e n a n c e o f improvement f o r s u b j e c t s i n b o t h b o o s t e r g r o u p s . To e x p l a i n t h e n o n - s i g n i f i c a n t f i n d i n g s , t h e a u t h o r s n o t e t h a t " i t i s p o s s i b l e t h a t t o o few s u b j e c t s r e s p o n d e d s u f f i c i e n t l y w e l l In t h e f i r s t p l a c e t o d e m o n s t r a t e a n y e f f e c t s o f b o o s t e r s e s s i o n s on r e l a p s e " ( p . 3 4 1 ) . T h a t i s , t h e d e g r e e t o w h i c h b o o s t e r s e s s i o n s a r e e f f e c t i v e i s c o n t i n g e n t t o an e x t e n t upon i n i t i a l t r e a t m e n t s u c c e s s . 22 H y p e r t e n s i o n : B o o s t e r s e s s i o n s have a l s o been used as a s t r a t e g y f o r m a i n t a i n i n g t r e a t m e n t g a i n s f o l l o w i n g t r e a t m e n t f o r h y p e r t e n s i o n . A g r a s , S c h n e i d e r , and T a y l o r (1984) found b o o s t e r s e s s i o n s t o be as e f f e c t i v e as u n d e r g o i n g t h e f u l l t r e a t m e n t p r o gram i n s u b j e c t s who had r e l a p s e d f o l l o w i n g r e l a x a t i o n t r a i n i n g . S u b j e c t s who had r e l a p s e d a f t e r u n d e r g o i n g e i g h t weeks o f r e l a x a t i o n t r a i n i n g were r a n d o m l y a s s i g n e d t o a b o o s t e r f o l l o w - u p g r o u p or a g r o u p r e c e i v i n g a n o t h e r 10 s e s s i o n s o f t h e o r i g i n a l t r e a t m e n t . The b o o s t e r s e s s i o n s were c o n d u c t e d b i m o n t h l y i n a s m a l l group f o r m a t i n v o l v i n g p r o b l e m s o l v i n g and s u p e r v i s e d r e l a x a t i o n p r a c t i c e . No s i g n i f i c a n t d i f f e r e n c e s were f o u n d between the g r o u p s a t t h e s i x month f o l l o w - u p a t w h i c h t i m e b o t h g r o u p s showed a d r o p i n b l o o d p r e s s u r e . Smoking: T h e r e a r e numerous r e p o r t s o f s t u d i e s u s i n g b o o s t e r s e s s i o n s t o promote t h e m a i n t e n a n c e o f s moking c e s s a t i o n . In one o f t h e f i r s t s t u d i e s , R e l i n g e r , B o r n s t e i n , Bugge, Carmody, and Zohn, (1977) r a n d o m l y a s s i g n e d s u b j e c t s who had r e c e i v e d n i c o t i n e a v e r s i o n t r a i n i n g t o one o f t h r e e m a i n t e n a n c e g r o u p s ; b o o s t e r a v e r s i o n g r o u p , t e l e p h o n e b o o s t e r g r o u p , and no-b o o s t e r c o n t r o l g r o u p . The r e s u l t s a t one week, and a t one, two, and t h r e e months p o s t - t r e a t m e n t showed no s i g n i f i c a n t d i f f e r e n c e s between g r o u p s i n t h e mean number o f c i g a r e t t e s smoked p e r d a y . I n d i v i d u a l g r o u p a n a l y s i s showed, i n f a c t , t h a t s u b j e c t s i n t h e b o o s t e r g r o u p s r e l a p s e d s i g n i f i c a n t l y more f r o m t h r e e months t o f o l l o w - u p t h a n t h e c o n t r o l s u b j e c t s . The a u t h o r s r e p o r t e d t h a t d i f f e r e n c e s i n t h e r a t i o n a l e g i v e n t o s u b j e c t s p a r t i c i p a t i n g i n . t h e b o o s t e r and c o n t r o l c o n d i t i o n s c o u l d have c o n f o u n d e d t h e r e s u l t s . B o o s t e r s u b j e c t s were g i v e n a r a t i o n a l e t h a t may have l e d them t o a t t r i b u t e t h e i r i n i t i a l t r e a t m e n t g a i n s e x t e r n a l l y " you p e r f o r m b e s t when g i v e n p e r i o d i c a i d and s u p e r v i s i o n " . I n c o n t r a s t , t h e c o n t r o l s u b j e c t s were t o l d t h a t t h e y were " i n d e p e n d e n t i n d i v i d u a l s who work b e s t on t h e i r own". The i n t e r n a l a t t r i b u t i o n s o f t h e c o n t r o l s u b j e c t s may have e n g e n d e r e d g r e a t e r e x p e c t a t i o n s and c o n f i d e n c e , and t h e r e f o r e enhanced m a i n t e n a n c e of t r e a t m e n t g a i n s w h i l e t h e e x t e r n a l a t t r i b u t i o n s of t h e b o o s t e r g r o u p may have promoted r e l a p s e . Some e v i d e n c e has been f o u n d t h a t b o o s t e r s e s s i o n s h e l p t o m a i n t a i n s m o k i n g a b s t i n e n c e . F o l l o w i n g g r o u p t h e r a p y , s u b j e c t s who had s t o p p e d s moking were r a n d o m l y a s s i g n e d e i t h e r t o a n o - b o o s t e r c o n t r o l g r o u p or one o f two b o o s t e r c o n d i t i o n s ( B r a n d o n , Zelman & B a k e r , 1987). The b o o s t e r s e s s i o n s , h e l d a t two, f o u r , e i g h t , and 12 weeks p o s t - t e s t p r o v i d e d e x p o s u r e and c o p i n g - r e s p o n s e t r a i n i n g : one g r o u p was g i v e n r a p i d s m o k i n g t r i a l s a s w e l l . Smoking c o n s u m p t i o n was measured m o n t h l y f o r a t h e f i r s t f o u r months and b i m o n t h l y t h e r e a f t e r t o one y e a r p o s t - t r e a t m e n t . S t a t i s t i c a l d i f f e r e n c e s were f o u n d between t h e b o o s t e r and c o n t r o l g r o u p s o n l y a t t h e t h r e e and f o u r month p e r i o d s a l t h o u g h t h e d a t a shows t h a t t h e b o o s t e r g r o u p s d i d 24 b e t t e r than the c o n t r o l group at every follow-up. Neither booster c o n d i t i o n was s u p e r i o r to the other. P o s i t i v e r e s u l t s have a l s o been r e p o r t e d by Lando (1977) who randomly assigned s u b j e c t s to r e c e i v e e i t h e r a one week a v e r s i o n therapy or a v e r s i o n therapy plus seven booster maintenance s e s s i o n s . The booster s e s s i o n s i n v o l v e d m u l t i p l e components i n c l u d i n g c o n t r a c t s , a v e r s i o n b o o s t e r s , and s t r u c t u r e d group support. The s i x month follow-up r e s u l t s showed t h a t , i n comparing the groups, more of the booster s u b j e c t s were a b s t i n e n t . A l a t e r study by Lando (1982) supported previous f i n d i n g s t hat a multi-component booster program enhanced maintenance on measures of smoking consumption a f t e r a v e r s i o n therapy. Weight Loss: S t u a r t (1967) s u c c e s s f u l l y pioneered the use of booster s e s s i o n s i n m a i n t a i n i n g weight l o s s e s of 12 to 41 pounds one year a f t e r s u b j e c t s had r e c e i v e d f i v e weeks of treatment. K i n g s l e y and Wilson (1977) administered booster s e s s i o n s as a means of m a i n t a i n i n g weight l o s s i n women who had r e c e i v e d one of three treatments. A f t e r treatment the women were randomly assigned e i t h e r to a booster group, held at two, f i v e , nine, and 14 weeks post-treatment, or a no-booster group. R e s u l t s at three and s i x month follow-up showed s i g n i f i c a n t maintenance of weight l o s s i n the booster group. By the nine and 12 month follow-ups there was no d i f f e r e n c e between the booster and no-booster groups i n weight r e d u c t i o n . H a l l , H a l l , B o r d e n and Hanson (1975) f o u n d t h a t p o s t -t r e a t m e n t b o o s t e r s e s s i o n s c o n d u c t e d by t h e i n i t i a l t h e r a p i s t f a c i l i t a t e d t h e m a i n t e n a n c e o f w e i g h t l o s s . In an e x t e n s i o n of t h e e a r l i e r s t u d y by H a l l e t a l . ( 1 9 7 5 ) , H a l l , B a s s , and Monroe (1977) a s s i g n e d s u b j e c t s t o t h r e e f o l l o w - u p c o n d i t i o n s a f t e r 10 weeks o f s e l f - m a n a g e m e n t t h e r a p y : m i n i m a l c o n t a c t , m o n i t o r i n g w i t h m i n i m a l c o n t a c t , and b i - m o n t h l y g r o u p c o n t a c t . At two and s i x months p o s t - t r e a t m e n t , t h e c o n t i n u e d c o n t a c t s u b j e c t s had l o s t s i g n i f i c a n t l y more w e i g h t t h a n t h e m i n i m a l c o n t a c t or m o n i t o r i n g - o n l y s u b j e c t s . The b o o s t e r t r e a t m e n t s were t e r m i n a t e d a t s i x months p o s t - t r e a t m e n t , and by t h e one y e a r f o l l o w - u p t h e b o o s t e r g r o u p had r e l a p s e d and t h e r e were no d i f f e r e n c e s between t h e g r o u p s . These s t u d i e s i n d i c a t e t h a t b o o s t e r s may f a c i l i t a t e m a i n t e n a n c e o n l y f o r t h e p e r i o d of t h e i r d u r a t i o n . An a l t e r n a t e m a i n t e n a n c e f o r m a t was examined by P e r r i , S h a p i r o , L u d w l g , Twentyman, and McAdoo ( 1 9 8 4 ) . In t h i s s t u d y , r a n d o m l y a s s i g n e d s u b j e c t s who had c o m p l e t e d t h e r a p y ( e i t h e r n o n - b e h a v i o r a l t h e r a p y , b e h a v i o u r t h e r a p y , or b e h a v i o u r t h e r a p y p l u s r e l a p s e p r e v e n t i o n ) were r e a s s i g n e d t o one o f two m a i n t e n a n c e c o n d i t i o n s : s i x months t h e r a p i s t c o n t a c t by m a i l and phone or no c o n t a c t . The r e s u l t s i n d i c a t e d g r e a t e r m a i n t e n a n c e o f w e i g h t l o s s f o r t h e g r o u p r e c e i v i n g t h e r a p i s t c o n t a c t when t h e i n i t i a l t r e a t m e n t had been n o n - b e h a v i o r a l t h e r a p y or b e h a v i o u r t h e r a p y p l u s r e l a p s e p r e v e n t i o n . F u r t h e r m o r e , s u b j e c t s r e c e i v i n g t h e r a p i s t c o n t a c t b o o s t e r s r e p o r t e d g r e a t e r use o f s t r a t e g i e s l e a r n e d i n t r e a t m e n t t h a n t h o s e who had no c o n t a c t . These r e s u l t s s u g g e s t t h a t e x t e n d e d t h e r a p i s t c o n t a c t may augment a d h e r e n c e t o t r e a t m e n t t e c h n i q u e s . The p r e c e d i n g r e s e a r c h p r o v i d e s some e v i d e n c e t h a t b o o s t e r s e s s i o n s do augment m a i n t e n a n c e f o l l o w i n g b e h a v i o u r and n o n - b e h a v i o u r t h e r a p y w i t h a r a n g e o f c l i n i c a l c o n c e r n s . E v e n l e s s i s known a b o u t how b o o s t e r s e s s i o n s enhance t h e d u r a b i l i t y of c h a n ge, however, a few a s s u m p t i o n s have been made. H a l l and H a l l (1980) s u g g e s t t h a t b o o s t e r s e s s i o n s s e r v e t o g r a d u a l l y d e c r e a s e d e p e n d e n c y on t r e a t m e n t c o n t a c t s and s h i f t a t t r i b u t i o n o f change from t h e t h e r a p i s t t o t h e c l i e n t . A c c o r d i n g t o Whisman (1990) t h e m a i n t e n a n c e f u n c t i o n of b o o s t e r s may o p e r a t e t h r o u g h t h r e e mechanisms. F i r s t , a n t i c i p a t i n g r e c e i v i n g b o o s t e r s e s s i o n s m i g h t r e d u c e c l i e n t a n x i e t y a t t e r m i n a t i o n a b o u t n o t b e i n g a b l e t o s u s t a i n g a i n s made i n t r e a t m e n t and promote p o s i t i v e e x p e c t a t i o n s t h a t change w i l l be m a i n t a i n e d . S e cond, t h e e x p e c t a t i o n o f f u t u r e t h e r a p i s t c o n t a c t c o u l d prompt c l i e n t s t o c o n t i n u e t o p r a c t i c e and implement t h e s k i l l s a c q u i r e d i n t h e r a p y . T h i r d , b o o s t e r s e s s i o n s may s e r v e t o c o n s o l i d a t e s k i l l s a c q u i r e d i n t h e r a p y t h e r e b y i n c r e a s i n g c l i e n t s ' m a s t e r y i n a p p l y i n g t h e s k i l l s i n d e p e n d e n t l y i n d a i l y l i f e . M a r i t a l T h e r a p y : B o o s t e r s e s s i o n s have been s u g g e s t e d as a m a i n t e n a n c e s t r a t e g y f o l l o w i n g b e h a v i o r a l m a r i t a l t h e r a p y , however, no 27 s u c h s t u d y c o u l d be f o u n d i n t h e l i t e r a t u r e . J a c o b s o n e t . a l . (1987) p r o p o s e t o c o n d u c t a p i l o t s t u d y o f an e x t e n d e d v e r s i o n o f BMT where an i n i t i a l phase o f w e e k l y t h e r a p y s e s s i o n s a r e f o l l o w e d by a s e c o n d phase i n w h i c h b o o s t e r s e s s i o n s a r e o f f e r e d . S i m i l a r l y , t h i s s t u d y may w e l l i n s t i g a t e f u r t h e r r e s e a r c h on t h e e f f i c a c y o f b o o s t e r s e s s i o n s i n m a i n t a i n i n g c o u p l e s ' g a i n s f o l l o w i n g n o n - b e h a v i o r a l m a r i t a l t h e r a p y . F A D I N G A S A M A I N T E N A N C E S T R A T E G Y The g o a l o f most t h e r a p y programs i s t h a t t h e t r e a t m e n t c o n t i n g e n c i e s ( r e i n f o r c e r s ) be e v e n t u a l l y w i t h d r a w n w h i l e t h e t r e a t m e n t g a i n s c o n t i n u e t o p e r s i s t . A common s t r a t e g y used i n b e h a v i o u r t h e r a p y t o promote t h e c o n t i n u a t i o n o f improvement, i s t h e g r a d u a l f a d i n g o u t or w i t h d r a w a l o f t r e a t m e n t c o n t i n g e n c i e s s o t h a t n a t u r a l l y o c c u r r i n g r e i n f o r c e m e n t and t h e o b s e r v a t i o n o f models t a k e o v e r t h e t a s k o f m a i n t a i n i n g b e h a v i o u r . S e v e r a l i n v e s t i g a t o r s s u p p o r t f a d i n g o f t h e t h e r a p i s t ' s i n f l u e n c e a s an i m p o r t a n t f a c t o r i n m a i n t a i n i n g t h e r a p e u t i c c h a n g e . J a c o b s o n e t a l . (1986) s t a t e t h a t : S i n c e t h e u l t i m a t e g o a l s o f [ m a r i t a l ] t h e r a p y i n v o l v e c h a n g e s i n t h e r e l a t i o n s h i p t h a t p e r s i s t i n d e p e n d e n t l y of t h e t h e r a p i s t , i t i s i m p o r t a n t t h a t h i s or her i n f l u e n c e 28 b e g i n t o s u b s i d e once t h e s k i l l s have been a c q u i r e d . The i n f l u e n c e o f t h e t h e r a p i s t must f a d e , c o u p l e s must assume i n c r e a s i n g r e s p o n s i b i l i t y f o r managing t h e i r own a f f a i r s , and t h e t h e r a p y s e s s i o n i t s e l f must g r a d u a l l y c e a s e t o be t h e f o c u s o f a l l i m p o r t a n t r e l a t i o n s h i p i s s u e s , (p.36) Bogner and Z i e l e n b a c h - C o e n e n (1984) i n v e s t i g a t e d t h e e f f e c t s o f t h e s y s t e m a t i c i n c l u s i o n o f a f a d i n g p r o c e d u r e i n a b e h a v i o r a l m a r i t a l t h e r a p y p rogram. The s t u d y was b a s e d on t h e n o t i o n t h a t c h a n g i n g t h e t h e r a p y s c h e d u l e would enhance th e s t a b i l i t y o f t r e a t m e n t g a i n s and b o o s t c o u p l e s ' competence i n c o p i n g w i t h t h e i r own p r o b l e m s a f t e r t h e r a p y . T w e n t y - f o u r c o u p l e s were r a n d o m l y a s s i g n e d t o two e x p e r i m e n t a l g r o u p s : one r e c e i v i n g c o n j o i n t r e c i p r o c i t y t r a i n i n g (RT) w i t h o u t f a d i n g , and one r e c e i v i n g t h e r e c i p r o c i t y t r a i n i n g w i t h f a d i n g ( R T F ) , and a w a i t i n g - l i s t c o n t r o l g r o u p . The a u t h o r s used a f a d i n g p r o c e d u r e i n w h i c h s e s s i o n s were s p a c e d a t one, two, and t h r e e weeks a p a r t r e s p e c t i v e l y . Outcome was a s s e s s e d on measures o f q u a r r e l l i n g , e x p r e s s i o n o f t e n d e r n e s s , c o m m u n i c a t i o n , g e n e r a l h a p p i n e s s , and number o f p r o b l e m s . The r e s u l t s showed t h e f a d e d g r o u p t o be s i g n i f i c a n t l y s u p e r i o r t o t h e o t h e r g r o u p s a t p o s t - t e s t on a l l m easures e x c e p t c o m m u n i c a t i o n . No s i g n i f i c a n t d i f f e r e n c e s were f o u n d between t h e t r e a t m e n t g r o u p s a t two and e i g h t month f o l l o w - u p s . I n s p e c t i o n o f g r o u p means, however, showed t h e s u p e r i o r i t y o f t h e f a d e d g r o u p on a l l v a r i a b l e s a f t e r t h e r a p y and a t b o t h f o l l o w - u p s . The a u t h o r s a t t r i b u t e t h e non-s i g n i f i c a n t f i n d i n g s t o t h e s m a l l numbers o f c o u p l e s i n b o t h e x p e r i m e n t a l g r o u p s . T h i s e x p l a n a t i o n was s u p p o r t e d by f u r t h e r a n a l y s i s u s i n g i n d i v i d u a l , r a t h e r t h a n c o u p l e , s c o r e s w h i c h r e v e a l e d t h e f a d e d g r o u p t o be s i g n i f i c a n t l y more e f f e c t i v e on a l l v a r i a b l e s a c r o s s a l l o c c a s i o n s . A c c o r d i n g t o K a z d i n and W i l s o n ( 1 9 7 8 ) , t h e d u r a b i l i t y o f change c a n be enha n c e d by t h e a d d i t i o n o f s p e c i f i c i n t e r v e n t i o n s t r a t e g i e s t o t h e b a s i c t r e a t m e n t a p p r o a c h . B e c a use f a d i n g shows p r o m i s e as a s t r a t e g y f o r e n h a n c i n g t h e m a i n t e n a n c e o f t r e a t m e n t g a i n s , a f a d i n g p r o c e d u r e was employed i n t h e s c h e d u l i n g o f b o o s t e r s e s s i o n s i n t h i s s t u d y . F a d i n g i s e x p e c t e d t o augment t h e m a i n t e n a n c e o f t r e a t m e n t g a i n s l a r g e l y t h r o u g h t h e same t h r e e mechanisms t h a t Whisman ( 1 9 9 0 ) , h y p o t h e s i z e d t o o p e r a t e i n t h e b o o s t e r s t r a t e g y ; r e d u c i n g t e r m i n a t i o n a n x i e t y , m o t i v a t i n g p r a c t i c e , and c o n s o l i d a t i n g s k i l l s . F o l l o w i n g Bogner and Z i e l e n b a c h - C o e n e n ( 1 9 8 4 ) , t h e f o u r b o o s t e r s e s s i o n s i n t h i s s t u d y were s p a c e d a t one, two, and t h r e e weeks a p a r t . W i t h t h i s f a d i n g p r o c e d u r e , t h e l e n g t h of t i m e between s e s s i o n s g r a d u a l l y l e n g t h e n s b e f o r e t e r m i n a t i o n t o p r o v i d e a maximum o f a t home p r a c t i c e t o h e l p s p o u s e s i n c o r p o r a t e t h e s k i l l s i n t o t h e i r e v e r y d a y l i f e and ea s e t h e a n x i e t y o f e n d i n g t h e r a p y . I n t h i s s t u d y , f a d i n g i s o p e r a t i o n a l l z e d i n t h e g r a d u a l w i t h d r a w a l o f b o t h t h e t h e r a p i s t i n f l u e n c e and t h e b o o s t e r s e s s i o n s t h e m s e l v e s . F o r i n s t a n c e , a s t h e f o u r b o o s t e r s e s s i o n s p r o g r e s s , t h e t h e r a p i s t s ' d i d a c t i c r o l e i s r e d u c e d ; g r a d u a l l y g i v i n g way t o a l e s s d i r e c t i v e f a c i l i t a t i n g / e n c o u r a g i n g r o l e . T h i s a l l o w s i n c r e a s i n g t i m e d u r i n g t h e s e s s i o n s f o r b e h a v i o u r a l r e h e a r s a l o f t h e c o m m u n i c a t i o n s k i l l s . A l s o , f a d i n g t h e b o o s t e r s e s s i o n s p r o v i d e s c o u p l e s w i t h i n c r e a s i n g t i m e between t h e s e s s i o n s f o r home p r a c t i c e , d u r i n g w h i c h t h e y a p p l y t h e s k i l l s t o i s s u e s a r i s i n g i n t h e i r r e l a t i o n s h i p . C O M M U N I C A T I O N S K I L L S T R A I N I N G B a c k g r o u n d C o u p l e s c o m m u n i c a t i o n s k i l l s t r a i n i n g p r o g r a m s , l i k e m a r i t a l t h e r a p y i n g e n e r a l , c a n be c a t e g o r i z e d a c c o r d i n g t o t h e i r t h e o r e t i c a l o r i g i n s . The two major s c h o o l s o f c o m m u n i c a t i o n s t r a i n i n g a r e ; b e h a v i o r a l m a r i t a l t h e r a p y (BMT) w h i c h e m p h a s i z e s s o c i a l l e a r n i n g mechanisms, and t h e non-b e h a v i o r a l p e r s p e c t i v e w h i c h t a k e s a p s y c h o e d u c a t i o n a l a p p r o a c h . The BMT c o m m u n i c a t i o n t r a i n i n g programs a r e by f a r t h e more w i d e l y s t u d i e d o f t h e two a p p r o a c h e s , due t o t h e e m p i r i c a l t r a d i t i o n s o f b e h a v i o r a l r e s e a r c h . BMT o r i g i n a t e d w i t h t h e a p p l i c a t i o n o f s o c i a l l e a r n i n g ( B a n d u r a , 1977) and b e h a v i o u r exchange p r i n c i p l e s t o t h e t r e a t m e n t o f m a r i t a l p r o b l e m s . The S o c i a l L e a r n i n g C o g n i t i v e model ( J a c o b s o n , & H o l t z w o r t h - M u n r o e , 1986) (SLC) has e v o l v e d f r o m c l a s s i c a l BMT 31 w h i c h e m p h a s i z e d t h e p r i m a c y o f t h e s o c i a l e n v i r o n m e n t and c o g n i t i v e - p e r c e p t u a l p r o c e s s e s i n d e t e r m i n i n g human b e h a v i o u r . SLC has b r o a d e n e d t h e t h e o r y t o a c c o u n t f o r t h e r o l e o f e m o t i o n and c o g n i t i v e p r o c e s s e s s u c h as a t t r i b u t i o n i n m a r i t a l d i s t r e s s . In t h e l a r g e , however, m a r i t a l p r o b l e m s a r e a t t r i b u t e d t o s p e c i f i c b e h a v i o r a l s k i l l d e f i c i t s w hich u n d e r l i e r e c i p r o c a l n e g a t i v e o r p u n i s h i n g b e h a v i o u r e x c h a n g e s between s p o u s e s . The g o a l o f t r e a t m e n t i s t h e r e m e d i a t i o n o f t h e s e b e h a v i o r a l d e f i c i t s t h r o u g h t h e t e a c h i n g o f s p e c i f i c s k i l l s p a r t i c u l a r l y i n t h e a r e a o f c o m m u n i c a t i o n , p r o b l e m -s o l v i n g and p o s i t i v e b e h a v i o u r e x c h a n g e . B e h a v i o u r change and s k i l l t r a i n i n g i n r e m a i n t h e h a l l m a r k s o f t h e SLC a p p r o a c h t o m a r i t a l t h e r a p y ( J a c o b s o n e t a l . , 1 9 8 6 ) . N o n - b e h a v i o r a l c o u p l e s c o m m u n i c a t i o n s k i l l s t r a i n i n g p r o g r a m s , s u c h as R e l a t i o n s h i p Enhancement (RE) (Guerney, 1 977), have emerged from t h e p s y c h o e d u c a t i o n a l or p s y c h o l o g i c a l s k i l l s t r a i n i n g t h e r a p e u t i c framework, a r e c e n t l y p r o p o s e d a l t e r n a t i v e t o t h e r e m e d i a l model o f b e h a v i o u r t h e r a p y . The p s y c h o e d u c a t i o n a l model " e m p h a s i z e s t h e t e a c h i n g o f i n t e r p e r s o n a l a t t i t u d e s and s k i l l s w h i c h t h e i n d i v i d u a l a p p l i e s t o s o l v e p r e s e n t and f u t u r e p s y c h o l o g i c a l p r o b l e m s and t o enhance h i s s a t i s f a c t i o n w i t h l i f e " ( G uerney, S t o l l a k & Guerney, 1971, p . 2 2 7 ) . The model r e a l i z e s t h e p r i m a r y g o a l s o f p r e v e n t i o n and p e r s o n a l d e v e l o p m e n t t h r o u g h a r a n g e o f s y s t e m a t i c programs ( r e p r e s e n t i n g v a r i o u s t h e o r e t i c a l o r i e n t a t i o n s ) d e s i g n e d t o t e a c h c l i e n t s t h e s k i l l s t h e y need t o manage t h e i r l i v e s more e f f e c t i v e l y . I t i s i m p o r t a n t t o n o t e t h a t s u c h programs were o r i g i n a l l y aimed a t c o u p l e s whose i n t e r a c t i o n s were b a s i c a l l y sound b u t who s o u g h t t o " e n r i c h " t h e i r r e l a t i o n s h i p . R e s e a r c h has now shown t h a t m a r i t a l e n r i c h m e n t programs a r e a l s o s u c c e s s f u l w i t h c o u p l e s e x p e r i e n c i n g g r e a t e r m a r i t a l d i s t r e s s ( G i b l i n , S p r e n k l e , & Sheehan, 1 9 8 5 ) . The Need f o r C o u p l e s C o m m u n i c a t i o n S k i l l s T r a i n i n g B e h a v i o r a l r e s e a r c h s u p p o r t s t h e need f o r c o m m u n i c a t i o n s k i l l t r a i n i n g i n m a r i t a l t h e r a p y . D i s t r e s s e d c o u p l e s e x h i b i t a number o f c o m m u n i c a t i o n s k i l l d e f i c i t s . These c o u p l e s exchange h i g h e r f r e q u e n c i e s o f p u n i s h e r s and l o w e r f r e q u e n c i e s of r e w a r d s t h a n h a p p i l y m a r r i e d c o u p l e s and a r e more r e c i p r o c a l i n t h e i r e x c h a n g e s o f n e g a t i v e b e h a v i o u r (Gottman, 1 9 7 9 ) . D i s t r e s s e d c o u p l e s a l s o t e n d t o r e a c t more i n t e n s e l y t o immediate e v e n t s , whether p o s i t i v e or n e g a t i v e , t h a n t h e i r n o n - d i s t r e s s e d c o u n t e r p a r t s . In o t h e r words i n d i s t r e s s e d r e l a t i o n s h i p s , when one p a r t n e r i s n e g a t i v e , t h e o t h e r i s more l i k e l y t o r e c i p r o c a t e i n k i n d , s e t t i n g up an e s c a l a t i n g c y c l e o f p u n i t i v e i n t e r a c t i o n s . A n a l y s e s b a s e d on s p o u s e r e p o r t s o f b e h a v i o u r i n t h e home show t h a t c o m m u n i c a t i o n p r o b l e m s a r e b e t t e r p r e d i c t o r s o f d a i l y m a r i t a l s a t i s f a c t i o n t h a n c o m p l a i n t s i n o t h e r a r e a s ( J a c o b s o n and Moore, 1 9 8 1 ) . M o r e o v e r , t h e r e i s e v i d e n c e t h a t d y s f u n c t i o n a l c o m m u n i c a t i o n p a t t e r n s b o t h p r e c e d e and p r e d i c t m a r i t a l d i s t r e s s (Markman, 1979). The i m p l i c a t i o n of the r e s e a r c h on m a r i t a l d i s t r e s s and communication i s t h a t both s p o u s a l d i s s a t i s f a c t i o n w i t h communication and s p o u s a l d e f i c i e n c y i n communication s k i l l appear t o be d i r e c t l y r e l a t e d t o the o v e r a l l h e a l t h of a r e l a t i o n s h i p (Jacobson e t a l . , 1986). The need t o d e v e l o p communication s k i l l s t r a i n i n g programs f o r c o u p l e s has been d r i v e n by the growing r e c o g n i t i o n by c l i n i c i a n s and r e s e a r c h e r s of the r o l e of communication i n r e l a t i o n s h i p s a t i s f a c t i o n . S e v e r a l s t u d i e s demonstrate t h a t t e c h n i q u e s t h a t i n c r e a s e c o u p l e ' s communication s k i l l s a r e the most e f f e c t i v e component of any form of m a r i t a l t h e r a p y (Jacobson e t a l . 1987, Jacobson and M a r g o l i n , 1979, Gurman and K n i s k e r n , 1981). G i v e n the e x i s t i n g s u p p o r t f o r communication s k i l l s t r a i n i n g i n f a c i l i t a t i n g m a r i t a l t h e r a p y outcome i t i s not s u r p r i s i n g t h a t i t i s "perhaps the one t h e r a p e u t i c t e c h n i q u e found u n i v e r s a l l y i n m a r i t a l t h e r a p i e s , r e g a r d l e s s of t h e o r e t i c a l o r i e n t a t i o n " ( Jacobson e t a l . , 1986). The p r i m a r y purpose of the James (1988) s t u d y d e s c r i b e d e a r l i e r was t o " t e s t , whether or not the a d d i t i o n of a communication s k i l l s t r a i n i n g (CT) component would enhance the e f f e c t i v e n e s s of EFT." In s e l e c t i n g from the range of e x i s t i n g communication s k i l l t r a i n i n g packages f o r one t o form a b a s i s f o r h i s CT component, James (1988) sought an e m p i r i c a l l y proven 34 program t h a t would be c l i n i c a l l y c o m p a t i b l e w i t h t h e non-b e h a v i o r a l EFT. The C o m p a t i b i l i t y o f E m o t i o n a l l y F o c u s e d T h e r a p y and t h e R e l a t i o n s h i p Enhancement P r o g r a m E m o t i o n a l l y f o c u s e d t h e r a p y i s an e x p e r i e n t i a l - s y s t e m i c a p p r o a c h t o c o u p l e s t h e r a p y d e v e l o p e d by G r e e n b e r g and J o h n s o n ( 1 9 8 6 ) . The t h e o r y combines t h e e x p e r i e n t i a l t r a d i t i o n s of p s y c h o t h e r a p y , w h i c h e m p h a s i z e s t h e r o l e o f a f f e c t and i n t r a p s y c h i c e x p e r i e n c e i n change, ( P e r l s , H e f f e r l i n e , & Goodman, 1951; R o g e r s , 1951) w i t h s y s t e m i c p e r s p e c t i v e s , which e m p h a s i z e e c o l o g i c a l c o n t e x t and t h e r o l e o f c o m m u n i c a t i o n and i n t e r a c t i o n a l c y c l e s i n m a i n t a i n i n g d y s f u n c t i o n a l r e l a t i o n s . I n d e v e l o p i n g E FT, G r e e n b e r g and J o h n s o n (1986) a l s o a c k n o w l e d g e c r e d i t t o V i r g i n i a S a t i r ' s (1967) a f f e c t i v e -s y s t e m i c a p p r o a c h t o f a m i l y t h e r a p y . S a t i r (1967) e m p h a s i z e s t h e i m p o r t a n c e o f t h e e m o t i o n a l s y s t e m o f t h e f a m i l y and t h r o u g h t h e r a p y p r o m o t e s t h e c o n g r u e n t c o m m u n i c a t i o n o f f e e l i n g s and needs by a l l f a m i l y members. The r o l e o f t h e EFT t h e r a p i s t i s t o b r i n g i n t r a - p s y c h i c e x p e r i e n c e i n t o p r e s e n t a w a r e n e s s and d e t e r m i n e how t h e s e e x p e r i e n c e s impact t h e m a r i t a l r e l a t i o n s h i p . The g o a l of EFT i s have b o t h p a r t n e r s , i n t h e s u p p o r t i v e p r e s e n c e o f e a c h o t h e r , a c c e s s and e x p r e s s p r e v i o u s l y u n a c k n o w l e d g e d f e e l i n g s and needs u n d e r l y i n g t h e i r n e g a t i v e i n t e r a c t i o n c y c l e . I n o t h e r words, EFT f a c i l i t a t e s p a r t n e r s u n d e r s t a n d i n g of how p a s t e x p e r i e n c e s a r e b r o u g h t i n t o t h e r e l a t i o n s h i p and how t h e y a f f e c t i n t e r a c t i o n . T h r o u g h m u t u a l s h a r i n g o f i n t i m a t e t h o u g h t s and f e e l i n g s , p a r t n e r s a r e a b l e t o u n d e r s t a n d e a c h o t h e r ' s b e h a v i o u r i n new ways t h a t f r e e them from p r e v i o u s n e g a t i v e c y c l e s , e n a b l i n g them t o be more s u p p o r t i v e of one a n o t h e r . T h i s c a n l e a d t o p o s i t i v e c h a n g e s i n t h e way t h e p a r t n e r s p e r c e i v e t h e m s e l v e s and e a c h o t h e r as w e l l as i n t h e i r c o m m u n i c a t i o n w i t h e a c h o t h e r . I n EFT, c o m m u n i c a t i o n p r o b l e m s a r e c o n s i d e r e d t o be t h e r e s u l t o f m o t i v a t i o n a l p r o b l e m s . C o u p l e s a r e n o t s e e n t o l a c k c o m m u n i c a t i o n s k i l l s p e r s e , but t o be b l o c k e d i n t h e i r a b i l i t y t o communicate by n e g a t i v e i n t e r a c t i o n c y c l e s . A c c o r d i n g t o G r e e n b e r g and J o h n s o n ( 1 9 8 6 ) , new a f f e c t i v e e x p e r i e n c e s u n d e r l i e change i n c o m m u n i c a t i o n p r o b l e m s : A f f e c t i v e l y o r i e n t e d e n c o u n t e r s c r e a t e change i n c o m m u n i c a t i o n s t y l e as p a r t n e r s e x p e r i e n c e t h e m s e l v e s and t h e i r p a r t n e r s d i f f e r e n t l y . The e x p e r i e n c i n g o f new f e e l i n g s h e l p s m o t i v a t e p r o b l e m - s o l v i n g and good c o m m u n i c a t i o n p r a c t i c e s . The p e r c e p t i o n o f t h e p a r t n e r as more a c c e s s i b l e and r e s p o n s i v e a l s o m o t i v a t e s and f a c i l i t a t e s open c o m m u n i c a t i o n ( p . 2 5 8 ) . D r a w ing f r o m t h e h u m a n i s t i c , i n t e r p e r s o n a l , b e h a v i o u r a l , and p s y c h o d y n a m i c t r a d i t i o n s i n p s y c h o t h e r a p y , R e l a t i o n s h i p Enhancement (RE) ( G u e r n e y , 1977) a c h i e v e s t h e p r i m a r y g o a l o f p r e v e n t i o n t h r o u g h a p s y c h o e d u c a t i o n a l a p p r o a c h i n w h i c h c l i e n t s a c q u i r e t h e s k i l l s t o enhance t h e i r own r e l a t i o n s h i p s and s o l v e t h e i r own c u r r e n t and f u t u r e p r o b l e m s . RE assumes t h a t a l a c k o f u n d e r s t a n d i n g o f s e l f and o t h e r i s a t t h e r o o t o f p e r s o n a l m a l a d j u s t m e n t and r e l a t i o n s h i p c o n f l i c t . The g o a l o f RE i s t o promote u n d e r s t a n d i n g by b u i l d i n g e m p a t h e t i c r e l a t i o n s h i p s t h r o u g h t h e t e a c h i n g o f s p e c i f i c c o m m u n i c a t i o n s k i l l s . I n RE, c o m m u n i c a t i o n p r o b l e m s a r e v i e w e d as t h e r e s u l t s of d e f i c i t s i n c o m m u n i c a t i o n s k i l l s . Change i n c o m m u n i c a t i o n p r o b l e m s i s e f f e c t e d by c o u p l e s l e a r n i n g new s k i l l s t h a t e l i m i n a t e t h e s e s k i l l d e f i c i t s . The r o l e o f t h e RE t h e r a p i s t i s t o a c t i v e l y t e a c h and model t h e new c o m m u n i c a t i o n s k i l l s . D e s p i t e h a v i n g d i f f e r e n t v i e w s o f and s o l u t i o n s t o c o m m u n i c a t i o n p r o b l e m s , EFT and RE a r e c o m p a t i b l e t r e a t m e n t p r o g r a m s . EFT u n b l o c k s c o m m u n i c a t i o n by c h a n g i n g n e g a t i v e i n t e r a c t i o n c y c l e s a l l o w i n g t h e p o s i t i v e c o m m u n i c a t i o n s k i l l s p a r t n e r s do have t o s u r f a c e i n t h e r e l a t i o n s h i p . RE s e r v e s t o t e a c h new s k i l l s t o p a r t n e r s whose d e s i r e t o communicate p o s i t i v e l y may be i n h i b i t e d by s p e c i f i c s k i l l d e f i c i t s . The two a p p r o a c h e s a r e c o m p l e m e n t a r y b e c a u s e EFT u n b l o c k s c o m m u n i c a t i o n by c h a n g i n g n e g a t i v e c y c l e s and RE e n h a n c e s c o m m u n i c a t i o n by t e a c h i n g new s k i l l s (James, 1 9 8 8 ) . The E f f e c t i v e n e s s o f RE G u e r n e y ' s (1977) R e l a t i o n s h i p Enhancement (RE) program i s a p r o m i n e n t p s y c h o e d u c a t i o n a l e n r i c h m e n t program i n t h e n o n - b e h a v i o u r a l t r a d i t i o n o f c o u p l e s c o m m u n i c a t i o n s k i l l s t r a i n i n g . U n l i k e c o m m u n i c a t i o n t r a i n i n g i n BMT w h i c h has f o c u s e d p r i m a r i l y on p r o b l e m - s o l v i n g , RE e m p h a s i z e s t h e r o l e o f a f f e c t i n r e l a t i o n t o t h e t e a c h i n g of l i s t e n i n g and e m p a t h i c r e s p o n d i n g s k i l l s . E v i d e n c e o f r a p p r o a c h m e n t between t h e b e h a v i o r a l and non-b e h a v i o r a l s c h o o l s i s r e f l e c t e d i n r e c e n t program d e v e l o p m e n t s . B o t h t h e RE and BMT programs now combine t h e d i r e c t t e a c h i n g o f s k i l l s and b e h a v i o u r r e h e a r s a l w i t h t e c h n i q u e s t o promote m u t u a l a f f e c t i v e e x p r e s s i o n of i n t i m a t e f e e l i n g s . A c c o r d i n g t o a r e c e n t r e v i e w o f m a r r i a g e e n r i c h m e n t programs ( C h a r t i e r , 1 9 8 6 ) , RE i s t h e most e f f e c t i v e e n r i c h m e n t a p p r o a c h t o c o u p l e s c o m m u n i c a t i o n s k i l l s t r a i n i n g . A t h o r o u g h r e v i e w o f t h e l i t e r a t u r e s u p p o r t i n g RE c o n d u c t e d i n c o n j o i n t g r o u p f o r m a t Is p r e s e n t e d e l s e w h e r e , (James, 1988). Many of t h e s e s t u d i e s r e p o r t m e t h o d o l o g i c a l p r o b l e m s a s s o c i a t e d w i t h sample a t t r i t i o n and s u b j e c t s s e r v i n g as own c o n t r o l s . The o n l y two s t u d i e s t h a t i n c l u d e n o - t r e a t m e n t c o n t r o l s and r e p o r t f o l l o w - u p d a t a a r e d e s c r i b e d h e r e . I n t h e f i r s t o f two c o n j o i n t g r o u p c o m p a r a t i v e s t u d i e s e m p l o y i n g c o n t r o l g r o u p s , Weiman (1973) r a n d o m l y a s s i g n e d 36 c o u p l e s t o one o f t h r e e c o n d i t i o n s : RE, R e c i p r o c a l R e i n f o r c e m e n t t h e r a p y (RR), and a w a i t - l i s t c o n t r o l . C o u p l e s i n b o t h t r e a t m e n t c o n d i t i o n s r e c e i v e d e i g h t s e s s i o n s h e l d 38 w e e k l y . Outcome was a s s e s s e d on s e l f - r e p o r t measures of m a r i t a l a d j u s t m e n t , m a r i t a l c o m m u n i c a t i o n and c o o p e r a t i v e n e s s . O b s e r v e r r a t i n g s o f i n - s e s s i o n p r o c e s s were a l s o t a k e n ( i n RE, r a t i n g s o f S p e a k e r and L i s t e n e r r o l e s ; i n RR, r a t i n g s of p o s i t i v e s t a t e m e n t s ) . The r e s u l t s o f t h i s s t u d y were t h a t b o t h t r e a t m e n t s showed s i g n i f i c a n t i n c r e a s e s o v e r t h e c o n t r o l c o n d i t i o n on a l l outcome m e a s u r e s . No s i g n i f i c a n t d i f f e r e n c e s were f o u n d between t h e two t r e a t m e n t s on any o f t h e outcome measures. The mean g a i n s a c h i e v e d by b o t h t r e a t m e n t s were m a i n t a i n e d a t t e n week f o l l o w - u p . In a l a t e r c o m p a r a t i v e s t u d y , B r o c k and J o a n n l n g (1983) r a n d o m l y a s s i g n e d a m i l d l y d i s t r e s s e d c o u p l e s t o t h r e e c o n d i t i o n s : an RE program, a M i n n e s o t a C o u p l e s Communication Program (MCCP), and a n o - t r e a t m e n t c o n t r o l . E a c h t r e a t m e n t g r o u p r e c e i v e d t e n two-hour s e s s i o n s c o n d u c t e d w e e k l y . The outcome measures were: t h e D y a d i c A d j u s t m e n t S c a l e , (DAS) ( S p a n i e r , 1 9 7 6 ) , t h e M a r i t a l C o m m u n i c a t i o n I n v e n t o r y (MCI) ( B i e n v e n u , 1970), and t h e Co m m u n i c a t i o n R a p i d A s s e s s m e n t S c a l e (CRAS) ( J o a n n i n g , K o v a l , & B r e w s t e r , 1 9 8 4 ) . The DAS measure y i e l d e d a t o t a l s c a l e s c o r e as w e l l a s s e p a r a t e s c o r e s f o r t h e f o u r s u b s c a l e s : A f f e c t i o n a l E x p r e s s i o n , C o h e s i o n , C o n s e n s u s and S a t i s f a c t i o n . The r e s u l t s a t p o s t - t e s t showed t h e RE c o n d i t i o n had made s i g n i f i c a n t l y g r e a t e r g a i n s t h a n t h e c o n t r o l c o n d i t i o n on a l l t h e d e p e n d e n t m e a s u r e s , w i t h t h e e x c e p t i o n o f one s u b - s c a l e of the DAS. The MCCP condition was not s i g n i f i c a n t l y d i f f e r e n t than the control. RE showed d i f f e r e n t i a l treatment effects on the DAS and MCI. At three-month follow-up, RE was s i g n i f i c a n t l y superior to the control on three sub-scales of the DAS, and the CRAS, while MCCP showed no greater gains than the control. RE showed d i f f e r e n t i a l treatment effects on two subscale of the DAS, and CRAS . Two conclusions arise from t h i s study: (1) that the RE communication tr a i n i n g program was more e f f e c t i v e than MCCP, and that RE was p a r t i a l l y successful in maintaining post-treatment gains at follow-up (James, 1988). RE is also supported in a one-couple conjoint study comparing i t with various alternate therapies (Baker, & Guerney, 1985). These authors randomly assigned 24 c l i n i c couples to a RE condition or to a therapists' Preferred Approach condition in which experienced marital therapists used their preferred approaches. The dependent measures assessed marital adjustment, interpersonal relationships, and marital communication. Results at outcome supported RE as highly s i g n i f i c a n t l y superior to the alternate therapies on a l l dependent measures. The authors attribute the greater magnitude of gains reported in t h i s study r e l a t i v e to previous studies to the greater severity of dist r e s s of couples in the i r study. Baker et. a l . (1985) also suggest that RE may be more e f f e c t i v e with more s e v e r e l y d i s t r e s s e d c o u p l e s t h a n t h e i r b e t t e r a d j u s t e d c o u n t e r p a r t s . M a i n t e n a n c e e f f e c t s c o u l d n o t be d e t e r m i n e d i n t h i s s t u d y and no f o l l o w - u p d a t a was r e p o r t e d . G i b l i n , S p r e n k l e , and Sheehan (1985) r e a c h s i m i l a r c o n c l u s i o n s a b o u t t h e e f f e c t i v e n e s s o f RE i n t h e i r meta-a n a l y s i s o f outcome s t u d i e s o f m a r i t a l e n r i c h m e n t p r o g r a m s . T h e s e a u t h o r s r e p o r t t h a t RE s t u d i e s have and a v e r a g e e f f e c t s i z e o f .96 compared t o one o f .42 f o r t h e M i n n e s o t a C o u p l e s eottRttnieation Program (MCCP). A l t h o u g h RE has r e c e i v e d s u b s t a n t i a l e m p i r i c a l v a l i d a t i o n a t outcome, as James (1988) a s s e r t s , " t h e e f f e c t i v e n e s s o f RE i n m a i n t a i n i n g p o s t - t r e a t m e n t g a i n s r e q u i r e s f u r t h e r i n v e s t i g a t i o n " (p.50.) p a r t i c u l a r l y i n t h e o n e - c o u p l e c o n j o i n t f o r m a t . J A M E S ' ( 1 9 8 8 ) C T C O M P O N E N T The CT component i n t h e James (1988) s t u d y was d e r i v e d f r o m G u e r n e y ' s (1977) R e l a t i o n s h i p Enhancement (RE) program. The f o u r t e e n o r i g i n a l c o u p l e s r e c e i v e d f o u r one-hour s e s s i o n s o f CT a f t e r h a v i n g f i r s t r e c e i v e d e i g h t s e s s i o n s o f EFT. CT was a d m i n i s t e r e d a f t e r t h e EFT t r e a t m e n t f o r two main r e a s o n s : f i r s t , i t was e x p e c t e d t h a t EFT would a l t e r c o u p l e s n e g a t i v e i n t e r a c t i o n c y c l e s and i n c r e a s e i n t i m a c y making c o u p l e s more w i l l i n g t o l e a r n c o m m u n i c a t i o n s k i l l s , and s e c o n d , the p r e v e n t a t i v e f u n c t i o n o f c o m m u n i c a t i o n s k i l l s would s e r v e 41 c l i e n t s in resolving their own issues after treatment termination (James, 1988). The CT component draws upon the RE approach with regard to format, s k i l l s and therapist a c t i v i t i e s . Sessions in the CT component were administered according to the structured format of RE: homework review, d i d a c t i c s k i l l presentation, behavioral rehearsal, debriefing and homework assignment. The CT therapists adopted an active teaching stance using RE techniques of modelling, prompting, structuring and reinforcement. CT was designed to teach three basic communication s k i l l s or modes outlined by Guerney (1977): (1) the expressive mode, (2) the empathetic responder mode, and (3) mode switching. The function of the expressive s k i l l s are to help partners: (a) underorstand their emotional-psychological-interpersonal wants and needs better; (b) express such wants and needs to each other in ways that do not i n c i t e unnecessary anxiety, defenslveness, c o n f l i c t , and h o s t i l i t y , but instead tend to engender respect, understanding, and cooperation; and (c) deal with c o n f l i c t s and problems with less anxiety, promptly, a s s e r t i v e l y , p o s i t i v e l y , and in terms of their own s p e c i f i c goals and needs (Guerney et a l . 1986). The l i s t e n i n g s u b - s k i l l s of understanding and acceptance are central to the s k i l l of empathetic responding. With these s k i l l s partners learn to respond to one another in such a way as to convey an understanding of each other's internal frame 42 o f r e f e r e n c e . G u e r n e y (1986) s t a t e s t h a t e m p a t h e t i c r e s p o n d i n g s k i l l s s e r v e t o h e l p p a r t n e r s (a) u n d e r s t a n d t h e e m o t i o n a l -p s y c h o l o g i c a l - i n t e r p e r s o n a l needs o f e a c h o t h e r b e t t e r , and (b) e l i c i t from e a c h o t h e r more prompt, f r e q u e n t , h o n e s t , r e l e v a n t , open, t r u s t i n g , and i n t i m a t e b e h a v i o u r s . Mode s w i t c h i n g i s d e s i g n e d t o f a c i l i t a t e p a r t n e r s ' a b i l i t y t o : (a) keep t r a c k o f t h e w h i c h mode e a c h p a r t n e r i s i n a t a g i v e n t i m e , and (b) u n d e r s t a n d when and how t o s w i t c h f r o m one mode t o a n o t h e r i n a c o o r d i n a t e d manner a ( G u e r n e y , 1984 ) . A s p e c t s o f t h e EFT model ( G r e e n b e r g , 1984) were a l s o i n c o r p o r a t e d I n t o t h e CT component. A c c o r d i n g t o James ( 1 9 8 8 ) , EFT c o n t r i b u t e s a t h e o r e t i c a l u n d e r s t a n d i n g o f t h e e x p r e s s i o n o f p r i m a r y , u n d e r l y i n g e m o t i o n s t o t h e e x p r e s s i v e mode. Here t h e a c c e n t i s on t e a c h i n g c o u p l e s how t o r e c o g n i z e t h e s e f e e l i n g s and e x p r e s s them i n t h e r e l a t i o n s h i p . C o u p l e s were t a u g h t t h e EFT c o n c e p t t h a t t h e e x p r e s s i o n o f u n d e r l y i n g e m o t i o n s b r i n g s t o a w a r e n e s s c e r t a i n wants and needs and p a r t n e r s were g i v e n p r a c t i c e i n e x p r e s s i n g t h e s e t o e a c h o t h e r . The f o l l o w i n g i s a summary of t h e f o u r s e s s i o n s i n James' (1988) CT component: S e s s i o n One - homework a s s i g n m e n t o f r e a d i n g t h e C o u p l e s C o m m u n i c a t i o n T r a i n i n g Manual i s r e v i e w e d . 43 - a u d i o t a p e o f a c o u p l e d i s c u s s i n g a r e l a t i o n s h i p i s s u e w i t h and w i t h o u t u s i n g t h e s k i l l s i s p r e s e n t e d and d i s c u s s e d . - c o u p l e s a r e t a u g h t t h e two b a s i c c o m m u n i c a t i o n s k i l l s o f e x p r e s s i o n and e m p a t h e t i c r e s p o n d i n g and t h e c o - o r d i n a t i n g s k i l l o f m o d e - s w i t c h i n g . - c o m m u n i c a t i o n s k i l l s a r e r e h e a r s e d and d e b r i e f e d - a s s i g n e d homework i s t o p r a c t i c e t h e s k i l l s a t home b e f o r e t h e n e x t s e s s i o n . S e s s i o n Two - home p r a c t i c e i s r e v i e w e d . - c o u p l e s a r e t a u g h t t h e c o n c e p t o f p r i m a r y u n d e r l y i n g f e e l i n g s and t h e v a l u e o f e x p r e s s i n g t h e s e f e e l i n g s i n t h e r e l a t i o n s h i p . - c o u p l e s a r e t a u g h t t h e c o n c e p t o f M £ e l t - n e e d s " ( i . e . , needs t h a t emerge f r o m an a w a r e n e s s o f u n d e r l y i n g f e e l i n g s ) and t h e v a l u e of e x p r e s s i n g t h e s e needs i n t h e r e l a t i o n s h i p . c o m m u n i c a t i o n s k i l l s a r e r e h e a r s e d w i t h p a r t i c u l a r a t t e n t i o n t o t h e e x p r e s s i o n o f u n d e r l y i n g f e e l i n g s and f e l t - n e e d s and d e b r i e f e d . - a s s i g n e d homework i s t o p r a c t i c e t h e s k i l l s a t home. Session Three - a s s i g n e d homework i s r e v i e w e d . - c o u p l e s a r e t a u g h t t o d i s t i n g u i s h between s e c o n d a r y or r e a c t i v e a n g e r and p r i m a r y or u n d e r l y i n g a n g e r and g u i d e l i n e s f o r e x p r e s s i n g p r i m a r y a n g e r . 44 - c o m m u n i c a t i o n s k i l l s a r e r e h e a r s e d w i t h e m p h a s i s on t h e e x p r e s s i o n o f p r i m a r y a n g e r / r e s e n t m e n t . S e s s i o n F o u r - no new s k i l l s a r e p r e s e n t e d - c o u p l e s p r a c t i c e t o c o n s o l i d a t e t h e i r s k i l l s - t h e i m p o r t a n c e o f o n g o i n g r e g u l a r p r a c t i c e and u s i n g t h e s k i l l s i n v a r i o u s e v e r y d a y l i f e s i t u a t i o n s i s d i s c u s s e d . - t h e r a p y t e r m i n a t e s w i t h t h e r a p i s t s and c o u p l e s e x p r e s s i n g t h e i r a p p r e c i a t i o n s and s a y i n g goodbye. F o r a c o m p l e t e d e s c r i p t i o n o f t h e CT component see t h e CT T h e r a p i s t T r a i n i n g Majmal and t h e CT CQUples Manual/ (James, 1 9 8 8 ) . T H E C T B O O S T E R S E S S I O N C O M P O N E N T The CT b o o s t e r s e s s i o n component i n t h i s s t u d y i s an a b b r e v i a t e d f o r m o f James' (1988) CT component. In k e e p i n g w i t h t h e o r i g i n a l CT component, t h e b o o s t e r s e s s i o n s w i l l f o l l o w RE's s t r u c t u r e d f o r m a t o f homework r e v i e w , d i d a c t i c c o n c e p t r e v i e w , b e h a v i o u r a l r e h e a r s a l , d e b r i e f i n g , and homework a s s i g n m e n t . A d e t a i l e d o u t l i n e o f t h e s e s s i o n c o n t e n t s i s p r o v i d e d f o r t h e r a p i s t s t o f o l l o w i n t h e B o o s t e r Component Manual ( s e e A p p e n d i x B.) The b o o s t e r component w i l l p l a c e a g r e a t e r emphasis on t h e b e h a v i o u r a l r e h e a r s a l or p r a c t i c e p a r t o f t h e f o r m a t i n o r d e r t o enhance t h e c o u p l e ' s m a s t e r y and m a i n t a i n e d use of the s k i l l s independently of the t h e r a p i s t once the booster s e s s i o n s terminate. In order to provide couples with more a c t i v e s k i l l r e h e a r s a l , s e s s i o n s w i l l be lengthened to 90 minutes and the d i d a c t i c , and d e b r i e f i n g segments w i l l be c u r t a i l e d . The f o l l o w i n g i s a summary of the contents of the four booster s e s s i o n s as o u t l i n e d i n the Booster Component Manual, S e s s i o n One review homework of readi n g the Couples Communication T r a i n i n g Manual - assessment of the c u r r e n t s k i l l l e v e l - b r i e f review of the two communication s k i l l s of ex p r e s s i o n and empathetic responding and the s k i l l of mode s w i t c h i n g - behaviour r e h e a r s a l of s k i l l s on t o p i c chosen by couple - d e b r i e f s e s s i o n - homework of at-home p r a c t i c e assigned f o r next s e s s i o n s e s s i o n Two - review homework - b r i e f review of the value of e x p r e s s i n g primary u n d e r l y i n g f e e l i n g s ( p a r t i c u l a r l y primary anger or resentment) and emergent wants and needs i n the r e l a t i o n s h i p . - behaviour r e h e a r s a l - d e b r i e f s e s s i o n - homework of at-home p r a c t i c e assigned S e s s i o n Three 46 - r e v i e w homework - no c o n c e p t s p r e s e n t e d by t h e r a p i s t - b e h a v i o u r r e h e a r s a l (minimum t h e r a p i s t i n p u t ) - d e b r i e f s e s s i o n - homework " a s s i g n e d Session Four - r e v i e w homework - b e h a v i o u r r e h e a r s a l (minimum t h e r a p i s t i n p u t ) - d e b r i e f r e h e a r s a l - t e r m i n a t i o n w i t h e m p h a s i s on i m p o r t a n c e o f r e g u l a r p r a c t i c e and g e n e r a l i z i n g use o f t h e s k i l l s by a p p l y i n g them i n v a r i o u s c o n t e x t s . C O N C E P T U A L H Y P O T H E S I S The p r e c e d i n g r e v i e w e s t a b l i s h e s t h a t , i n EFT m a r i t a l t h e r a p y r e s e a r c h , t h e r e i s a t r e n d t o w a r d p o s t - t r e a t m e n t r e g r e s s i o n o f c o u p l e s g a i n s a f t e r t h e t e r m i n a t i o n o f t r e a t m e n t . T h i s f i n d i n g v e r i f i e s t h a t t h e m a i n t e n a n c e p r o b l e m , r e c o g n i z e d i n p s y c h o t h e r a p y , b e h a v i o u r t h e r a p y and b e h a v i o r a l m a r i t a l t h e r a p y r e s e a r c h , a l s o e x i s t s i n n o n - b e h a v i o u r m a r i t a l t h e r a p y . T h i s r e v i e w a l s o p r o v i d e s e v i d e n c e t h a t b o o s t e r s e s s i o n s show p r o m i s e as a s t r a t e g y f o r e n h a n c i n g t h e m a i n t e n a n c e o f c o u p l e s t r e a t m e n t g a i n s a f t e r m a r i t a l t h e r a p y . In James' (1988) s t u d y , c o u p l e s who r e c e i v e d EFT+CT r e g r e s s e d between p o s t - t e s t and f o u r - m o n t h f o l l o w - u p a s s e s s m e n t s , a t r e n d t h a t t h i s r e s e a r c h e r t h e o r i z e d would c o n t i n u e i n t h e a b s e n c e o f i n t e r v e n t i o n . G i v e n t h e s e f i n d i n g s , i t i s h y p o t h e s i z e d t h a t a d m i n i s t e r i n g f o u r CT b o o s t e r s e s s i o n s a f t e r t e r m i n a t i o n o f t h e EFT+CT t r e a t m e n t w o u l d : 1) i n c r e a s e r e g r e s s e d c o u p l e s ' s c o r e s on t h e d e p e n d e n t m e a s u r e s , 2) enhance t h e s h o r t term m a i n t e n a n c e o f t h e b o o s t e r s e s s i o n e f f e c t s , and 3) enhance c o u p l e s ' l o n g t e r m m a i n t e n a n c e o f t h e EFT+CT t r e a t m e n t g a i n s a c h i e v e d i n James' (1988) s t u d y . T r e a t m e n t g a i n s a r e i n d i c a t e d by improvement o f c o u p l e s ' mean s c o r e s from p r e - t r e a t m e n t t o p o s t - t r e a t m e n t on t h e d e p e n d e n t m e a s u r e s : t h e D y a d i c A d j u s t m e n t S c a l e , t h e C o m m u n i c a t i o n S c a l e , and T a r g e t C o m p l a i n t s . 48 CHAPTER I I I : METHODOLOGY T h i s c h a p t e r b e g i n s w i t h a summary o f t h e m e t h o d o l o g y o f th e s t u d y c o n d u c t e d by James ( 1 9 8 8 ) . The d e s i g n , s u b j e c t s , t h e r a p i s t s , r e s e a r c h p r o c e d u r e s , and r e s e a r c h i n s t r u m e n t s o f t h e b o o s t e r s t u d y a r e t h e n d e s c r i b e d . The c h a p t e r c o n c l u d e s w i t h a d e s c r i p t i o n o f t h e d a t a a n a l y s i s p r o c e d u r e s employed i n t h e s t u d y . M E T H O D O F J A M E S ' ( 1 9 8 8 ) S T U D Y D e s i g n The c u r r e n t s t u d y f o l l o w s f r o m a c o n s t r u c t i v e outcome s t u d y by James (1988) who i n v e s t i g a t e d t h e t h e r a p e u t i c e f f e c t i v e n e s s o f a d d i n g a c o m m u n i c a t i o n s k i l l s t r a i n i n g component (CT) t o an E m o t i o n a l l y F o c u s e d T h e r a p y (EFT) f o r 28 v o l u n t e e r c o u p l e s . The d e s i g n i n t h e James (1988) s t u d y was " a t h r e e f a c t o r , 3x7x3 ( t r e a t m e n t - b y - t h e r a p i s t - b y - o c c a s l o n ) mixed model w i t h t h e r a p i s t n e s t e d w i t h i n t r e a t m e n t , t r e a t m e n t f u l l y c r o s s e d w i t h o c c a s i o n and r e p e a t e d measures o v e r t h r e e o c c a s i o n s as t h e t h i r d f a c t o r " (James, 1988, p. 5 7 ) . The t h r e e l e v e l s o f t h e t r e a t m e n t f a c t o r were EFT, EFT+CT, and a w a i t -l i s t c o n t r o l . The t h r e e l e v e l s of t h e o c c a s i o n f a c t o r were p r e - t e s t , p o s t - t e s t , and f o u r - m o n t h f o l l o w - u p . 49 The design of the James (1988) study is i l l u s t r a t e d as: 01 RG1 T l 02 03 01 RG2 T2 02 03 01 RG3 02 03 T2 In th i s design 01, 02, and 03 refer to the pre-test, post-t e s t , and four month follow-up testing occasions respectively. The subjects were randomly assigned to two treatment groups, Gl, and G2, and a w a i t - l i s t control group, G3. The treatment groups received EFT and EFT+CT, denoted by T l and T2, respectively. Couples in the EFT group received 12, one-hour sessions of EFT. Couples in the EFT+CT group received eight, one-hour sessions of EFT and four one-hour sessions of CT. Couples in the control group received the EFT+CT treatment afte r data c o l l e c t i o n at 03. Subjects James (1988) s o l i c i t e d volunteer couples from advertisements and interviews that were published in l o c a l newspapers. The couples who responded were subjected to an i n i t i a l telephone screening and an Interview to ensure they met research c r i t e r i a . Of the 42 couples who were selected, 14 couples were randomly assigned to each of the two treatment groups (EFT and EFT+CT) and 14 couples were assigned to the w a i t - l i s t control group. The screening c r i t e r i a for couple selection were: 50 1. P a r t n e r s must have c o - h a b i t e d f o r a minimum o f t w e l v e months and be c u r r e n t l y l i v i n g t o g e t h e r . 2. P a r t n e r s must have had no immediate p l a n s f o r d i v o r c e . 3. P a r t n e r s must n o t have r e c e i v e d p s y c h i a t r i c t r e a t m e n t or p s y c h i a t r i c h o s p i t a l i z a t i o n w i t h i n t h e l a s t two y e a r s . 4. P a r t n e r s must have had no r e p o r t e d p r o b l e m s w i t h d r u g s or a l c o h o l . 5. P a r t n e r s must have had no r e p o r t e d p r i m a r y s e x u a l d y s f u n c t i o n . 6. P a r t n e r s s c o r e s on t h e D y a d i c A d j u s t m e n t S c a l e must n o t have f a l l e n i n t h e s e v e r e l y d i s t r e s s e d r a n g e (one p a r t n e r s c o r e d below 100, B u r g e r & J a c o b s o n , 1979; or a c o u p l e s c o r e o f l e s s t h a n 7 0 ) . 7. P a r t n e r s had t o c o n s e n t t o r e s e a r c h p r o c e d u r e s , t e s t i n g and a u d i o - v i d e o t a p i n g . 8. P a r t n e r s must n o t have been c u r r e n t l y i n v o l v e d i n any o t h e r p s y c h o l o g i c a l t r e a t m e n t , e i t h e r as i n d i v i d u a l s or as c o u p l e s (James, 1 9 8 8 ) . Demographic d a t a on s u b j e c t s * e d u c a t i o n , o c c u p a t i o n , income, y e a r s m a r r i e d , age, number o f c h i l d r e n , and p r e v i o u s c o u n s e l l i n g were r e p o r t e d i n t h e s t u d y . T h e r a p i s t s The t h e r a p i s t s i n t h e s t u d y were g r a d u a t e s t u d e n t s f r o m t h e D epartment o f C o u n s e l l i n g P s y c h o l o g y who v o l u n t e e r e d t o r e c e i v e c l i n i c a l t r a i n i n g i n m a r i t a l c o u n s e l l i n g . F i v e male 51 and n i n e f e m a l e t h e r a p i s t s were r a n d o m l y a s s i g n e d t o t r e a t m e n t g r o u p s . James (1988) r e p o r t e d d a t a r e g a r d i n g t h e r a p i s t e d u c a t i o n , t r a i n i n g i n c o u p l e s c o u n s e l l i n g , g e n e r a l c l i n i c a l e x p e r i e n c e , and c l i n i c a l e x p e r i e n c e c o u n s e l l i n g c o u p l e s . T h e r a p i s t T r a i n i n g T h e r a p i s t s i n b o t h t r e a t m e n t c o n d i t i o n s r e c e i v e d 12 h o u r s o f t r a i n i n g i n EFT (James, 1 9 8 8 ) . T h e r a p i s t s i n t h e EFT+CT c o n d i t i o n r e c e i v e d an a d d i t i o n a l 11 h o u r s o f t r a i n i n g i n c o u p l e s ' c o m m u n i c a t i o n u s i n g t h e CT manual w h i c h i s p r e s e n t e d i n t h e a p p e n d i c e s o f t h e James (1988) s t u d y . The t r a i n i n g was c o n d u c t e d by t h e p r i n c i p l e i n v e s t i g a t o r and s u p e r v i s e d by D r . J o h n F r i e s e n , D e p a r t m e n t o f C o u n s e l l i n g P s y c h o l o g y . The t r a i n i n g f o r m a t i n c l u d e d a w r i t t e n manual, s u p e r v i s e d i n s t r u c t i o n , m o d e l l i n g , a u d i o - t a p e of i n t e r v e n t i o n , b e h a v i o r a l r e h e a r s a l , and f e e d b a c k . A l l t h e r a p i s t s r e c e i v e d a p p r o x i m a t e l y one hour o f i n d i v i d u a l s u p e r v i s i o n and p a r t i c i p a t e d i n o n g o i n g g r o u p s u p e r v i s i o n s e s s i o n s o f f e r e d d u r i n g t h e main e x p e r i m e n t a l p e r i o d . T h e r a p i s t s i n t h e EFT c o n d i t i o n r e c e i v e d t h e CT t r a i n i n g d u r i n g t h e p o s t - t r e a t m e n t p e r i o d . R e s e a r c h M e a s u r e s The d e p e n d e n t measures i n t h e James s t u d y were: t h e D y a d i c A d j u s t m e n t S c a l e (DAS), P a s s i o n a t e Love S c a l e ( P L S ) , C o m m u n i c a t i o n S c a l e ( C S ) , P s y c h o s o c i a l I n t i m a c y Q u e s t i o n n a i r e ( P I Q ) , and T a r g e t C o m p l a i n t s ( T C ) . I n a d d i t i o n , a p o s t -t r e a t m e n t s t r u c t u r e d i n t e r v i e w was c o n d u c t e d t o a s s e s s c l i e n t s r e a c t i o n s t o t r e a t m e n t . I m p l e m e n t a t i o n Check T r e a t m e n t i n t e g r i t y , t h e e x t e n t t o w h i c h t r e a t m e n t i s c a r r i e d o u t as i n t e n d e d ( K a z d i n , 1 9 8 6 ) , was i n s u r e d t h r o u g h i m p l e m e n t a t i o n c h e c k s c o n d u c t e d t h r o u g h o u t t h e s t u d y . V i d e o t a p e a n a l y s i s o f s e s s i o n c o n t e n t was p r o v i d e d i n g r o u p and i n d i v i d u a l f o r m a t s . I n d e p e n d e n t r a t e r s were t r a i n e d t o use s e p a r a t e i m p l e m e n t a t i o n c h e c k l i s t s ( f o r t h e EFT and CT components) t o a s s e s s whether t h e r a p i s t s a d h e r e d t o t h e t r e a t m e n t a s o u t l i n e d i n t h e EFT and CT ma n u a l s . Randomly s e l e c t e d segments (one p e r c o u p l e ) r e p r e s e n t a t i v e o f t h e f o u r CT s e s s i o n s were e v a l u a t e d by two o f t h e r a t e r s . M E T H O D O F T H E B O O S T E R S T U D Y R e s e a r c h D e s i g n T h i s e x p e r i m e n t i n v e s t i g a t e s t h e e f f e c t s o f r e c e i v i n g f o u r CT b o o s t e r s e s s i o n s on t h e d e p e n d e n t measures o f m a r i t a l a d j u s t m e n t , c o m m u n i c a t i o n , and t a r g e t c o m p l a i n t r e d u c t i o n f o r 10 o f t h e 14 c o u p l e s who r e c e i v e d t h e EFT+CT t r a i n i n g i n t h e James (1988) s t u d y . 53 As described above, James' (1988) study was i l l u s t r a t e d as: 01 RG1 T l 02 03 01 RG2 T2 02 03 01 RG3 02 03 T2 This study employs a comparative experimental time-lagged crossover control design for two equivalent groups in the booster treatment phase. The design can be i l l u s t r a t e d as: James' study ^ Booster study  01 T2 02 03 04 RGl T3 05 06 04 RG2 05 T3 06 where T2 is the EFT+CT treatment and 01, 02, and 03 denote the pre-test, post-test, and four-month follow-up occasions in the James (1988) study. The booster treatment crossover phase of the design begins at 04 which is the pre-test occasion in the booster study. R is the random assignment of the 10 EFT+CT couples to the two booster treatment groups: the first-booster group (FB), and the delayed-booster group (DB). 05 and 06 denote the booster post-test and four-month follow-up occasions for the FB group. For the DB group, 05 and 06 denote the post-wait and booster post-treatment occasions, respectively. In t h i s crossover design, both groups are assessed on the DAS, CS, and TC measures at 04, prior to intervention. Then, 54 t h e b o o s t e r t r e a t m e n t i s a d m i n i s t e r e d t o t h e F B , or e x p e r i m e n t a l g r o u p , w h i l e t h e DB g r o u p s e r v e s a s t h e w a i t - l i s t c o n t r o l . A f t e r t h e F B g r o u p r e c e i v e s t h e b o o s t e r s e s s i o n s , ou tcome m e a s u r e s a r e t a k e n f o r b o t h g r o u p s a t 0 5 . A t t h i s p o i n t , t h e t r e a t m e n t c r o s s o v e r t a k e s p l a c e w h e r e b y t h e DB g r o u p becomes t h e e x p e r i m e n t a l g r o u p r e c e i v i n g t h e b o o s t e r t r e a t m e n t , a n d t h e F B g r o u p becomes t h e p o s t - t r e a t m e n t f o l l o w -up g r o u p , r e c e i v i n g no i n t e r v e n t i o n . The e x p e r i m e n t i s c o m p l e t e d when outcome m e a s u r e s a r e t a k e n a t 06 f o r b o t h g r o u p s a f t e r t h e s e c o n d i n t e r v e n t i o n . The c o u p l e s i n t h i s s t u d y were t e s t e d on t h r e e d e p e n d e n t m e a s u r e s : t h e D y a d i c A d j u s t m e n t S c a l e , t h e C o m m u n i c a t i o n S c a l e , a n d T a r g e t C o m p l a i n t s . The m a i n u n i t o f a n a l y s i s i s t h e mean c o u p l e s c o r e w h i c h i s t h e sum o f t h e i n d i v i d u a l p a r t n e r s c o r e s d i v i d e d by t w o . The mean c o u p l e s c o r e i s u s e d as t h e u n i t o f a n a l y s i s i n p r e v i o u s outcome s t u d i e s o f E F T ( J a m e s , 1988; H a n s e n , 1990) a n d i n m a r i t a l t h e r a p y outcome r e s e a r c h i n g e n e r a l ( J a c o b s o n , e t . a l . , 1 9 8 6 ) . Rationale of the Crossover Design C r o s s o v e r c o m p a r a t i v e e x p e r i m e n t a l d e s i g n s make i t p o s s i b l e t o c o m p a r e t h e r e l a t i v e e f f e c t i v e n e s s o f a t r e a t m e n t i n t e r v e n t i o n w i t h a c o n t r o l c o n d i t i o n f o r a l l s u b j e c t s w i t h o u t d e n y i n g a n y s u b j e c t s t h e t r e a t m e n t ( E p s t e i n & T r i p o d i , 1 9 7 7 ) . E q u i v a l e n t g r o u p s o f c l i e n t s a r e g i v e n t h e t r e a t m e n t I n t e r v e n t i o n a t l a g g e d i n t e r v a l s so t h a t a l l g r o u p s s e r v e as 55 experimental or control groups at d i f f e r e n t times. The groups are compared after the f i r s t intervention and then the intervention is switched or crossed over to the other groups and they are measured again. In the r e s u l t i n g analysis, the effectiveness of every intervention on every experimental group is measured. Within this design, the intervention after the crossover e s s e n t i a l l y serves as a r e p l i c a t i o n of the i n i t i a l experimental intervention. The crossover design has a number of advantages. F i r s t , as a randomized experiment i t provides superior control of threats to internal v a l i d i t y , thus allowing the researcher to infer a causal rel a t i o n s h i p between the variables. Random assignment to treatment groups controls for the confounding effects of selection bias, instrumentation and s t a t i s t i c a l regression by ensuring group equivalence (Cook & Campbell, 1979). The use of control groups l i m i t s the effects of contemporary history, maturation process and subject mortality. The potential effects of pretesting are reduced by using standardized measures for assessing group two on the two w a i t - l i s t occasions (Epstein & Tripodi, 1977). Cook and Campbell (1979) describe four threats to internal v a l i d i t y that randomization does not control: d i f f u s i o n or imitation of treatment, compensatory equalization, compensatory r i v a l r y , and resentful demoralization. These threats arise from the subjects' perception of treatment inequities in the experiment. It is 56 u n l i k e l y t h a t t h e s e t h r e a t s a f f e c t e d t h i s s t u d y . I t a p p e a r s t h a t t h e c r o s s o v e r d e s i g n e f f e c t i v e l y l i m i t s c o n f o u n d i n g e f f e c t s t h a t r a n d o m i z a t i o n a l o n e does n o t c o n t r o l ( H i g g i n s , 1990) . I m i t a t i o n of t h e t r e a t m e n t c a n be r u l e d out b e c a u s e c o u p l e s i n b o t h g r o u p s had r e c e i v e d t h e c o m m u n i c a t i o n s k i l l s t r a i n i n g p r i o r t o t h e e x p e r i m e n t . C o m p e n s a t o r y e q u a l i z a t i o n d oes n o t a f f e c t t h i s s t u d y b e c a u s e a l l of t h e c o u p l e s r e c e i v e d e x a c t l y t h e same t r e a t m e n t o n l y a t d i f f e r e n t t i m e s . I n t h e i n i t i a l i n t e r v i e w , c o u p l e s were t o l d t h e y would r e c e i v e t r e a t m e n t commencing e i t h e r i n F e b r u a r y or March, a d i f f e r e n c e o f a p p r o x i m a t e l y e i g h t weeks. N e i t h e r d e m o r a l i z a t i o n nor c o m p e n s a t o r y r i v a l r y seem l i k e l y f a c t o r s b e c a u s e a l l o f t h e c o u p l e s e x p e c t e d and r e c e i v e d t h e same t r e a t m e n t . None o f t h e c o u p l e s i n t h e s t u d y knew e a c h o t h e r nor d i d t h e y have any c o n t a c t w i t h e a c h o t h e r making c o m p a r i s o n o f t r e a t m e n t among c o u p l e s u n l i k e l y . I n a d d i t i o n , s p o u s e s were t e s t e d i n d i v i d u a l l y t o e n s u r e t h a t t h e y d i d n o t i n f l u e n c e e a c h o t h e r i n t h e t e s t i n g s i t u a t i o n . A n o t h e r a d v a n t a g e of t h e c r o s s o v e r d e s i g n i s t h a t i t i n c r e a s e s e x t e r n a l v a l i d i t y b e c a u s e i t c o n t a i n s a b u i l t In r e p l i c a t i o n ( E p s t e i n & T r i p o d i , 1977) o f t h e e x p e r i m e n t when t h e t r e a t m e n t i s c r o s s e d o v e r t o t h e c o n t r o l g r o u p . Cook and C a m p b e l l (1979) s t a t e t h a t " I n t h e f i n a l a n a l y s i s , e x t e r n a l v a l i d i t y i s . . . l i k e c o n s t r u c t v a l i d i t y . . . a m a t t e r o f r e p l i c a t i o n " ( p . 7 8 ) . These a u t h o r s s u g g e s t t h a t " c o n s e c u t i v e 57 r e p l i c a t i o n w i t h i n a s i n g l e s t u d y o f f e r s some t e s t , however r e s t r i c t e d , of whether a c a u s a l r e l a t i o n s h i p c a n be c o r r o b o r a t e d a t two d i f f e r e n t t i m e s " (Cook & C a m p b e l l , 1979, p.78) . The r e p l i c a t i o n i n t h i s d e s i g n a l s o h e l p s t o c o u n t e r t h e p r o b l e m o f low power or Type I I e r r o r w h i c h i n c r e a s e s when sample s i z e s a r e s m a l l . Type I I e r r o r , or t h e e r r o r of o v e r c o n s e r v a t i s m , o c c u r s when t h e n u l l h y p o t h e s i s o f no d i f f e r e n c e between g r o u p s i s f a l s e l y a c c e p t e d . C a t e s (1985) c o n t e n d s t h a t t h e e x p e r i m e n t a l r e s u l t s a r e c o n f i r m e d when t h e y r e p e a t i n e q u i v a l e n t g r o u p s from t h e same p o p u l a t i o n who r e c e i v e t h e same t r e a t m e n t a t d i f f e r e n t t i m e s . In o t h e r words, r e p r o d u c i n g t h e t r e a t m e n t e f f e c t i n a s e c o n d g r o u p i n t h e c r o s s o v e r d e s i g n r e d u c e s t h e p r o b a b i l i t y of making a c l a i m t h a t t h e r e i s no t r e a t m e n t when, i n f a c t , t h e r e i s . I n t h e b o o s t e r s t u d y , where t h e sample s i z e i s s m a l l , t h e c r o s s o v e r d e s i g n d e c r e a s e s t h e p o s s i b i l i t y of o v e r c o n s e r v a t i s m . B e c a u s e e a c h s u b j e c t a l s o a c t s as h i s or her own c o n t r o l t h e s o u r c e o f e r r o r due t o v a r i a n c e between s u b j e c t s i s r e d u c e d as c o m p a r i s o n s a r e made w i t h i n s u b j e c t s . H i l l s and A r m i t a g e (1979) s t a t e , " A c o m p a r i s o n o f t r e a t m e n t s i n t h e same s u b j e c t i s e x p e c t e d t o be more p r e c i s e t h a n a c o m p a r i s o n between s u b j e c t s and t h e r e f o r e t o r e q u i r e fewer s u b j e c t s f o r t h e same p r e c i s i o n " ( p . 7 ) . P e r h a p s t h e most c o m p e l l i n g a d v a n t a g e o f t h e c r o s s o v e r d e s i g n i n c l i n i c a l p r a c t i c e i s t h a t i t i s e t h i c a l l y s o u n d . 58 U n l i k e most c o m p a r a t i v e e x p e r i m e n t a l d e s i g n s , i t a l l o w s c o n t r o l g r o u p c o m p a r i s o n s w i t h o u t d e n y i n g t r e a t m e n t t o any s u b j e c t or c l i e n t . E p s t e i n and T r i p o d i (1979) c o n c l u d e t h a t " t h e u n i q u e a d v a n t a g e o f t h i s d e s i g n i s t h a t i t p r o v i d e s t h e s c i e n t i f i c r i g o r o f a c o n t r o l g r o u p e x p e r i m e n t w i t h o u t r e q u i r i n g any s e r v i c e d e n i a l t o a n y . . . c l i e n t s " ( p . 1 6 5 ) . S u b j e c t s The t a r g e t p o p u l a t i o n i n t h i s s t u d y was t h e c o u p l e s who had r e c e i v e d t h e EFT+CT t r a i n i n g i n t h e James (1988) s t u d y . The a c c e s s i b l e p o p u l a t i o n was t h e c o u p l e s i n James' (1988) T2 g r o u p who had r e c e i v e d t h e EFT+CT t r a i n i n g . The sample p o p u l a t i o n was t h e c o u p l e s i n t h e T2 g r o u p who a g r e e d t o p a r t i c i p a t e i n t h e s t u d y . A l l o f t h e c o u p l e s i n t h i s s t u d y were c o m p r i s e d o f m a l e / f e m a l e p a r t n e r s h i p s . T h r e e months a f t e r James (1988) took t h e f o u r - m o n t h f o l l o w - u p m e a s u r e s , e a c h o f t h e c o u p l e s i n t h e T2 (EFT+CT) g r o u p r e c e i v e d a l e t t e r i n v i t i n g them t o p a r t i c i p a t e i n a s t u d y o f c o u p l e ' s c o m m u n i c a t i o n and r e c e i v e f o u r a d d i t i o n a l c o m m u n i c a t i o n s k i l l s t r a i n i n g s e s s i o n s . The c o u p l e s were t o l d t h a t , i f t h e y c h o s e t o p a r t i c i p a t e , t h e y had a 50% chance t h a t t h e i r s e s s i o n s would commence i n e i t h e r F e b r u a r y or March 1989. C o u p l e s were i n f o r m e d t h a t , as r e s e a r c h p a r t i c i p a n t s , t h e y would be r e q u i r e d t o c o m p l e t e t h r e e b r i e f q u e s t i o n n a i r e s on t h r e e o c c a s i o n s ; a p p r o x i m a t e l y a 20 m i n u t e t a s k e a c h t i m e . 59 F o u r of t h e 14 c o u p l e s from t h e s t u d y c h o s e n o t t o p a r t i c i p a t e . T h r e e o f t h e s e d e c l i n e d b e c a u s e of work commitments and t h e f o u r t h o f f e r e d no e x p l a n a t i o n . T h i s i n v e s t i g a t o r a p p l i e d James* (1988) s c r e e n i n g c r i t e r i a t o t h e 10 c o u p l e s who v o l u n t e e r e d f o r t h e c u r r e n t s t u d y t o e n s u r e t h a t t h e y were s t i l l r e p r e s e n t a t i v e of t h e o r i g i n a l s a m ple. The c o u p l e s were r a n d o m l y a s s i g n e d u s i n g a random d i g i t s t a b l e t o e i t h e r t h e FB g r o u p or t h e DB g r o u p . There were five couples i n each group, couples were t h e n r a n d o m l y a s s i g n e d t o t h e r a p i s t s . D e m ographic d a t a were o b t a i n e d f o r e a c h c o u p l e p a r t i c i p a t i n g i n t h e s t u d y (see A p p e n d i x B ) . T h e r a p i s t s F o u r t h e r a p i s t s p a r t i c i p a t e d i n t h i s s t u d y . These t h e r a p i s t s had p r e v i o u s l y a d m i n i s t e r e d t h e CT component i n t h e James (1988) s t u d y . T h e r e f o r e t h e y had r e c e i v e d t h e i n i t i a l CT t r a i n i n g and, s u p e r v i s i o n and were e x p e r i e n c e d i n i m p l e m e n t i n g CT w i t h c o u p l e s . The t h e r a p i s t s r e c e i v e d t h r e e h o u r s of a d d i t i o n a l t r a i n i n g i n a d m i n i s t e r i n g t h e CT b o o s t e r t r e a t m e n t i n t h i s s t u d y . The t r a i n i n g was c o n d u c t e d by t h e r e s e a r c h e r under t h e s u p e r v i s i o n of James ( 1 9 8 8 ) , c o - a u t h o r o f t h e CT m anual. The t h e r a p i s t s were a l s o g i v e n t w o - h o u r s of g r o u p s u p e r v i s i o n a f t e r t h e b o o s t e r t r e a t m e n t phase began. The t h e r a p i s t g r o u p , w h i c h i n c l u d e d t h e r e s e a r c h e r , was c o m p r i s e d o f two male and two f e m a l e s t u d e n t s ; a l l o f whom 60 were e n r o l e d i n e i t h e r m a g i s t r a l or d o c t o r a l programs i n t h e Department of C o u n s e l l i n g P s y c h o l o g y . These t h e r a p i s t s v o l u n t e e r e d t o p a r t i c i p a t e i n t h i s s t u d y t o g a i n f u r t h e r e x p e r i e n c e i n m a r i t a l c o u n s e l l i n g . E x p e r i m e n t a l P r o c e d u r e s P r e - t e s t measures were c o m p l e t e d f o r a l l 10 c o u p l e s d u r i n g an i n i t i a l i n t e r v i e w c o n d u c t e d by t h e r e s e a r c h e r . D u r i n g t h e i n t e r v i e w c o u p l e s were t o l d of t h e g e n e r a l p r o c e d u r e s f o r t h e t r e a t m e n t and t e s t i n g a c t i v i t i e s i n t h e s t u d y . C o u p l e s were t h e n r a n d o m l y a s s i g n e d t o t r e a t m e n t and t h e r a p i s t . The r e s e a r c h e r i n s p e c t e d t h e i n i t i a l DAS s c o r e s f o r e a c h c o u p l e f o l l o w i n g a s s i g n m e n t t o g r o u p t o e n s u r e t h e g r o u p s were e v e n l y matched w i t h r e g a r d t o c o u p l e s ' l e v e l o f d i s t r e s s . The mean DAS s c o r e was 9 6 . 4 f o r t h e FB g r o u p and 96.9 f o r t h e DB g r o u p w i t h a p o o l e d s t a n d a r d d e v i a t i o n o f 12.62. The d i f f e r e n c e s between g r o u p means were n o t s t a t i s t i c a l l y s i g n i f i c a n t . N e x t , t h e t h e r a p i s t s f o r t h e FB g r o u p c o n t a c t e d t h e i r a s s i g n e d c o u p l e t o a r r a n g e t h e t r e a t m e n t s e s s i o n s . P o s t - t e s t m easures were o b t a i n e d a f t e r FB c o u p l e s c o m p l e t e d t h e i r l a s t s e s s i o n s . C o u p l e s a s s i g n e d t o t h e DB g r o u p c o m p l e t e d t h e d e p e n d e n t measures on t h e p o s t - t e s t o c c a s i o n as w e l l . Then t h e t r e a t m e n t c r o s s o v e r o c c u r r e d ; t h e DB g r o u p , f o r m e r l y t h e c o n t r o l c o n d i t i o n , r e c e i v e d t h e b o o s t e r s e s s i o n s and t h e FB 61 g r o u p , f o r m e r l y t h e e x p e r i m e n t a l g r o u p , e n t e r e d became a no-t r e a t m e n t f o l l o w - u p g r o u p . In b o t h g r o u p s , t h e a d m i n i s t r a t i o n of t h e f o u r b o o s t e r s e s s i o n s was s p a c e d o v e r a p e r i o d of s e v e n weeks a c c o r d i n g t o t h e a f o r e m e n t i o n e d f a d i n g p r o c e d u r e . C o u p l e s i n t h e DB g r o u p r e c e i v e d t h e i r f i r s t b o o s t e r s e s s i o n a p p r o x i m a t e l y e i g h t weeks a f t e r t h e FB g r o u p had commenced t r e a t m e n t . A f t e r t h e i r l a s t s e s s i o n , c o u p l e s i n t h e DB g r o u p c o m p l e t e d t h e i r p o s t - b o o s t e r m e a s u r e s . A l s o on t h i s o c c a s i o n , t h e FB c o u p l e s r e c e i v e d t h e i r f o l l o w - u p measures by m a i l . The c o u p l e s c o m p l e t e d t h e measures and r e t u r n e d them i n t h e e n c l o s e d e n v e l o p e s . No f o l l o w - u p measures were o b t a i n e d from t h e DB. The p a r t n e r s i n e a c h c o u p l e were t e s t e d i n d i v i d u a l l y t o e n s u r e t h a t t h e y d i d n o t i n f l u e n c e e a c h o t h e r d u r i n g t h e t e s t i n g p e r i o d . C o u p l e s c o m p l e t e d t h r e e measures on e a c h t e s t i n g o c c a s i o n : (1) The D y a d i c A d j u s t m e n t S c a l e (DAS) (2) C o m m u n i c a t i o n S c a l e (CS) (3) T a r g e t C o m p l a i n t s (TC) E a c h c o u p l e r e c e i v e d f o u r , 90-minute Communication S k i l l s T r a i n i n g b o o s t e r s e s s i o n s c o n d u c t e d a t t h e E d u c a t i o n C l i n i c on t h e U.B.C. campus. C o u p l e s i n t h e FB g r o u p r e c e i v e d t h e i r s e s s i o n s i n t h e p e r i o d F e b r u a r y t o March 1989, and c o u p l e s i n t h e DB g r o u p r e c e i v e d t h e i r s e s s i o n s i n t h e p e r i o d March t o A p r i l 1989. The s e s s i o n s were s p a c e d one, two, and t h r e e weeks a p a r t r e s p e c t i v e l y t o promote m a i n t e n a n c e of t h e c o m m u n i c a t i o n 62 s k i l l s and increase the couples' independence from the therapist. Four was the least number of booster sessions needed to establish t h i s fading technique as described in a study by Kingsley and Wilson (1977). A l l sessions were administered according to the CT Booster manual and audio taped to v e r i f y proper implementation (see Appendix B for a description of the manual). Research Measures The Dyadic Adjustment Scale (DAS) (Spanler r 1976) The DAS is a measure of marital adjustment that can be used to assess the l e v e l of adjustment experienced by either the individual or the couple to their r e l a t i o n s h i p . Factor analysis supports the four components of marital adjustment that comprise the DAS subscales: Dyadic Consensus (the degree to which partners agree on important issues), Dyadic Cohesion (the degree to which partners mutually engage in a c t i v i t i e s ) , Dyadic S a t i s f a c t i o n (the degree of partners' present s a t i s f a c t i o n and commitment to the r e l a t i o n s h i p ) , and A f f e c t l o n a l Expression (the degree to which partners express a f f e c t i o n and sex in the relationship) (Spanier, 1976). The t o t a l scale has 32 items with a score range of 0 to 151 and a reported r e l i a b i l i t y (Chronbach's alpha) of .96 (Spanier, 1976). According to Spanier (1976), the DAS has the following types of v a l i d i t y : content v a l i d i t y (determined by judges on 63 the basis of t h e o r e t i c a l dimensions), discriminant v a l i d i t y (discriminates between married and divorced populations), concurrent v a l i d i t y (correlates with the Marital Adjustment Test, Locke & Williamson, 1958), and construct v a l i d i t y (conforms to a t h e o r e t i c a l structure. Spanier (1976) established norms for married (114.8, SD 17.8) and divorced (70.7, SD 23.8) couples based on mean t o t a l couple scores. Couples were the unit of analysis in this study. Communication Scale (CS) (Olson r Fournler r and Druckman. 1985) The CS is a ten-item subscale in a marital inventory c a l l e d ENRICH (Evaluating and Nurturing Relationship Issues, Communication, and Happiness). The CS assesses an individual's feelings and b e l i e f s about marital communication. The authors report an internal consistency (Cronbach's alpha) of .68 based on a sample of 672 couples, and a test -retest r e l i a b i l i t y of .90 based on a sample of 115 individuals. The v a l i d i t y of the CS derives from PREPARE, a premarital inventory (Fournier, 1979) for which the subscale was o r i g i n a l l y developed. Fournier (1979) reports that the CS was s i g n i f i c a n t l y correlated with the Marital Adjustment Scale (Locke & Williamson, 1958). 64 Target Complaints (TC) (Battle. Imber. Hoehn-Sarlc. Stome. Nash and Frank. 1966) The TC is an individualized measure that evaluates treatment effectiveness on the basis of the degree of resolution of the three presenting problems or target complaints i d e n t i f i e d by the individual prior to treatment. Mintz and Kiesler ( 1 9 8 2 ) , two reviewers of this measure, report improvement ratings on the TC to be ef f e c t i v e outcome measures in various therapy studies. This measure is recommended by Waskow and Parloff (1975) as a core instrument for use in psychotherapy outcome research. The TC is comprised of three Llkert-type scales on which the subject rates the amount of change on three major problems in their r e l a t i o n s h i p . Battle et a l . ( 1 9 6 6 ) report that this measure correlated s i g n i f i c a n t l y with four other outcome measures, establishing i t s concurrent v a l i d i t y . The face v a l i d i t y of the TC derives from the process of subjects spontaneously generating their own target complaints. The authors also report r e l i a b i l i t y data from two studies: one in which subjects' rankings of problems from pre and post interviews were s i g n i f i c a n t l y correlated (Spearman's rho = . 6 8 ) and another in which showed consistency in target complaints reported to d i f f e r e n t interviewers. In the James study (1988) couples were asked to i d e n t i f y and p r i o r i t i z e three s p e c i f i c relationship issues that they 65 w i s h e d t o r e s o l v e i n t h e r a p y . At p o s t - t r e a t m e n t t h e y were a s k e d t o r a t e t h e d e g r e e of improvement on t h e s e c o m p l a i n t s . D a t a a n a l y s i s was ba s e d on the c l i e n t ' s r a t i n g s of improvement o f t h e p r i m a r y t a r g e t c o m p l a i n t o n l y , t o c o r r e c t f o r M i n t z and K i e s l e r ' s (1982) o b s e r v a t i o n t h a t v a r i a t i o n i n t h e s e v e r i t y o f t h e p r i m a r y p r o b l e m i s l e s s l i k e l y t h a n v a r i a t i o n i n t h e s e v e r i t y o f t h e s e c o n d and t h i r d c o m p l a i n t s . From t h i s , James (1988) r e a s o n e d t h a t t h e o v e r a l l s c o r e c o u l d t e n d t o be more h i g h l y c o r r e l a t e d w i t h p e r i p h e r a l c o m p l a i n t s r a t h e r t h a n w i t h t h e p r i m a r y p r o b l e m . The same a n a l y s i s p r o c e d u r e w i l l be used i n t h e b o o s t e r s t u d y . Post-treatment Structured interview The r e s e a r c h e r c o n d u c t e d a s t r u c t u r e d i n t e r v i e w w i t h e a c h c o u p l e a t t h e end o f t h e r a p y t o e x p l o r e t h e i r r e a c t i o n s t o t h e CT b o o s t e r s e s s i o n s and a s s e s s t h e i r p e r c e p t i o n s o f t h e impact o f t h e s e s s i o n s on t h e r e l a t i o n s h i p . The i n t e r v i e w q u e s t i o n s were a d d r e s s e d t o e a c h p a r t n e r c o n s e c u t i v e l y , and t h e i r v e r b a l r e s p o n s e s were r e c o r d e d i n w r i t i n g . See A p p e n d i x C f o r a co p y o f t h e i n t e r v i e w q u e s t i o n n a i r e . Implementation Check for the Integrity Of Treatment K a z d i n (1986) i n t e r p r e t s the I n t e g r i t y o f t r e a t m e n t as t h e e x t e n t t o w h i c h t r e a t m e n t has been c a r r i e d o ut as i n t e n d e d . He has i d e n t i f i e d t h e f o l l o w i n g s t e p s as b e i n g n e c e s s a r y t o e n s u r i n g t r e a t m e n t i n t e g r i t y : (1) t h e r a p i s t s a r e 66 trained to carry out the treatment procedures, (2) procedures are implemented to ensure that therapists continue to adhere to treatment procedures once therapy has commenced, (3) an assessment is conducted of how the treatment was a c t u a l l y carried out. In this study the following steps were taken to ensure treatment i n t e g r i t y : 1. Therapists were given a CT Booster Session Manual outlining the booster treatment intervention. 2. Therapists received a three hour t r a i n i n g session on the experimental and treatment procedures conducted by the researcher. 3. Therapists were given group supervision; individual supervision was given as requested. 4. Therapists were required to audio or video tape each session. Taped segments of therapy sessions were randomly selected for review by the researcher who used a CT implementation c h e c k l i s t (Guerney, 1977) to determine the extent to which the therapists adhered to the CT Booster manual. The CT implementation che c k l i s t defines seven CT and eight non-CT therapist interventions. The CT interventions were: reinforcement, structuring, modelling, encouraging/prompting, encouraging a mode switch, trouble shooting, and other non-codeable interventions consistent with CT. The non-CT interventions were: d i r e c t i v e lead, interpretation, suggestion/ explanation, encouragement 67 / a p p r o v a l , p e r s o n a l c r i t i c i s m , i n a p p r o p r i a t e l y d i r e c t e d t h e r a p i s t r e s p o n s e s , and f a i l u r e t o c o r r e c t . The u n i t of a n a l y s i s used i n t h e r a t i n g t h e t a p e segments was a " m e a n i n g f u l " t h e r a p i s t ' s s t a t e m e n t . A c c o r d i n g t o Guerney (1977), a m e a n i n g f u l s t a t e m e n t e x c l u d e d t h o s e i n s t a n c e s when t h e t h e r a p i s t ' s s t a t e m e n t was n o t an i n t e l l i g i b l e e x p r e s s i o n , s u c h as when t h e t h e r a p i s t was i n t e r r u p t e d . DATA ANALYSIS PROCEDURES The a n a l y s i s o f t h e d a t a was c o n d u c t e d i n two p a r t s : f i r s t , a p r e l i m i n a r y a n a l y s i s t o e s t a b l i s h a b a s e l i n e p r i o r t o a d m i n i s t e r i n g t h e b o o s t e r s e s s i o n s ; and s e c o n d , an a n a l y s i s of t h e t r e a t m e n t e f f e c t s o f t h e b o o s t e r s e s s i o n s . P r e l i m i n a r y A n a l y s i s A p r e l i m i n a r y a n a l y s i s was c o n d u c t e d p r i o r t o t h e a n a l y s i s o f b o o s t e r - t r e a t m e n t e f f e c t s f o r t h e p u r p o s e of e s t a b l i s h i n g t h e r e l a t i o n s h i p between t h e James (1988) s t u d y and t h i s s t u d y . T h i s a n a l y s i s p r o v i d e d a b a s e l i n e a g a i n s t w h i c h t o compare t h e h y p o t h e s i z e d t r e a t m e n t and m a i n t e n a n c e e f f e c t s o f t h e b o o s t e r i n t e r v e n t i o n . The p r e l i m i n a r y a n a l y s i s i n t h i s s t u d y t o o k t h e f o l l o w i n g f o r m : 01 T2 02 03 04 68 where T2 r e p r e s e n t s t h e EFT+CT t r e a t m e n t . 01, 02, and 03 r e p r e s e n t t h e p r e - t e s t , p o s t - t e s t , and f o u r - m o n t h f o l l o w - u p o c c a s i o n s i n t h e James (1988) s t u d y and 04 r e p r e s e n t s t h e b o o s t e r p r e - t e s t o c c a s i o n i n t h e c u r r e n t s t u d y . The p r e l i m i n a r y a n a l y s i s i n v o l v e d t h r e e a n a l y s e s i n c o r p o r a t i n g d a t a f r o m th e James (1988) s t u d y : a r e p e a t e d measures ANOVA, a t r e n d a n a l y s i s , and Neuman-Keuls p a i r w i s e c o m p a r i s o n s . F i r s t , a r e p e a t e d measures ANOVA was p e r f o r m e d on t h e 10 p a r t i c i p a t i n g c o u p l e s s c o r e s o v e r t h e f o u r o c c a s i o n s i n d i c a t e d a b o v e . T h i s a n a l y s i s was done t o e s t a b l i s h t h a t EFT+CT had a s i g n i f i c a n t t r e a t m e n t e f f e c t . S e c ond, a t r e n d a n a l y s i s was p e r f o r m e d t o e s t a b l i s h , as a b a s e l i n e , t h e p a t t e r n o f change i n c o u p l e mean s c o r e s a c r o s s t h e f o u r o c c a s i o n s . James (1988) r e p o r t e d r e g r e s s i o n i n s c o r e s f o u r months a f t e r t h e CT i n t e r v e n t i o n . T h i s a n a l y s i s was p e r f o r m e d b e c a u s e t h e downward t r e n d i n d i c a t i n g p o s t - t r e a t m e n t r e g r e s s i o n o f EFT+CT g a i n s was e x p e c t e d t o c o n t i n u e u n t i l t h e b o o s t e r p r e - t e s t o c c a s i o n . I t was i m p o r t a n t t o o b t a i n an o v e r a l l p i c t u r e o f t h e d e c l i n e i n s c o r e s o v e r t i m e s i n c e i t was h y p o t h e s i z e d t h a t t h e b o o s t e r s e s s i o n s would r e v e r s e t h i s t r e n d . In o t h e r words a r e v e r s a l i n t h e downward t r e n d a f t e r t h e b o o s t e r i n t e r v e n t i o n would s u p p o r t t h e e f f i c a c y of b o o s t e r m a i n t e n a n c e s e s s i o n s i n r e v e r s i n g p o s t - t r e a t m e n t r e g r e s s i o n t h a t had begun a f t e r t e r m i n a t i o n of t h e EFT+CT t r e a t m e n t . T r e n d a n a l y s i s i s deemed a p p r o p r i a t e where t h e r e Is a c o n t i n u u m u n d e r l y i n g t h e l e v e l s of t h e i n d e p e n d e n t v a r i a b l e 69 ( G l a s s & H o p k i n s , 1 9 8 4 ) . These a u t h o r s s t a t e t h a t t r e n d a n a l y s i s a l l o w s t h e s t a t i s t i c a l e x a m i n a t i o n o f t h e shape o f t h e c u r v e t h a t r e s u l t s when t h e means o f t h e d e p e n d e n t v a r i a b l e s a r e p l o t t e d f o r the l e v e l s o f t h e i n d e p e n d e n t v a r i a b l e . In t h i s c a s e , c o u p l e s ' s c o r e s a r e p l o t t e d a g a i n s t t i m e . T r e n d a n a l y s i s c a n be "more i n f o r m a t i v e t h a n m u l t i p l e c o m p a r i s o n s " ( G l a s s & H o p k i n s , 1984, p.386) w h i c h t e n d t o f r a g m e n t t h e o v e r a l l c o n t i n u u m i n t h e d a t a i n t o p a r t s . S i n c e s u c h a c o n t i n u u m e x i s t s i n t h e d a t a i n t h i s s t u d y , t r e n d r e s u l t s c o u l d enhance the I n t e r p r e t a t i o n o f t h e m u l t i p l e c o m p a r i s o n s . The t h i r d t a s k i n t h e p r e l i m i n a r y a n a l y s i s was t o c o n d u c t Neuman-Keuls p a i r w i s e c o m p a r i s o n s of t h e g r o u p means o v e r t h e a f o r e m e n t i o n e d o c c a s i o n s . The p u r p o s e o f t h i s a n a l y s i s was t o e s t a b l i s h w h i c h means were s i g n i f i c a n t l y d i f f e r e n t a f t e r f i n d i n g a s i g n i f i c a n t F s t a t i s t i c w i t h t h e r e p e a t e d measures ANOVA. D e s i g n C o n s i d e r a t i o n s i n t h e A n a l y s i s o f B o o s t e r E f f e c t s The c r o s s o v e r d e s i g n f i r s t a p p e a r e d i n a g r i c u l t u r a l r e s e a r c h c o n d u c t e d i n t h e 1940's, and has been used e x t e n s i v e l y i n c l i n i c a l p h a r m a c o l o g i c a l r e s e a r c h s i n c e t h e n . More r e c e n t l y , c r o s s o v e r d e s i g n s have a p p e a r e d i n c l i n i c a l p s y c h o l o g i c a l r e s e a r c h on t h e e f f e c t i v e n e s s o f d i f f e r e n t t h e r a p i e s ( K a z d i n , 1 9 8 0 ) . One s t u d y has been c o n d u c t e d u s i n g t h e c r o s s o v e r d e s i g n ( H i g g i n s , 1990) t o e v a l u a t e t r a i n i n g and 70 maintenance of tra i n i n g e f f e c t s . This is also the aim of the current study. Despite the apparent longevity of this popular, s c i e n t i f i c a l l y rigorous and e t h i c a l design, there seems to be l i t t l e written about the s t a t i s t i c a l treatment of the data. Armitage and H i l l s (1982) note that " One might have thought that i t s s t a t i s t i c a l properties were...well documented. However, i t is d i f f i c u l t to find adequate discussions of the design in textbooks" (p. 119). Epstein and Tripodi (1977) also neglect to specify the data analysis procedures to use with the crossover design. However, they do suggest four comparisons relevant to an experiment, l i k e this study, with one intervention strategy and two comparison groups. F i r s t , both groups are pre-tested on the dependent measures prior to intervention to establish group equivalence. Second, as in c l a s s i c a l comparative experimental/control group design, pre/post-test comparisons between and within groups are made, after the f i r s t intervention, to test for treatment e f f e c t s . Third, comparisons made within and between groups after the treatment crossover r e p l i c a t e the experiment and determine whether treatment affected the groups equally. Fourth, comparisons at post-test, and follow-up within the FB group indicate whether treatment has been maintained over time. Figure 1 is a schematic representation of the two-factor, time-lagged crossover experimental design used in this study. 71 The two levels of the experimental independent variable, factor A (group), are first-booster and delayed-booster. The treatment phases in both groups are indicated by the shaded bars. Factor A is a between-group fixed factor. Factor B, occasion, is a fixed, within-groups, repeated-measures factor. The three levels of factor B (occasion) are 04, 05, and 06. Factor B Testing Occasion Factor A Group First-booster 1 2 3 Group (FB) Delayed-booster Group (DB) 4 5 6 Figure 1. Design of the Six C e l l Means Used To Test the Research Hypotheses. Subjects and therapists are random factors. Treatment was f u l l y crossed with group. The random factor, therapist, was not included in th i s design because the same therapists did not deliv e r treatment to the same couples over a l l six measurement occasions. In Figure 1, the numbers 1 to 6 represent the c e l l s of the 2X2 ANOVA designs used to test the hypotheses in the booster study. The c e l l s , which represent a l l possible combinations of levels of factor A and factor B, each contain five observations, one for each couple in the group. 72 To t e s t t h e r e s e a r c h h y p o t h e s e s i n t h i s s t u d y i t was i m p o r t a n t t o employ a d a t a a n a l y s i s p r o c e d u r e t h a t would compare t h e d i f f e r e n t i a l e f f e c t s , on two e q u i v a l e n t g r o u p s , of a d m i n i s t e r i n g i d e n t i c a l t r e a t m e n t s a t d i f f e r e n t t i m e s . H i g g i n s (1990) s t u d y o f empathy t r a i n i n g w i t h m e d i c a l s t u d e n t s s u g g e s t e d an a p p r o p r i a t e model f o r t e s t i n g s u c h h y p o t h e s e s w i t h d a t a from a c r o s s o v e r c o n t r o l e x p e r i m e n t . S t a t i s t i c a l T r e a t m e n t o f t h e D a t a F o l l o w i n g H i g g i n s (1990) s t r a t e g y , I p e r f o r m e d a s e r i e s o f 2X2 r e p e a t e d - m e a s u r e s a n a l y s e s o f v a r i a n c e w i t h one b e t w e e n - g r o u p s f a c t o r ( g r o u p ) and one w i t h i n - g r o u p s r e p e a t e d f a c t o r ( o c c a s i o n ) . These a n a l y s e s were r e p e a t e d t h r e e t i m e s , once f o r e a c h d e p e n d e n t measure: DAS, CS, TC. The .05 l e v e l of s i g n i f i c a n c e was u t i l i z e d t o t e s t t h e F r a t i o s f o r t h e main e f f e c t s . A d e p e n d e n t t - t e s t was u s e d t o t e s t f o r l o n g t e r m m a i n t e n a n c e e f f e c t s a t t h e .05 l e v e l o f s i g n i f i c a n c e . N e x t , a s e r i e s o f d e p e n d e n t t - t e s t s were p e r f o r m e d t o t e s t f o r w a i t -l i s t and s h o r t t e r m m a i n t e n a n c e e f f e c t s . To be s u r e t h e r e was no c h a n g e , a r e l a x e d a l p h a of .25 was used f o r t h e s e c o n t r a s t s . R e l a x i n g a l p h a i n c r e a s e s t h e l i k e l i h o o d o f a Type I e r r o r , b u t r e d u c e s t h e l i k e l i h o o d of a Type I I e r r o r . In t h e c a s e o f w a i t - l i s t and m a i n t e n a n c e e f f e c t s , i t was more i m p o r t a n t t o r e d u c e Type I I e r r o r i n o r d e r t o make a c l a i m t h a t t h e s c o r e s d i d n o t change o v e r t i m e . T h a t i s , i f t h e 73 r e s u l t s a r e s t a t i s t i c a l l y i n s i g n i f i c a n t , e ven w i t h t h e l a r g e a l p h a , a c l a i m c a n be made t h a t t h e r e a r e no w a i t l i s t e f f e c t s and s c o r e s were m a i n t a i n e d o v e r t i m e . E f f e c t s i z e s were a l s o c a l c u l a t e d f o r t h e g r o u p means. " The e f f e c t s i z e m e t r i c i s a u s e f u l d e s c r i p t i v e e s t i m a t e of t h e m a g n i t u d e o f t h e d i f f e r e n c e between means when t h e d e p e n d e n t v a r i a b l e has an a r b i t r a r y n u m e r i c a l s c a l e " ( G l a s s and H o p k i n s , 1984, p . 3 7 3 ) . E f f e c t s i z e s e x p r e s s t h e m a g n i t u d e of t r e a t m e n t g a i n s i n s t a n d a r d d e v i a t i o n u n i t s (Cohen, 1988 ). F o l l o w i n g t h e p r o c e d u r e s u g g e s t e d by Cohen ( 1 9 8 8 ) , t h e e f f e c t s i z e s i n t h i s s t u d y were c a l c u l a t e d by t a k i n g t h e d i f f e r e n c e i n t h e p r e - t e s t and p o s t - t e s t means and d i v i d i n g i t by t h e p o o l e d p r e - t r e a t m e n t s t a n d a r d d e v i a t i o n . D e s i g n s Used t o T e s t t h e R e s e a r c h H y p o t h e s e s T h i s s e c t i o n p r e s e n t s e a c h r e s e a r c h h y p o t h e s i s f o l l o w e d by t h e c o r r e s p o n d i n g s t a t i s t i c a l h y p o t h e s e s s p e c i f y i n g t h e c e l l s u s e d t o t e s t t h a t h y p o t h e s i s . The s t a t i s t i c a l h y p o t h e s e s a r e s t a t e d i n n u l l f o r m . H l ( a ) : C o u p l e s i n t h e f i r s t - b o o s t e r g r o u p , who r e c e i v e b o o s t e r s e s s i o n s , w i l l d e m o n s t r a t e s t a t i s t i c a l l y s i g n i f i c a n t l y h i g h e r s c o r e s a t t h e b o o s t e r p o s t - t e s t o c c a s i o n on measures o f m a r i t a l a d j u s t m e n t (DAS), c o m m u n i c a t i o n ( C S ) , and t a r g e t c o m p l a i n t r e d u c t i o n (TC) t h a n w i l l w a i t i n g - l i s t c o u p l e s i n t h e d e l a y e d - b o o s t e r g r o u p . 74 The n u l l h y p o t h e s i s i s s t a t e d a s : HO: ( U a - U i ) - ( U a - U 4 ) = 0 T h i s a n a l y s i s i s a c l a s s i c p r e - p o s t d e s i g n w i t h a c o n t r o l g r o u p . The p u r p o s e o f t h i s a n a l y s i s was t o d e t e r m i n e whether t h e r e i s a t r e a t m e n t e f f e c t and whether t h i s e f f e c t i s g r e a t e r f o r t h e t r e a t e d FB g r o u p t h a n f o r t h e u n t r e a t e d DB c o n t r o l g r o u p . The Group-By-Time I n t e r a c t i o n was o f p r i m a r y i n t e r e s t i n t e s t i n g t h i s h y p o t h e s i s . T h a t i s , i f t h e b o o s t e r t r e a t m e n t has a s u f f i c i e n t e f f e c t , t h i s i n t e r a c t i o n would be s i g n i f i c a n t . H l ( b ) : C o u p l e s i n t h e f i r s t - b o o s t e r g r o u p , who r e c e i v e b o o s t e r s e s s i o n s , w i l l d e m o n s t r a t e s t a t i s t i c a l l y s i g n i f i c a n t l y h i g h e r s c o r e s on t h e DAS, CS, and TC on t h e b o o s t e r p o s t - t e s t and b o o s t e r f o l l o w - u p o c c a s i o n s t h a n w i l l w a i t i n g - l i s t c o u p l e s i n t h e d e l a y e d - b o o s t e r g r o u p . The n u l l h y p o t h e s i s i s s t a t e d a s : HO: < - *--±-a= > = o T h i s a n a l y s i s i s a p o s t - t e s t o n l y d e s i g n w i t h a c o n t r o l g r o u p . The p u r p o s e o f t h i s a n a l y s i s was t o t e s t whether t h e b o o s t e r t r e a t m e n t e f f e c t s were m a i n t a i n e d f o r t h e FB g r o u p i n t h e p o s t - t r e a t m e n t f o l l o w - u p p e r i o d and whether t h e b o o s t e r t r e a t m e n t e f f e c t was g r e a t e r f o r t h e t r e a t e d g r o u p t h a n t h e u n t r e a t e d g r o u p . T h i s a n a l y s i s compared p o s t - t e s t and f o l l o w -up c e l l s f o r t h e FB g r o u p w i t h p r e and p o s t - w a i t c e l l s f o r t h e 75 DB group. The Group main eff e c t was the contrast of primary interest in testing this hypothesis. H l ( c ) : Couples in the first-booster and delayed-booster groups, who receive booster sessions at d i f f e r e n t times, w i l l demonstrate a s t a t i s t i c a l l y s i g n i f i c a n t increase in scores on the DAS, CS, and TC between' the pre-test and post-test occas ions. The n u l l hypothesis is stated as: This analysis is a pre-post design with r e p l i c a t i o n and no control group. The purpose of t h i s analysis is to test whether treatment has a similar e f f e c t for both groups. The contrast of interest here, the Time main e f f e c t , would be s i g n i f i c a n t i f the groups were equivalent, and the treatment potent. H2: Couples who are in the delayed-booster control group w i l l not improve on the DAS, CS, and TC during the w a i t i n g - l i s t per iod. The n u l l hypothesis is stated as: HO: U s - u.* = 0 H3: Couples in the fir s t - b o o s t e r group, who receive booster sessions, w i l l maintain scores on the DAS, CS, and TC between HO: = 0 76 t h e b o o s t e r p o s t - t e s t and b o o s t e r f o l l o w - u p o c c a s i o n s . The n u l l h y p o t h e s i s i s s t a t e d a s : HO: U a - U 2 = 0 H4: C o u p l e s i n t h e f i r s t - b o o s t e r g r o u p , who r e c e i v e CT b o o s t e r s e s s i o n s a f t e r t e r m i n a t i o n o f EFT+CT, w i l l n o t d i f f e r i n s c o r e s on t h e DAS, CS, and TC a t t h e b o o s t e r p o s t - t e s t and t h e p o s t - t e s t o c c a s i o n i n t h e James (1988) s t u d y . The n u l l h y p o t h e s i s i s s t a t e d a s : HO: U a - u a ' = 0, where u 2 ' Is t h e mean of t h e f i r s t -b o o s t e r g r o u p a s s e s s e d a t James' (1988) EFT+CT p o s t -t r e a t m e n t o c c a s i o n , and U s i s t h e mean a t t h e b o o s t e r p o s t - t r e a t m e n t o c c a s i o n . In t h i s s t u d y , H y p o t h e s i s 1 ( c ) i s t h e most p o w e r f u l t e s t o f a b o o s t e r t r e a t m e n t e f f e c t b e c a u s e t h e p r e - b o o s t e r s c o r e s f o r b o t h g r o u p s a r e c o l l a p s e d and compared w i t h t h e c o l l a p s e d p o s t - b o o s t e r s c o r e s . In t h i s way t h e 10 t r e a t e d c o u p l e s p o s t -b o o s t e r s c o r e s a r e compared w i t h 10 u n t r e a t e d c o u p l e s p r e -b o o s t e r s c o r e s . In c o n t r a s t , t h e d e s i g n s i n H y p o t h e s i s 1 ( a ) and 1 ( b ) compare o n l y f i v e t r e a t e d c o u p l e s s c o r e s w i t h 15 u n t r e a t e d c o u p l e s s c o r e s . H y p o t h e s i s 2 t e s t s w a i t - l i s t e f f e c t s and h y p o t h e s i s 3(a) and (b) t e s t s h o r t and l o n g t e r m m a i n t e n a n c e e f f e c t s r e s p e c t i v e l y . 77 CHAPTER IV: RESULTS The r e s u l t s o f t h e d a t a a n a l y s e s a r e p r e s e n t e d i n t h i s c h a p t e r . The c h a p t e r opens w i t h a d e s c r i p t i o n o f t h e sample and a s t a t e m e n t on t h e r e s e a r c h p r o c e d u r e s . N e x t, t h e r e s u l t s o f t h e p r e l i m i n a r y t h e a n a l y s e s a r e d i s c u s s e d . The r e s u l t s o f t h e a n a l y s e s p e r t a i n i n g t o t h e r e s e a r c h h y p o t h e s e s a r e t h e n p r e s e n t e d under t h r e e s u b - s e c t i o n s : t r e a t m e n t e f f e c t s o f b o o s t e r s e s s i o n s , w a i t - l i s t e f f e c t s , and s h o r t and l o n g t e r m m a i n t e n a n c e e f f e c t s . A summary of t h e r e s u l t s c o n c l u d e s t h e c h a p t e r . IMPLEMENTATION CHECK To e n s u r e t h a t t h e t r e a t m e n t i n t e r v e n t i o n was a d m i n i s t e r e d c o n s i s t e n t l y by t h e r a p i s t s , a CT B o o s t e r T r e a t m e n t manual d o c u m e n t i n g t h e r e s e a r c h p r o t o c o l was g i v e n t o a l l t h e r a p i s t s . The t h e r a p i s t s r e c e i v e d t h r e e h o u r s of t r a i n i n g and t h r e e h o u r s of g r o u p s u p e r v i s i o n i n i m p l e m e n t i n g t h e CT B o o s t e r i n t e r v e n t i o n . In a d d i t i o n , t h e r e s e a r c h e r r a n d o m l y s e l e c t e d 10 m i n u t e segments o f t h e b e h a v i o r a l r e h e a r s a l s e c t i o n o f t h e c t b o o s t e r s e s s i o n s and r a t e d t h e r a p i s t s t a t e m e n t s as CT or non-CT i n t e r v e n t i o n s a c c o r d i n g t o t h e CT Component I m p l e m e n t a t i o n C h e c k l i s t (Guerney, 1977). The CT Component I m p l e m e n t a t i o n C h e c k l i s t i s d e s c r i b e d i n t h e 78 James (1988) study. A t o t a l of 10 sessions representative of the four booster sessions were reviewed by the researcher. Of the 141 therapist statements rated, seven were categorized as non-CT. This proportion f a l l s within l i m i t s of the c r i t e r i o n of five per cent for treatment i n t e g r i t y set in the James (1988) study. TESTS OF GROUP EQUIVALENCE Because the sample in t h i s study consisted of 10 of James (1988) 14 o r i g i n a l EFT+CT couples, i t was necessary to estab l i s h that couples who participated were not c h a r a c t e r i s t i c a l l y d i f f e r e n t from the couples who did not pa r t i c i p a t e . Results of an independent t- t e s t on the mean scores at the i n i t i a l four-month follow-up showed no s i g n i f i c a n t differences between participants (M. = 100.5) and non-participants (H = 98.5) [t(12) = .870, p < .25]. The equivalence of the participants and non-participants allows the results from this study to be generalized with confidence to a l l of the couples in James (1988) study. It was also important to ensure group equivalence on the dependent measures before treatment. An independent t-test was performed on the pre-test means of both groups in the booster study No s i g n i f i c a n t differences were found between group one (U = 96.4) and group two ML = 96.9), tt(8) = .06, p < .25] . 79 RESULTS OF PRELIMINARY ANALYSES Table 1 presents the results of a repeated measures ANOVA on the 10 p a r t i c i p a t i n g couples mean DAS scores over four occasions: pre-test, post-test, and four month follow-up in the James (1988) study and booster pre-test in this study. Results showed a s i g n i f i c a n t difference in mean scores over time, [F(3, 27) = 13.80, p < .0001]. This finding supports the i n i t i a l success of the EFT+CT intervention. Following the repeated measures ANOVA, the Student Neuman-Keuls method of pairwise comparisons was used to determine which means were s i g n i f i c a n t l y d i f f e r e n t . Table 2 shows these r e s u l t s . A s i g n i f i c a n t difference was found between James' (1988) EFT+CT pre-test and each of the other occasions; EFT+CT post-test, EFT+CT follow-up, and booster pre-test. S i g n i f i c a n t differences were also found between EFT+CT post-test and EFT+CT follow-up, and EFT+CT post-test and booster pre-test. No s i g n i f i c a n t differences were found between EFT+CT follow-up and booster pre-test. Results of the trend analysis indicated that there was a s i g n i f i c a n t quadratic trend [F(2, 27) = 14.20, p< .0001] in the data spanning the period from James' (1988) EFT+CT pre-test to the booster pre-test in th i s study. A summary trend analysis is presented in Table 3. 80 150 140 130 120 110 100 90 80 70 _ i _ _ i _ 01 P r e 02 P o s t L e g e n d : = FB g r o u p o = DB g r o u p A = EFT+CT g r o u p Q 03 F.U. -H- 04 P r e 05 P o s t 06 F.U. O c c a s i o n s F i g u r e 2: Mean S c o r e s on D y a d i c A d j u s t m e n t S c a l e a t EFT+CT P r e - t e s t , P o s t - t e s t , and 4-month F o l l o w - u p , and B o o s t e r P r e - t e s t , P o s t - t e s t and 4-month F o l l o w -up . 50 .45 c40 £35 o u c30 0 « 225 20 Legend: = FB groupo = DB groupA = EFT+CT gro u p D -H-01 02 03 04 Pre Post F.U. Pre Occa s i o n s 05 Post 06 F.U. F i g u r e 3: Mean Scores on Communication S c a l e a t EFT+CT P r e - t e s t , P o s t - t e s t , and 4-month F o l l o w -up, and Booster P r e - t e s t , P o s t - t e s t and 4-month Follow-up. 81 5 I I I y!/ I I 1 01 02 03 04 05 06 Pre Post F.U. Pre Post F.U. Occasions Figure 4: Mean Scores on Target Complaints at EFT+CT Pre-test, Post-test, and 4-month Follow-up, and Booster Pre-test, Post-test and 4-month Foilow-up. 8 2 Table 1. Scores Across Four Occasions: Pre-test r Post-test and 4-month Follow -UD in the James (1988) Studv. and Pre-booster in the Booster Study pre-test post-test 4-month pre-f. u. booster X X X X S S df F P 87.85 107.70 100.55 96.65 2052.97 3,27 13.80 .0001* Ngte : l . n. = i o * = s i g n i f i c a n t at .0001 Table 2. Student Newman-Keuls Analysis of DAS Mean Scores Across Four Occasions: Pre-test. Post-test and 4-month Follow-us In the James (1999) study and Pre-booster i n the Booster Study Occasion X M Grouping MSE 27 49.605 Pre-test 87.85 10 A Post-test 107.70 10 B 4-mo. f.u. 100.55 10 C pre-booster 96.65 10 C Note: 1. per-contrast alpha = .05 2. Means with the same l e t t e r are not s i g n i f i c a n t l y d i f f e r e n t Table 3 . TL&M A n a l y s i s of CAS Means Scores Across Four Occasions: Pre-test. Post-test, and 4-month FO11OW-UD in the James (1988) studv. and Pre-booster in the Booster Study Contrast df S S M S E F P T Linear 1 185.28 1339. 34 3.74 .0638 T d r a t i c 1 1410.16 1339 . 34 28. 43 .0001* Note: i . a = io * = s i g n i f i c a n t at .0001 83 Table 4. Table of Means and Standard Deviations for Dependent Measures with Couple Mean Score as the Unit of Analysis. FB Pre- Post- 4-month Group booster booster F. U. Occasion DB Group Pre-wait Post-wait Booster Measure X X X FB 96.40 104.50 94.20 DAS (16.21) (15.15) (22.96) DB 96.90 90.80 95.40 (9.04) (9.89) (11.95) FB 29.90 34.90 32.40 CS (7.66) (8.51) (8.85) DB 26.60 26.10 27.80 (2.41) (2.16) (4.48) TC FB DB 3.50 (1.12) 3.40 (0.65) 4.30 ( .76) 2.80 (1.04) 3.80 ( .91) 3 . 30 (1.48) Note: 1. a = 10 2. FB = First-booster group DB = Delayed-booster group 3. DAS = Dyadic Adjustment Scale; CS = Communication Scale; TC = Target Complaints 84 Table 5. Analyses of Variance for Each Dependent Variable for Hypothesis 1 (a); Comparison of C e l l s 1 & 2 with 4 & 5 5(a) Dyadic Adjustment Scale Source SS df MS Between Groups [G] 217.79 1 217.79 .73 .419 Error 2405.06 8 300.63 Within Time [T] 5.00 1 5.00 .14 .720 G x T 252.05 1 5.00 6.94 .030* Error 290.69 8 36.34 * = s i g n i f i c a n t at .05 5(b) Communication Scale Source SS df MS Between Groups [G] 183.01 1 183.01 2.88 .128 Error 508.56 8 63.57 Within Time [T] 25.31 1 25.31 3. 5>1 .098 G x T 37.81 1 37.81 5.24 .051 Error 57.75 8 7.22 85 5(c) T a r g e t C o m p l a i n t s Source SS df MS F P Between Groups [G] 3.20 1 3.20 3.18 .112 Error 8.05 8 1.01 Within Time [T] .05 1 .05 .08 .789 G x T 2 . 45 1 2 . 45 3.73 .089 Error 5.25 8 .66 Table 6. Analyses of Variance for Each Dependent Variable for Hypothesis K b ) : Comparison of C e l l s 2 & 3 with 4 & 5 6(a) Dyadic Adjustment scale Source SS df MS Between Groups [G] Error 151.25 3015.13 1 8 151.25 376.89 .40 544 Within T i me [ T ] G x T Error 336.19 22.05 738.69 1 1 8 336.19 22.05 92.34 3 .64 .24 093 638 86 6(b) Communication Scale Source SS df MS Between Groups [G] Error 266.45 549.55 1 8 266.45 68 .69 3.88 084 Within Time [T] G x T Error 11.25 5.00 95.25 1 1 8 11.25 5.00 11.91 95 . 42 .359 .535 6(c) Target Complaints Source SS df MS Between Group [G] Error 4.51 6.75 1 8 4.51 .85 5.35 .049* W i t h i n Time [T] G x T Error 1.51 .01 4.85 1 1 8 1.51 .01 .61 2.50 .02 .153 .889 * = s i g n i f i c a n t at .05 87 Table 7. Analyses o£ Variance for Dependent Variable for Hypothesis 1(C): Comparison of Ce l l s 1 & 5 with 2 & 6 7(a) Dyadic Adjustment Scale Sour SS df MS Between Groups [G] Error 270.10 2722.06 1 8 270.10 340.26 79 400 Within Time [Tl G x T Error 201.60 15.33 217.19 1 1 8 201.60 15.33 27.15 7.43 .57 .026* .474 * = s i g n i f i c a n t at .05 7(b) Communication Scale Source SS df MS Between Groups [G] Error 148.51 537.01 1 8 148.51 67.13 2.21 175 Within Time t G x T Err 56.11 13.61 86.40 1 1 8 56.11 13.61 10.80 5.20 1.26 .052 . 294 88 7(c) Target complaints Source SS df MS Between Groups [G] Error 3.61 17.50 1 8 3.61 2.19 1.65 .235 Within Time [T1 G x T Error 2.11 .11 2.90 1 1 8 2.11 .11 .36 5.83 . 31 042* 593 * = s i g n i f i c a n t at .05 89 T a b l e 8. R e s u l t s o f P a i r e d t - T e s t s f o r S h o r t - t e r m M a i n t e n a n c e a n d W a i t - l i s t E f f e c t s : H y p o t h e s e s 2 ( C o m p a r i s o n o f C e l l s 2 & 3 ) a n d 3 ( C o m p a r i s o n o f C e l l s 4 & 5 ) M e a s u r e DAS CS T C M a i n t e n a n c e E f f e c t s ( C e l l 2 v s c e l l 3 ) C e l l 2 M e a n ( p o s t ) 1 0 4 . 5 0 3 4 . 9 0 4 . 3 0 C e l l 3 Mean ( f o l l o w - u p ) 9 4 . 2 0 3 2 . 4 0 3 . 8 0 n = 5 t 1 . 3 5 . 8 5 1 . 2 0 p . 2 5 . 4 4 . 3 0 W a i t - l i s t E f fec t s ( C e l l 4 v s C e l l 5 ) C e l l 4 mean ( p r e - w a i t ) 9 6 . 9 0 2 6 . 6 0 3 . 4 0 C e l l 5 mean ( p o s t - w a i ) 9 0 . 8 0 2 6 . 1 0 2 . 8 0 n = 5 t 1 . 5 4 . 5 1 1 . 0 8 p . 2 0 * . 6 4 . 3 4 * = s i g n i f i c a n t a t . 2 5 9 0 Table 9. Results of Dependent t-Tests for Hypothesis 4: Long Term Maintenance Ef f e c t s [Comparison of James' (1988) Post-test and Booster Post-test Means for FB Group! Measure DAS CS TC Occasion X X X Post-test 108.40 37.50 4.70 Post-booster 104.50 34.90 4 . 30 n= 5 t 1.37 1.97 1.37 P .22 .12 .22 Note 1. p = .05 Table 10. Effe c t Sizes For Dependent Measures Occasion E f f e c t Measure SD Size DAS Group 1 Group 2 W a i t - l i s t CS Group 1 Group 2 W a i t - l i s t TC Group 1 Group 2 W a i t - l i s t 96.40 96.90 29.90 26.60 3.50 3.40 104.50 90.80 90.80 34.90 26.10 26.10 4.30 2 .80 2.80 95.40 27.80 3.30 11.71 4.08 94 + .69 + .39 -.52 + 1.05 + .35 -.10 85 53 64 Note: 1. a = 10 2. SD = pooled pre-treatment standard deviation 91 TREATMENT EFFECTS OF BOOSTER SESSIONS The r e s u l t s of a n a l y s e s of H y p o t h e s i s 1 ( a ) , K B ) , and 1 ( c ) p e r t a i n t o t h e t r e a t m e n t e f f e c t s of t h e CT b o o s t e r s e s s i o n s . T a b l e 4 shows t h e g r o u p means and s t a n d a r d d e v i a t i o n s f o r t h e d e p e n d e n t measures o v e r t h e t h r e e t e s t i n g o c c a s i o n s t h e b o o s t e r s t u d y . The g r a p h s i n F i g u r e s 2, 3, and 4 t r a c k t h e t r a j e c t o r y o f t h e t r e n d o f g r o u p mean s c o r e s f o r e a c h d e p e n d e n t measure, from James' (1988) p o s t - t e s t o c c a s i o n t o t h e b o o s t e r f o l l o w - u p o c c a s i o n i n t h i s s t u d y . H y p o t h e s i s 1 ( a ) : C o u p l e s who a r e i n t h e f i r s t - b o o s t e r t r e a t m e n t g r o u p , w i l l d e m o n s t r a t e s i g n i f i c a n t l y h i g h e r s c o r e s a t t h e b o o s t e r p o s t - t r e a t m e n t o c c a s i o n on t h e DAS, CS, and TC t h a n w i l l w a i t i n g - l i s t c o u p l e s i n t h e d e l a y e d - b o o s t e r g r o u p . T a b l e 5 shows t h e r e s u l t s o f t h e 2 x 2 r e p e a t e d measures a n a l y s e s o f v a r i a n c e on t h e d e p e n d e n t measures f o r H y p o t h e s i s 1 ( a ) . The r e s e a r c h q u e s t i o n h e r e i s whether t h e b o o s t e r t r e a t m e n t has an e f f e c t and whether t h i s e f f e c t i s g r e a t e r f o r t h e t r e a t e d g r o u p t h a n t h e u n t r e a t e d g r o u p . The c o m p a r i s o n o f i n t e r e s t i n e s t a b l i s h i n g a s i g n i f i c a n t t r e a t m e n t e f f e c t i s t h e g r o u p - b y - t i m e i n t e r a c t i o n . D y a d i c A d j u s t m e n t S c a l e R e s u l t s of t h e 2 x 2 ANOVA f o r t h e DAS, c o m p a r i n g c e l l s 1 & 2 w i t h 4 & 5, a r e shown i n T a b l e 5 ( a ) . The g r o u p - b y - t i m e i n t e r a c t i o n i s s t a t i s t i c a l l y s i g n i f i c a n t [ F ( l , 8 ) = 6.94, 92 p = .030] i n d i c a t i n g t h a t t h e t r e a t e d FB c o u p l e s s c o r e d s i g n i f i c a n t l y h i g h e r t h a n t h e w a i t i n g - l i s t c o u p l e s i n t h e DB g r o u p . I n s p e c t i o n of t h e means i n T a b l e 4 shows t h a t t h e p o s t -t e s t mean f o r t h e FB g r o u p i s h i g h e r t h a n any of t h e o t h e r c e l l means. The g r a p h o f g r o u p means f o r t h e DAS measure i n F i g u r e 2 shows t h e i n c r e a s e i n p o s t - t r e a t m e n t s c o r e s a t 02 f o r t h e FB g r o u p . E v i d e n c e of a downward t r e n d c a n be s e e n i n t h e d e c l i n e o f s c o r e s from 02 t o 04 f o r b o t h g r o u p s . A r e v e r s a l o f t h i s t r e n d i s n o t e d a t 05, t h e p o s t - t r e a t m e n t o c c a s i o n f o r t h e FB g r o u p , i n d i c a t i n g t h e e f f e c t o f t h e b o o s t e r t r e a t m e n t . A s i m i l a r d e c l i n e i s o b s e r v e d f o r t h e DB g r o u p s c o r e s . H e r e , t h e d e c l i n e e x t e n d s from 02 t o 05. A r e v e r s a l o f t h i s t r e n d i s o b s e r v e d a t 06, t h e p o s t - t r e a t m e n t o c c a s i o n f o r t h i s g r o u p . Communication sc a l e T a b l e 5(b) shows t h e r e s u l t s o f t h e 2 x 2 ANOVA f o r t h e CS c o m p a r i n g c e l l s 1 & 2 w i t h 4 & 5. The g r o u p - b y - t i m e I n t e r a c t i o n i s n o t s t a t i s t i c a l l y s i g n i f i c a n t IF (1,8) = 5.24, p = .051], b u t t h e r e was a s t r o n g e f f e c t i n t h e h y p o t h e s i z e d d i r e c t i o n . The f a i l u r e t o a c h i e v e s i g n i f i c a n c e h e r e c a n be a t t r i b u t e d t o t h e low power o f t h e t e s t r e s u l t i n g f r o m t h e s m a l l sample s i z e . T a b l e 4 shows t h a t t h e p o s t - t e s t mean f o r t h e FB g r o u p i s h i g h e r t h a n any o t h e r c e l l mean. The g r a p h o f g r o u p means f o r t h e CS i n F i g u r e 3 shows an i n c r e a s e In t h e FB g r o u p ' s p o s t - t e s t s c o r e s a t T5 i n c o n t r a s t t o t h e downward t r e n d i n s c o r e s e s t a b l i s h e d between EFT+CT 93 post-test at T2 and the booster pre-test occasion at T4. A similar downward trend is seen in the DB group's mean scores. Here, the decline extends from T2 to T5 with a reversal occurring at T6, this group's booster post-test occasion. Target Complaints Table 5(c) shows the results of the 2 x 2 ANOVA on TC comparing c e l l s 1 & 2 with 4 & 5. The group-by-time interaction was not s i g n i f i c a n t , [F(l,8) = 3.73, p = .081], but the e f f e c t was in the hypothesized d i r e c t i o n . Table 4 shows the booster post-test mean for the FB group is higher that any of the other group means, evidence favouring a treatment e f f e c t . The graph of group means for TC in Figure 4 shows a downward trend in scores for both groups from T2 to T4. At T5, after the FB group received the booster treatment, the growth t r a j e c t o r i e s for the two groups move in opposing directions with the FB group scores increasing and the DB group scores decreasing. At T6, after the booster treatment crossover, both group trends reverse d i r e c t i o n as the DB group's scores increase and the FB group's scores decline at follow-up. These results indicate that the following their booster session, couples in the FB group was superior in levels of marital adjustment, communication and to some extent problem resolving their main problems than the untreated DB couples. 94 Hypothesis 1(b): Couples who are in the FB group w i l l demonstrate s i g n i f i c a n t l y higher scores on the DAS, CS, and TC on the booster post-test and booster follow-up occasions than w i l l w a i t i n g - l i s t couples in the delayed-booster group. Results of the 2 x 2 ANOVA on the dependent measures for Hypothesis 1(b), comparing c e l l s 2 & 3 with 4 & 5, are shown in Table 6. This hypothesis questions whether the i n i t i a l treatment effects are maintained and remain higher than the pre-treatment control group l e v e l . The group main eff e c t is the r e s u l t of interest. The Dyadic Adjustment Scale As Table 6(a) shows, no s i g n i f i c a n t e f f e c t was found for DAS, [F(l,8) = .40, p = .5441. The small F obtained for the DAS was l i k e l y due to the decline in the FB group's scores at follow-up, a finding contrary to the hypothesized maintenance e f f e c t . Figure 2 shows that while the FB group achieved a s i g n i f i c a n t improvement in scores at T5, DB group scores had declined. By the 4-month follow-up, however, the FB group scores had dropped below pre-treatment l e v e l s . Table 4 shows that FB mean scores at booster post-test and follow-up were higher than DB group mean at post-wait, just prior to receiving treatment. This indicates that FB couples remained better adjusted in their relationships during the four-month follow-up period than were the untreated DB couples at the end of the w a i t - l l s t period. 95 The Communication Scale The results of the ANOVA for the CS shown in Table 6(b) were not s i g n i f i c a n t , [F(l,8) = 3.88, p = .084], but the e f f e c t was in the hypothesized d i r e c t i o n . Supporting the claim for maintenance effects on the CS measure, Table 4 shows that FB couples maintained superior gains in communication in the follow-up period in comparison to couples in the w a i t - l i s t condition. Figure 3 shows that FB group maintained gains in communication during the four-month follow-up period r e l a t i v e to the untreated DB group. Target Complaints The group main eff e c t was s i g n i f i c a n t for TC, tF(l,8) 5.35, p = .049] as shown in Table 6(c). This indicates that the treated couples perception of improvement in their relationship problems at follow-up was s i g n i f i c a n t l y higher than that of the untreated couples in the w a i t - l i s t period. Table 4 confirms that the FB group achieved and maintained superior gains in resolving their main problems during the follow-up period in r e l a t i o n to the untreated DB couples. Hypothesis 1(c): Couples in the first-booster and delayed-booster groups who receive booster sessions w i l l demonstrate a s i g n i f i c a n t increase in scores on the DAS, CS, and TC when the pre-test and post-test occasions are compared. Using the combined pre/post scores for both groups, this hypothesis tests whether there is a booster treatment e f f e c t , 96 and whether this e f f e c t i s replicated in both groups. The contrast of primary interest in this analysis is time main e f f e c t . Results of the 2x2 ANOVA on the dependent measures for Hypothesis 1(c), comparing c e l l s 1 & 5 with 2 & 6, are presented in Table 4. The Dyadic Adjustment Scale Table 7(a) reveals a s i g n i f i c a n t time main effect for the DAS measure, [F (1,8) = 7.43, p = .026]. This indicates that, after the booster treatment, the couples in both groups reported s i g n i f i c a n t l y increased levels of marital adjustment in comparison to their pre-test scores. The Communication Scale Table 7(b) presents the results of the 2 x 2 ANOVA for the CS. The main time e f f e c t was not s i g n i f i c a n t , [F(l,8) = 5.20, p = .052], but there was a strong ef f e c t in the hypothesized d i r e c t i o n . Table 4 shows that for both groups, the booster post-test mean scores for both groups increase over the booster pre-test scores. A d i f f e r e n t i a l increase in scores can be seen in the graph i l l u s t r a t e d in Figure 3. Here, the line representing the increase in the FB group scores has a steeper slope than the l i n e representing the gains in the DB group. It seems that, on the measure of communication, the booster sessions had a greater ef f e c t on couples in the FB group than on couples in the DB group. Inspection of the group means in Table 4 confirms t h i s observation. 97 Target Complaints T a b l e 7 ( c ) shows a s i g n i f i c a n t t i m e main e f f e c t f o r t h e 2 x 2 ANOVA on t h e TC, [ F ( l , 8 ) = 5.83, p = . 0 4 2 ] . T h i s r e s u l t c o n f i r m s t h a t , w i t h r e s p e c t t o r e s o l v i n g t h e i r t a r g e t c o m p l a i n t s or main p r o b l e m s , t h e b o o s t e r t r e a t m e n t was e q u a l l y b e n e f i c i a l t o b o t h g r o u p s . O v e r a l l , f o r b o t h g r o u p s t h e b o o s t e r p o s t - s c o r e s on a l l measures were d i f f e r e n t from t h e p r e - s c o r e s i n t h e h y p o t h e s i z e d d i r e c t i o n . The c o n t r a s t o f p r i m a r y i n t e r e s t , t h e main t i m e e f f e c t , was s i g n i f i c a n t on t h e DAS, and TC and showed a s t r o n g e f f e c t on t h e CS. E x a m i n a t i o n o f t h e means i n T a b l e 4 and t h e ANOVA r e s u l t s i n T a b l e s 7 a-c shows t h a t , b o t h g r o u p ' s p o s t - t e s t s c o r e s were s u p e r i o r t o t h e p r e - t e s t s c o r e s on a l l m e a s u r e s . F i g u r e s 2-4 show t h a t , when o c c a s i o n s 04 and 05 f o r t h e FB g r o u p a r e compared w i t h t e s t i n g o c c a s i o n s 05 and 06 f o r t h e DB g r o u p , t h e b o o s t e r p o s t - t e s t s c o r e s a r e h i g h e r t h a n t h e b o o s t e r p r e - t e s t s c o r e s . F o r two o f t h e m e a s u r e s , DAS and TC, t h e p l o t t i n g of t h e s e s c o r e s r e s u l t s i n p a r a l l e l l i n e s i n d i c a t i n g no i n t e r a c t i o n . The a b s e n c e o f i n t e r a c t i o n i n t h e s e r e s u l t s i n d i c a t e s t h a t t h e s i g n i f i c a n t t r e a t m e n t g a i n s a c h i e v e d on t h e two p o s t - t e s t o c c a s i o n s c a n be g e n e r a l i z e d w i t h c o n f i d e n c e o v e r b o t h g r o u p s . 98 WAIT-LIST EFFECTS Hypothesis 2: Couples who are in the delayed-treatment control group w i l l not increase scores on the dependent measures during the w a i t - l i s t period. Inspection of Table 4 shows that the DB couples scores on a l l the dependent measures decreased during the w a i t - l i s t period. Results of a dependent t-te s t comparing DB group c e l l s 4 and 5 for w a i t - l i s t e f f e c t s , are presented in Table 8. A relaxed alpha of .25 was used in th i s analysis. No s i g n i f i c a n t differences within group over the two occasions were found for the CS (p = .64) and TC (p = .34). Significance is reached for the DAS (p = .20), but this a c t u a l l y r e f l e c t s a decrease in mean scores for the DB couples during the w a i t - l i s t period. In other words, th i s effect i s in the hypothesized d i r e c t i o n and confirms that w a i t i n g - l i s t couples scores did not increase over the two occasions prior to receiving treatment. MAINTENANCE EFFECTS Hypothesis 3: Couples who are in the first-booster treatment group w i l l maintain scores on the DAS, CS, and TC between the booster post-treatment and follow-up occasions. Results of a dependent t-t e s t comparing c e l l s 2 and 3 for short-term booster maintenance effects are summarized in Table 8. A relaxed alpha of .25 was used in thi s analysis. The 99 finding of no s i g n i f i c a n t differences within the FB group from post-test to four-month follow-up on any of the dependent measures provides evidence of short-term, four-month, maintenance of booster treatment e f f e c t s . It i s notable that the DAS res u l t almost reaches s i g n i f i c a n c e , however, indicating increased levels of marital s a t i s f a c t i o n were not well maintained for the FB group. In fact, as Figure 1 shows, couple scores had dropped below booster pre-test levels by the four-month follow-up. Figure 3 shows that the FB group did maintain increased communication between 05 and 06 with scores remaining above the booster pre-test l e v e l . Figure 4 shows that the FB couples perceived that they had maintained improvement in the l e v e l of target complaint resolution. The TC scores also remained higher at booster follow-up than at booster pre-test. The decline in scores on the dependent measures for the FB group at booster follow-up is consistent with the post-treatment regression documented in James1 (1986) study. Hypothesis 4: Couples in the first-booster group, who receive CT booster sessions after EFT+CT w i l l not d i f f e r in scores on the DAS, CS, and TC at the booster post-test and the post-test occasion in the James (1988) study. This analysis provides comparison between FB couples' scores at post-treatment in the James (1988) study and the FB couples scores at booster post-test in the current study-a 100 comparison necessary to establishing whether the booster sessions served to maintain couples' EFT+CT treatment gains over the long term. These are termed as long term maintenance eff e c t s because the booster sessions were administered to the FB group one year after termination of James' (1988) EFT+CT treatment. Results of the dependent t-tests on the mean scores for the FB group at EFT+CT post-test occasion and at the booster post-test occasion are presented in Table 9. No s i g n i f i c a n t differences were found on any of the measures at p = .05. Figures 2-4 i l l u s t r a t e these results in graph form. The graphs show that the magnitude of the EFT+CT treatment gains at 02 is equivalent to the magnitude of the CT booster gains at 05 for the FB group. These findings indicate that the booster treatments were potent enough to return the FB couples scores to their EFT post-treatment levels on a l l measures. The booster sessions therefore maintained couples' i n i t i a l treatment gains-those achieved through EFT+CT in James' (1988) study. EFFECT SIZES E f f e c t sizes for the dependent measures in this study are presented in Table 10. The ef f e c t sizes in this study were calculated by taking the difference in the booster pre-test 101 and p o s t - t e s t means and d i v i d i n g i t by t h e p o o l e d p r e -t r e a t m e n t s t a n d a r d d e v i a t i o n . The magnitude o f t h e e f f e c t s i z e s i s l a r g e r f o r t h e FB g r o u p t h a n t h e DB g r o u p o v e r a l l m e a s u r e s . F o r example, t h e FB g r o u p g a i n e d .69 s t a n d a r d u n i t s on t h e DAS, 1.05 s t a n d a r d u n i t s on t h e CS, and .85 s t a n d a r d u n i t s on t h e TC; t h e DB g r o u p g a i n e d .39 s t a n d a r d u n i t s on t h e DAS, .35 s t a n d a r d u n i t s on t h e CS and .53 s t a n d a r d u n i t s on t h e TC. These r e s u l t s s u p p o r t t h e c l a i m o f a s i g n i f i c a n t b o o s t e r t r e a t m e n t e f f e c t . On a l l t h r e e m e a s u r e s , t h e magn i t u d e o f e f f e c t s i z e s f o r b o t h g r o u p s a t b o o s t e r p o s t - t e s t i s s u b s t a n t i a l l y l a r g e r and i n t h e o p p o s i t e d i r e c t i o n t h a n t h e e f f e c t s i z e s o f t h e u n t r e a t e d w a i t - l i s t . T h a t t h e t r e a t e d and u n t r e a t e d g r o u p means a r e moving i n o p p o s i n g d i r e c t i o n s a l s o s u p p o r t s t h e c l a i m f o r a b o o s t e r t r e a t m e n t e f f e c t . SUMMARY OF QUANTITATIVE RESULTS I n g e n e r a l , t h e r e s u l t s o f t h e q u a n t i t a t i v e d a t a a n a l y s i s c o n f i r m t h e h y p o t h e s e s . F o r H y p o t h e s i s 1 ( a ) , a s i g n i f i c a n t d i f f e r e n c e between t h e t r e a t m e n t and c o n t r o l g r o u p s was r e p o r t e d on t h e DAS (p = .030); t h e t r e a t e d g r o u p was a l s o s u p e r i o r on t h e CS (p = .051) and on t h e TC (p = .089). F o r H y p o t h e s i s 1 ( b ) , t h e FB g r o u p m a i n t a i n e d s c o r e s on t h e TC t h a t were s i g n i f i c a n t l y h i g h e r t h a n t h o s e o f t h e DB g r o u p d u r i n g t h e w a i t i n g - l i s t p e r i o d on t h e TC (p = .049); e f f e c t s f a v o r i n g 102 t h e FB g r o u p d u r i n g f o l l o w - u p o v e r t h e DB d u r i n g w a i t - l i s t were a l s o f o u n d on t h e CS, (p =.084). DAS s c o r e s were n o t w e l l m a i n t a i n e d i n t h e FB g r o u p a t f o u r - m o n t h f o l l o w - u p . The r e p l i c a t i o n of p r e - p o s t b o o s t e r e f f e c t s i n H y p o t h e s i s 1 ( c ) was s u p p o r t e d on t h e DAS (p = .026), and TC (p =.042); the CS showed a s t r o n g e f f e c t i n t h e h y p o t h e s i z e d d i r e c t i o n , (p = .052). A p a r t from t h e n o n - s i g n i f i c a n t DAS r e s u l t c o n t r a v e n i n g h y p o t h e s i z e d m a i n t e n a n c e e f f e c t s , f a i l u r e t o r e a c h s i g n i f i c a n c e i n t h e above c a s e s c a n be a t t r i b u t e d t o t h e s m a l l sample s i z e , and t h u s t h e s m a l l number per c e l l . R e s u l t s o f a n a l y s e s o f t h e p l a n n e d c o n t r a s t s s u p p o r t h y p o t h e s e s 2 and 3 a t t h e p = .25 l e v e l o f s i g n i f i c a n c e . No s i g n i f i c a n t w a i t - l i s t e f f e c t s were f o u n d . The s h o r t - t e r m m a i n t e n a n c e of b o o s t e r e f f e c t s was d e m o n s t r a t e d i n t h e FB g r o u p when no s i g n i f i c a n t d i f f e r e n c e s were f o u n d between the b o o s t e r p o s t - t e s t and f o u r - m o n t h f o l l o w - u p o c c a s i o n on any of t h e m e a s u r e s . T h a t i s t h e FB c o u p l e s m a i n t a i n e d t h e i r g a i n s on a l l m e a s u r e s , and t h e u n t r e a t e d c o u p l e s i n t h e w a i t - l i s t c o n d i t i o n d i d n o t I n c r e a s e i n s c o r e s . The r e s u l t s a l s o s u p p o r t e d h y p o t h e s i s 4, t h a t t h e b o o s t e r s e s s i o n s would enhance t h e l o n g - t e r m m a i n t e n a n c e o f EFT+CT g a i n s . The a n a l y s e s showed t h a t t h e r e were no s i g n i f i c a n t d i f f e r e n c e s on t h e DAS, CS and TC measures between t h e EFT+CT p o s t - t e s t and b o o s t e r p o s t - t e s t o c c a s i o n s a t t h e p = .50 l e v e l o f s i g n i f i c a n c e . R e s u l t s o f t h e p r e l i m i n a r y t r e n d a n a l y s i s i n d i c a t e d a s i g n i f i c a n t q u a d r a t i c t r e n d f o r t h e DAS. T h i s 103 p r o v i d e d a b a s e l i n e a g a i n s t w h i c h t o compare t h e e f f e c t s of t h e b o o s t e r t r e a t m e n t . The d e c r e a s i n g t r e n d e s t a b l i s h e d t h a t t h e c o u p l e s had r e g r e s s e d a f t e r James' EFT+CT t r e a t m e n t and c o n t i n u e d t o r e g r e s s u n t i l t h e y r e c e i v e d b o o s t e r s e s s i o n s . O v e r a l l , t h e b o o s t e r s e s s i o n s i n c r e a s e d c o u p l e s s c o r e s on measures o f m a r i t a l a d j u s t m e n t and c o m m u n i c a t i o n , and r e d u c e d t a r g e t c o m p l a i n t s . G a i n s a c h i e v e d by t h e FB g r o u p were m a i n t a i n e d a t f o u r - m o n t h f o l l o w - u p . In c o n t r a s t , u n t r e a t e d DB c o u p l e s d e c r e a s e d i n s c o r e s on a l l measures d u r i n g t h e w a i t -l i s t p e r i o d . When the b o o s t e r s e s s i o n s were a d m i n i s t e r e d t o t h e DB g r o u p , t h e s e c o u p l e s a l s o i n c r e a s e d i n s c o r e s on t h e d e p e n d e n t m e a s u r e s . F o r b o t h g r o u p s , t h e b o o s t e r p r e - t e s t s c o r e s were s i g n i f i c a n t l y h i g h e r t h a n t h e b o o s t e r p o s t - t e s t s c o r e s . No s i g n i f i c a n t d i f f e r e n c e s were fo u n d between a s s e s s m e n t s o f t h e FB g r o u p a t p o s t - t e s t i n t h e b o o s t e r s t u d y and a t p o s t - t e s t i n t h e James (1988) s t u d y s u p p o r t i n g t h e e f f i c a c y o f b o o s t e r s e s s i o n s i n m a i n t a i n i n g t r e a t m e n t g a i n s a c h i e v e d a f t e r p r e v i o u s n o n - b e h a v i o r a l m a r i t a l t h e r a p y . The e f f e c t s i z e s o f t h e b o o s t e r s e s s i o n s a r e l a r g e r a c r o s s a l l measures f o r t h e FB g r o u p t h a n t h e DB g r o u p . QUALITATIVE RESULTS A s t r u c t u r e d i n t e r v i e w was c o n d u c t e d a t p o s t - t e s t t o e l i c i t s u b j e c t s r e a c t i o n s t o t h e b o o s t e r t r e a t m e n t . R e s p o n s e s were p r o v i d e d by i n d i v i d u a l s i n b o t h t r e a t m e n t g r o u p s (n = 104 2 0 ) . The i n t e r v i e w q u e s t i o n n a i r e i s p r o v i d e d i n A p p e n d i x B. The r e s u l t s of t h e i n t e r v i e w a r e summarized below. In r e s p o n s e t o t h e q u e s t i o n a b o u t what i t was l i k e t o r e c e i v e t h e CT b o o s t e r s e s s i o n s one y e a r a f t e r t h e i n i t i a l CT component t e r m i n a t e d , i n d i v i d u a l s r e p o r t e d t h e f o l l o w i n g : (1) 85% were s u r p r i s e d a t how q u i c k l y t h e s k i l l s r e t u r n e d and how e a s y i t was t o resume u s i n g t h e s k i l l s (2) 80% f e l t a s e n s e of renewed o p t i m i s m a b o u t b e i n g a b l e t o communicate b e t t e r i n t h e i r r e l a t i o n s h i p (3) 75% r e a l i z e d how b e n e f i c i a l u s i n g t h e s k i l l s had been t o t h e i r r e l a t i o n s h i p s . P a r t n e r s a l s o s a i d t h a t t h e CT t r a i n i n g had h e l p e d them t o i d e n t i f y and r e s o l v e c o n f l i c t , a v o i d d i s t a n c i n g , and g e n e r a l l y , t a k e a c t i o n t o improve t h e i r r e l a t i o n s h i p s . Some i n d i v i d u a l s t h o u g h t t h a t t h e br e a k between CT r e g i m e s h e l p e d them t o i n t e g r a t e t h e l e a r n i n g . They d e s c r i b e d f e e l i n g overwhelmed when t h e s k i l l s were p r e s e n t e d i n t h e James' (1988) s t u d y , had a b s o r b e d a l l t h e i n f o r m a t i o n t h e y c o u l d a t t h a t t i m e . In r e s p o n s e t o t h e q u e s t i o n o f whether t h e y had been u s i n g t h e CT s k i l l s f o l l o w i n g t e r m i n a t i o n o f James' (1988) CT s e s s i o n s : 90% o f t h e s u b j e c t s r e p o r t e d t h e y had n o t c o n s i s t e n t l y and c o n s c i o u s l y used t h e CT s k i l l s . The main r'easons s u b j e c t s gave f o r n o t u s i n g t h e c o m m u n i c a t i o n s k i l l s were: (1) t h e y had n o t l e a r n e d t h e s k i l l s w e l l enough and t h e y l a c k e d c o n f i d e n c e i n u s i n g t h e s k i l l s , (2) t h e y f o u n d t h e p r o c e s s t o o c o n t r i v e d and s t i l t e d , (3) t h e y had n o t made time f o r s t r u c t u r e d p r a c t i c e and l o s t t h e i r s k i l l s . A number o f 105 couples reported that they had only attempted to use their s k i l l s when c o n f l i c t situations arose, but their lack of confidence and mastery resulted in f a i l u r e and they abandoned the s k i l l s . A few individuals noted that, although they had not formally or consciously been using the CT format, they recognized that the s k i l l s t r a i n i n g had p o s i t i v e l y influenced their communication. In response to the questions of what they found most helpful about the booster session format, individuals mentioned the following in order of preference: (1) the practice focus of the sessions, (2) the scheduled home practice which improved their s k i l l s and renewed their commitment to continue using them, (3) the structure which allowed partners to express negative emotions and address d i f f i c u l t issues constructively, (4) l i s t e n i n g to one's partner and being listened to in return enhanced understanding of own and partner's feelings and thoughts, (5) the teaching focus of the sessions, (6) the v a l i d a t i o n and encouragement of the therapist, (7) incorporating the s k i l l s naturally into everyday communication. 60% of the participants mentioned that the fading procedure had been helpful in, providing more time to practice between sessions, enhancing integration of s k i l l s into everyday l i f e , enhancing retention of s k i l l s over a longer period, and f a c i l i t a t i n g the termination of therapy. 106 In response to the question of what impact they perceived the CT booster sessions had on their relationship, 85% said their relationships had improved. None of the subjects said their relationships had deteriorated as a function of the treatment. One couple had decided to separate early in the project but said they had continued attending the sessions because the s k i l l s helped them to communicate better in the separation process. Only three of the 10 couples reported not completing their regular weekly homework practice. In response to the question asking partners to rate how helpful the homework session were in learning the s k i l l s , 17 of the 20 subjects rated the homework as "very" helpful. The remaining individuals, who had not completed the homework, rated i t as "somewhat" helpful. Overall , partners commented that the homework allowed them to hone their s k i l l s and increased their confidence in using the s k i l l s independently. Most couples favoured the increase in structured practice in the booster component compared to the ammount of practice time in James' (1988) CT component. Perhaps the most frequently reported d i f f i cu l ty couples had in using the s k i l l s , was that alternating listening and responding roles seemed contrived or unnatural. With the extra practice partners were able to integrate the s k i l l s more naturally with their own style of communicating. 107 Of t h e i r e x p e r i e n c e w i t h t h e b o o s t e r s e s s i o n s one s u b j e c t s a i d , "I t h i n k t h e CT ( b o o s t e r ) t r a i n i n g i s e x t r e m e l y e f f e c t i v e , e ven t h o u g h I was d u b i o u s a t f i r s t . " Summing up a number o f s i m i l a r comments, one c o u p l e s a i d " We a r e a b l e t o d e a l w i t h , s o l v e , t a l k a b o u t , and a d d r e s s p r o b l e m s i n our r e l a t i o n s h i p l o n g b e f o r e t h e y g e t o u t o f hand. We f e e l c l o s e r s i n c e we s t a r t e d ; s i n c e we g o t our c l o s e t s c l e a n e d o u t . Now t h a t we c a n g e t t h e c a r d s on t h e t a b l e , we f e e l b e t t e r e q u i p p e d t o d e a l w i t h f u t u r e p r o b l e m s t h a t f a c e us as a c o u p l e . " 108 CHAPTER V: DISCUSSION AND CONCLUSIONS REVIEW OF THE MAINTENANCE PROBLEM How t o m a i n t a i n change i s one o f t h e b a s i c c o n c e r n s o f any a p p r o a c h t o t h e r a p y , i n f a c t , a number of r e s e a r c h e r s h o l d t h a t m a i n t e n a n c e or t h e d u r a b i l i t y o f t h e r a p e u t i c g a i n s i s a c r i t e r i o n o f t h e r a p e u t i c s u c c e s s ( G o l d s t e i n e t a l . , 1979; Z i e l i n s k i , 1 9 7 8 ) . E x a m i n a t i o n o f outcome r e s e a r c h i n p s y c h o t h e r a p y r e v e a l s t h a t m a i n t e n a n c e p a s t p o s t - t e s t i s r a r e . In most s u c h e n c o u n t e r s , "be t h e y p s y c h o d y n a m i c , b e h a v i o r a l , e x i s t e n t i a l , or o t h e r w i s e . . . p a t i e n t improvement n e i t h e r p e r s i s t s nor g e n e r a l i z e s t o new s e t t i n g s " ( G o l d s t e i n e t . a l . , 1979, p . l ) . E x p r e s s i n g a s i m i l a r c o n c e r n w i t h t h e p r a c t i c e of m a r i t a l t h e r a p y , C o o k e r l y (1980) o b s e r v e d t h a t t h e r e were a l m o s t no s y s t e m a t i c l o n g i t u d i n a l f o l l o w - u p s t u d i e s i n m a r i t a l t h e r a p y t o answer h i s p r o v o c a t i v e q u e s t i o n "Does m a r i t a l t h e r a p y do a n y l a s t i n g g ood?" ( p . l ) . Gurman e t . a l . (1986) c o n c l u d e t h a t inasmuch as m a r i t a l t h e r a p y s t u d i e s have d e m o n s t r a t e d t h e e f f i c a c y of m a r i t a l t h e r a p y s t u d i e s a t outcome, t h e r e i s a need f o r m a r i t a l t h e r a p y r e s e a r c h t h a t e x t e n d s beyond e v a l u a t i o n a t outcome t o i n v e s t i g a t e t h e p r o c e s s of m a i n t a i n i n g change a f t e r t h e f o r m a l t r e a t m e n t p e r i o d . 109 Regression In Non-behavioral Marital Therapy The need for research investigating the maintenance of change is e s p e c i a l l y acute in the area of non-behavioral marital therapy which, compared to i t s behavioral counterpart, has received l i t t l e controlled empirical study. The few non-behavioral studies that report follow-up results indicate that, as in behavioral marital therapy, regression or loss of treatment gains is a v e r i f i e d concern. Table 11 summarizes the results of four recent controlled studies of EFT, the contemporary non-behavioral couples therapy that preceded the CT component in James* (1988) study. Post-treatment regression occurred in a l l four studies; the two most recent studies (Hansen, 1990) reporting a s i g n i f i c a n t decrease in gains from post-treatment to follow-up. Table 11. Results at follow-up of EFT Outcome Studies; Mean Couple Total DAS scores Researcher(s) Pre Post Follow-up Johnson & Greenberg (1985) 92.80 112.70 112.10 (8 wk. ) Goldman (1987) 86.30 100.10 92.05 (4 mo. ) Remple (1987) 89.30 105.85 100.20 (1 yr. ) James (1988) EFT 87.61 103.30 98.11 (4 mo. ) EFT+CT 88.29 105.60 100.00 (4 mo. ) Hansen (1990) EFT 86.50 106.80 98.10 (1 yr. )* Elbe (1991) EFT+CT 87.85 107.70 96.65 (1 yr . ) Note: * = s i g n i f i c a n t difference between post and follow -up occasions (p=.05) 110 J o h n s o n and G r e e n b e r g (1985) r e p o r t n e g l i g i b l e p o s t -t r e a t m e n t t o f o l l o w - u p d i f f e r e n c e s i n mean c o u p l e s c o r e s . The f o l l o w - u p p e r i o d i n t h i s s t u d y was o n l y e i g h t weeks, however, p o s s i b l y t o o b r i e f a t i m e t o o b s e r v e t h e e x t e n t of t h e r e g r e s s i o n p o t e n t i a l . C o n s i d e r a b l e l e v e l s o f p o s t - t r e a t m e n t r e g r e s s i o n were f o u n d by Goldman ( 1 9 8 7 ) , Remple ( 1 9 8 7 ) , Hansen (1990) and E l b e ( 1 9 9 1 ) . James (1988) f o u n d t h a t c o u p l e s i n t h e EFT and EFT+CT g r o u p s had a l s o r e g r e s s e d a p p r e c i a b l y f r o m p o s t - t e s t t o f o l l o w - u p w i t h d r o p s i n s c o r e s of 5.19 and 5.60, r e s p e c t i v e l y . T h i s f i n d i n g was p a r t i c u l a r l y p e r p l e x i n g w i t h r e g a r d t o t h e EFT+CT g r o u p as t h e a d d i t i o n o f a CT component was h y p o t h e s i z e d t o enhance the m a i n t e n a n c e o f t r e a t m e n t g a i n s . The b a s i s o f t h i s h y p o t h e s i s was t h a t t h e CT component was d e r i v e d from RE w h i c h has a m a i n t e n a n c e f u n c t i o n . The m a i n t e n a n c e o f g a i n s a f t e r RE, a p s y c h o e d u a c t i o n a l a p p r o a c h t o c o u p l e s c o m m u n i c a t i o n t r a i n i n g , has r e c e i v e d l i m i t e d p a r t i a l s u p p o r t o v e r s h o r t p e r i o d s r a n g i n g f r o m 10 weeks t o t h r e e months Weiman, 1973; B r o c k & J o a n n i n g , 1 9 8 3 ) . James s u g g e s t e d t h a t EFT+CT c o u p l e s had r e g r e s s e d i n t h e f o l l o w - u p p e r i o d b e c a u s e t h e y had n o t l e a r n e d t h e c o m m u n i c a t i o n s k i l l s w e l l enough t o i n c o r p o r a t e them i n t o e v e r y d a y l i f e . N o t i n g t h a t d u r i n g t h e p o s t - t r e a t m e n t i n t e r v i e w some c o u p l e s r e q u e s t e d a d d i t i o n a l CT s e s s i o n s , James (1988) q u e s t i o n e d whether b o o s t e r s e s s i o n s would enhance t h e m a i n t e n a n c e of g a i n s a c h i e v e d i n t h e r a p y . B o o s t e r s e s s i o n s 111 have shown moderate success In producing maintenance effects after behaviour therapy (Whisman, 1990). The primary purpose of th i s study was to investigate whether receiving booster sessions in communication s k i l l s t r a i n i n g after a combined non-behavioral marital therapy package of EFT+CT would be more ef f e c t i v e than no treatment in increasing couples scores on the DAS, CS, and TC measures. It was also of interest in this study whether the booster treatment effects would me maintained in the booster follow-up period. The secondary purpose of the study was to test whether couples who received booster sessions following the termination of James' (1988) EFT+CT treatment would maintain their EFT+CT treatment gains. DISCUSSION OF PRELIMINARY RESULTS A preliminary analysis was conducted on the pa r t i c i p a t i n g EFT+CT couples' DAS scores over four occasions: (1) EFT+CT pre-test, (2) EFT+CT post-test, (3) EFT+CT four-month follow-up, and (4) booster pre-test. The analysis included a repeated measures ANOVA, Student Kneuman-Keuls pairwise comparisons and a trend analyses. The purpose of these analyses was to est a b l i s h : (1) that the i n i t i a l EFT+CT treatment had been successful, (2) that couples had f a i l e d to maintain their treatment gains after the EFT+CT treatment, and (3) the shape of the trend of the scores across the two studies as a 112 b a s e l i n e a g a i n s t w h i c h t o compare the e f f e c t o f t h e b o o s t e r t r e a t m e n t s . The r e s u l t s of t h e r e p e a t e d measure ANOVA p e r t a i n t o t h e f i r s t p u r p o s e o f t h e p r e l i m i n a r y a n a l y s i s . The r e s u l t s were s i g n i f i c a n t [F (3,27) = 13.80, p< .0001] i n d i c a t i n g t h a t t h e i n i t i a l EFT+CT t r e a t m e n t had been s u c c e s s f u l f o r c o u p l e s p a r t i c i p a t i n g i n t h e b o o s t e r s e s s i o n s . The e f f e c t i v e n e s s of EFT+CT was i m p o r t a n t t o e s t a b l i s h s i n c e t h e e x t e n t t o which b o o s t e r s e s s i o n s c a n be shown t o p r e v e n t r e g r e s s i o n d e p e n d s , a t l e a s t i n p a r t , on t h e s u c c e s s o f t h e i n i t i a l i n t e r v e n t i o n (Whisman, 1 9 9 0 ) . The f o l l o w i n g a n a l y s e s p e r t a i n t o t h e s e c o n d p u r p o s e of th e p r e l i m i n a r y a n a l y s i s . The r e s u l t s o f t h e Newman-Keuls p a i r w i s e c o m p a r i s o n s i n d i c a t e d t h a t t h e r e were s i g n i f i c a n t i n c r e a s e s between EFT+CT p r e - t e s t (87.85) and EFT+CT p o s t - t e s t (107.7) and s i g n i f i c a n t d e c r e a s e s between EFT+CT p o s t - t e s t and EFT+CT f o l l o w - u p ( 1 0 0 . 5 5 ) , and EFT+CT p o s t - t e s t and b o o s t e r p r e - t e s t ( 9 6 . 6 5 ) . E v i d e n t l y , c o u p l e s had made s i g n i f i c a n t g a i n s by p o s t - t r e a t m e n t b u t had e x p e r i e n c e d s i g n i f i c a n t r e g r e s s i o n o f t h e i r g a i n s f o u r months a f t e r t r e a t m e n t . The d i f f e r e n c e i n means between t h e i n i t i a l f o u r month f o l l o w - u p and p r e - b o o s t e r was n o t s i g n i f i c a n t a l t h o u g h i n s p e c t i o n o f t h e means i n T a b l e 1 shows t h a t c o u p l e s ' s c o r e s c o n t i n u e d t o s l i p between t h e two o c c a s i o n s . T h a t c o u p l e s were e x p e r i e n c i n g s i g n i f i c a n t l o s s e s i n t r e a t m e n t g a i n s f o u r months a f t e r t h e 113 EFT+CT t r e a t m e n t and c o n t i n u e d t o r e g r e s s t o t h e b o o s t e r p r e -t e s t o c c a s i o n one y e a r l a t e r , i s w o r t h y of c o n c e r n . As one c r i t e r i a f o r a s s e s s i n g c l i n i c a l l y s i g n i f i c a n t c h ange, J a c o b s o n and F o l l e t t e (1985) e s t a b l i s h e d a c u t o f f s c o r e o f 97 on t h e DAS as the s c o r e above w h i c h c o u p l e s a r e c o n s i d e r e d n o n d i s t r e s s e d , and below w h i c h c o u p l e s a r e c o n s i d e r e d d i s t r e s s e d , compared t o t h e g e n e r a l p o p u l a t i o n . When t h i s c u t o f f i s a p p l i e d t o t h e change i n means a c r o s s t h e a f o r e m e n t i o n e d o c c a s i o n s a c l e a r e r p i c t u r e emerges. On t h e whole, c o u p l e s had moved from t h e r a n k s o f t h e d i s t r e s s e d p r i o r t o t h e EFT+CT t r e a t m e n t , t o t h e r a n k s o f t h e n o n d i s t r e s s e d a f t e r t r e a t m e n t , and t h e n s l i p p e d back i n t o t h e d i s t r e s s e d r a n g e between t h e EFT+CT f o u r month f o l l o w - u p and b o o s t e r p r e - t e s t o c c a s i o n s . The d e t r i m e n t a l e f f e c t o f m a r i t a l d i s t r e s s on s p o u s e s and c h i l d r e n i s d i s c u s s e d e a r l i e r i n t h i s s t u d y . The f o l l o w i n g r e s u l t s r e l a t e t o t h e t h i r d p u r p o s e o f t h e p r e l i m i n a r y a n a l y s i s . A s i g n i f i c a n t q u a d r a t i c t r e n d was f o u n d i n t h e d a t a a c r o s s t h e f o u r o c c a s i o n s m e n t i o n e d a b o v e . A q u a d r a t i c t r e n d f e a t u r e s one bend or change o f d i r e c t i o n i n t h e t r a j e c t o r y o f t h e c u r v e ( G l a s s & H o p k i n s , 1 9 8 4 ) . I l l u s t r a t e d i n F i g u r e 2, t h e f i r s t segment o f t h e i n c l i n e c u r v e s upward from EFT+CT p r e - t e s t a t 01 and peaks a t t h e EFT+CT p o s t - t e s t a t 02 i n t h e James (1988) s t u d y . A f t e r r e a c h i n g a h i g h a t 02, a bend o c c u r s and t h e n e x t segment of t h e i n c l i n e c u r v e s downwards t h r o u g h t h e EFT+CT f o u r - m o n t h 114 f o l l o w - u p a t 03 t o t h e b o o s t e r p r e - t e s t o c c a s i o n a t 04. The bend r e p r e s e n t s t h e i n i t i a l e f f e c t of t h e EFT+CT t r e a t m e n t . The e f f e c t of t h e b o o s t e r t r e a t m e n t i s s e e n a t 05, i n the r e v e r s a l of t h e d e c l i n i n g segment of t h e c u r v e a t b o o s t e r p o s t - t e s t i n t h e FB g r o u p . T h i s r e v e r s a l r u n s i n a d i r e c t i o n c o n t r a r y t o t h e e x p e c t e d t r a j e c t o r y o f t h e i n v e r t e d , U-shaped q u a d r a t i c t r e n d . T h a t s u c h a r e v e r s a l e x i s t s i n t h e a b s e n c e o f an e s t a b l i s h e d c u b i c t r e n d ( w h i c h would p r e d i c t a s e c o n d upward b e n d ) , p r o v i d e s e v i d e n c e of a s i g n i f i c a n t b o o s t e r t r e a t m e n t e f f e c t . I n o t h e r words, s i n c e t h e q u a d r a t i c t r e n d i n th e d a t a r a n g i n g from EFT+CT p r e - t e s t , a t 01, t o b o o s t e r p r e -t e s t , a t 04, f e a t u r e s o n l y one bend, a t 02, i t must be t h e b o o s t e r i n t e r v e n t i o n t h a t p r o d u c e d t h e s e c o n d bend or i n c r e a s e i n FB g r o u p s c o r e s a t 05. I n t h e a b s e n c e of i n t e r v e n t i o n , t h e segment o f t h e i n c l i n e f r o m b o o s t e r p r e - t e s t t o b o o s t e r p o s t -t e s t would be e x p e c t e d t o c o n t i n u e t h e d e c l i n e p r e d i c t e d by t h e s i g n i f i c a n t q u a d r a t i c t r e n d . DISCUSSION OF BOOSTER TREATMENT EFFECTS R e s u l t s o f t h e a n a l y s i s o f b o o s t e r e f f e c t s i n t h i s e x p e r i m e n t p r o v i d e s u p p o r t f o r t h e h y p o t h e s e s on a t l e a s t one of t h e d e p e n d e n t m e a s u r e s . H y p o t h e s i s 1 ( a ) , t h a t t h e FB c o u p l e s who r e c e i v e d CT b o o s t e r s e s s i o n s would a c h i e v e h i g h e r s c o r e s on t h e d e p e n d e n t measures t h a n t h e DB c o n t r o l c o u p l e s , was s u p p o r t e d by t h e 115 r e s u l t s . Compared t o t h e u n t r e a t e d DB g r o u p , t h e FB g r o u p was s t a t i s t i c a l l y s u p e r i o r on t h e DAS ( p = . 0 3 0 ) / and showed an e f f e c t i n t h e h y p o t h e s i z e d d i r e c t i o n on t h e CS (p =.051) and TC (p=.089). F a i l u r e t o r e a c h s i g n i f i c a n c e on t h e CS and TC was l i k e l y due t o t h e s m a l l number of s u b j e c t s . These r e s u l t s i n d i c a t e t h a t b o o s t e r s e s s i o n s a r e s u p e r i o r t o no t r e a t m e n t i n e n h a n c i n g c o u p l e s m a r i t a l a d j u s t m e n t , c o m m u n i c a t i o n and t o a l e s s e r e x t e n t i n r e s o l v i n g c o u p l e s main r e l a t i o n s h i p p r o b l e m s or t a r g e t c o m p l a i n t s . More t h a n i n c r e a s i n g s c o r e s , when J a c o b s o n and F o l l e t e ' s (1985) c u t o f f o f 97 i s a p p l i e d t o t h e DAS g a i n s i n t h i s a n a l y s i s , b o o s t e r s e s s i o n s e l e v a t e d t h e FB g r o u p ' s mean fr o m t h e d i s t r e s s e d r a n g e (96.4 a t p r e - t e s t ) t o t h e n o n d i s t r e s s e d r a n g e (104.5 a t p o s t - t e s t ) . H y p o t h e s i s K b ) , t h a t c o u p l e s who a r e i n t h e b o o s t e r p o s t - t e s t f o l l o w - u p g r o u p w i l l d e m o n s t r a t e h i g h e r s c o r e s on t h e d e p e n d e n t measures t h a n c o u p l e s i n t h e w a i t - l i s t c o n t r o l g r o u p was p a r t i a l l y s u p p o r t e d . B o o s t e r t r e a t m e n t g a i n s were m a i n t a i n e d d u r i n g t h e f o l l o w - u p p e r i o d a t a s i g n i f i c a n t l y h i g h e r l e v e l f o r t h e b o o s t e r c o u p l e s t h a n t h e w a i t - l i s t c o n t r o l c o u p l e s on t h e TC (p=.049). R e s u l t s f o r t h e CS showed an e f f e c t i n t h e h y p o t h e s i z e d d i r e c t i o n (p=.084). No s i g n i f i c a n t d i f f e r e n c e was f o u n d between t h e g r o u p s on t h e DAS (p=.54), i n d i c a t i n g t h a t b o o s t e r t r e a t e d c o u p l e s d i d n o t m a i n t a i n s u p e r i o r s c o r e s i n c o m p a r i s o n t o t h e u n t r e a t e d c o n t r o l s on t h e g l o b a l measure o f m a r i t a l a d j u s t m e n t f o u r 116 months after treatment. This finding bears some explanation as the CT boosters were designed to enhance maintenance of gains. The CT booster sessions emphasize the teaching of the s p e c i f i c s k i l l s of expression and empathetic responding which are seen to enhance intimacy by promote understanding of s e l f and other. The use of positive communication s k i l l s in the dyadic relationship was expected to enable the couple to solve their own current and future problems and foster intimacy. The results appear to mirror how the CT component is expected to function. Compared to w a i t - l i s t e d DB couples, the FB couples had s i g n i f i c a n t l y improved their i n i t i a l problems at booster post-test and had maintained these gains at the four-month follow-up. The results also indicate that the FB couples attained and retained higher levels of communication than their untreated counterparts. The f a i l u r e to reach significance on the measure of communication is l i k e l y due to the small number of subjects in this analysis.. The FB couples, who received treatment, could have f a i l e d to maintain their gains in marital adjustment r e l a t i v e to the w a i t - l i s t e d DB couples for two reasons. F i r s t , as a global measure of marital adjustment, the DAS assesses the extent of a f f e c t i o n , agreement, cohesion, and overal l s a t i s f a c t i o n in the rel a t i o n s h i p . It i s possible that these subscales of marital adjustment are d i f f e r e n t i a l l y affected by improved communication s k i l l s ; some may lag behind others, taking longer to improve. For instance, the subscales 117 t a p p i n g t h e i n t i m a c y c o n s t r u c t may improve l a t e r as t h e s k i l l s o f e m p a t h e t i c r e s p o n d i n g and e x p r e s s i o n improve t h e e m o t i o n a l c l i m a t e and l e v e l o f s e l f / o t h e r u n d e r s t a n d i n g i n t h e r e l a t i o n s h i p . I t c o u l d be t h a t i n s u f f i c i e n t i n t i m a c y had d e v e l o p e d between p a r t n e r s i n t h e s h o r t term t o h o l d t h e i r g a i n s . P e r h a p s a b r i e f i n t e r v e n t i o n of f o u r b o o s t e r s e s s i o n s i s s u f f i c i e n t t o r e c a p t u r e p r e v i o u s g a i n s b u t n o t t o s u s t a i n l a s t i n g c h a n g e . How c o m m u n i c a t i o n s k i l l s e f f e c t t h e v a r i o u s d i m e n s i o n s o f m a r i t a l a d j u s t m e n t r e m a i n s an unanswered e m p i r i c a l q u e s t i o n . I f t h e r e a r e d i f f e r e n t i a l r a t e s of change i n d i f f e r e n t d i m e n s i o n s o f m a r i t a l a d j u s t m e n t , p e r h a p s l o n g e r t r e a t m e n t and f o l l o w - u p p e r i o d s would r e v e a l m a i n t e n a n c e e f f e c t s . A s e c o n d , r e a s o n f o r c o u p l e s f a i l u r e t o m a i n t a i n g a i n s made a f t e r b o o s t e r t r e a t m e n t was t h a t t h e c o m m u n i c a t i o n s k i l l s i n c r e a s e d p e r m i s s i o n i n t h e r e l a t i o n s h i p t o e x p r e s s f e e l i n g s and needs a r o u n d c o n f l i c t i s s u e s . I n f a c t c o u p l e s were e n c o u r a g e d t o e x p r e s s and r e s o l v e i n t e n s e e m o t i o n a l i s s u e s r a t h e r t h a n a v o i d d e a l i n g w i t h them. P e r h a p s t h e c o n t i n u e d e f f o r t s o f FB c o u p l e s t o r a i s e and d e a l w i t h t h e i r i s s u e s i n d e p e n d e n t l y i n t h e b o o s t e r f o l l o w - u p p e r i o d may have c a u s e d i n c r e a s e s i n some d i m e n s i o n s o f m a r i t a l a d j u s t m e n t and d e c r e a s e s i n o t h e r s . S u p p o r t f o r t h i s e x p l a n a t i o n i s p r o v i d e d by t h e r e s u l t s o f James' (1988) a n a l y s e s o f t h e DAS s u b s c a l e s as w e l l as t h e DAS t o t a l s c o r e . The r e s u l t s showed t h a t , a t t h e i r f o u r month f o l l o w - u p , t h e EFT+CT g r o u p had d r o p p e d below 118 t h e EFT g r o u p on o n l y t h e C o n s e n s u s s u b s c a l e o f t h e D A S - t h a t w h i c h measures t h e e x t e n t o f agreement i n t h e r e l a t i o n s h i p . In t h i s v i e w , t h e d e c l i n e i n FB g r o u p s c o r e s on t h e DAS a t b o o s t e r f o l l o w - u p c o u l d r e f l e c t t e m p o r a r y i n c r e a s e s i n l e v e l s o f d i s a g r e e m e n t , and d i s c o m f o r t t h a t a r e o f t e n s e e n by c l i n i c i a n s t o accompany t h e d i s r u p t i o n o f o l d , s a f e and d y s f u n c t i o n a l p a t t e r n s i n c o u p l e s w o r k i n g on r e l a t i o n s h i p i s s u e s . L e n d i n g s u p p o r t t o t h i s p e r s p e c t i v e , many c o u p l e s s a i d i n t h e i n t e r v i e w t h a t t h e y were now a b l e t o a i r t h e i r c o n c e r n s and d e a l w i t h p r o b l e m s t h a t would p r e v i o u s l y have been s u p p r e s s e d . I f t h e p r e v i o u s s p e c u l a t i o n i s v a l i d , a l o n g e r b o o s t e r f o l l o w - u p p e r i o d may show DAS s c o r e i n c r e a s e as c o u p l e s r e s o l v e f u n d a m e n t a l d i s a g r e e m e n t s and s e t t l e i n t o more f u n c t i o n a l p a t t e r n s . H y p o t h e s i s 1 ( c ) , t h a t c o u p l e s who r e c e i v e b o o s t e r t r e a t m e n t s w i l l i n c r e a s e i n s c o r e s on t h e d e p e n d e n t m e a s u r e s , was c o n f i r m e d by s i g n i f i c a n t r e s u l t s on two o f t h e m e a s u r e s . A f t e r t r e a t m e n t , c o u p l e s i n b o t h t h e FB and DB g r o u p s showed s i g n i f i c a n t i n c r e a s e s compared t o p r e - t r e a t m e n t s c o r e s on t h e DAS (p=.026), t h e TC (p=.042). The CS (p=.052), which showed a s t r o n g e f f e c t i n t h e h y p o t h e s i z e d d i r e c t i o n , p r o b a b l y f a i l e d t o r e a c h s i g n i f i c a n c e b e c a u s e o f t h e s m a l l sample s i z e . From t h i s a n a l y s i s i t c a n be c o n c l u d e d t h a t b o o s t e r s e s s i o n s were p o t e n t enough t o show s i g n i f i c a n t t r e a t m e n t e f f e c t s f o r b o t h t h e FB and DB g r o u p s . The c r o s s o v e r d e s i g n p r o v i d e s r e l i a b l e 119 evidence that the booster intervention was s u f f i c i e n t l y potent by r e p l i c a t i n g the FB booster effects in the DB group. Evidence of th i s r e p l i c a t i o n can be seen graphed in Figures 2-4, and in the eff e c t sizes displayed in table 10. It is important to account for the d i f f e r e n t i a l effectiveness of the FB and DB interventions on the communication measures since the tra i n i n g was aimed s p e c i f i c a l l y at enhancing communication s k i l l s . Two explanations are offered for the apparently reduced impact of the delayed-booster treatment. F i r s t , three of the five w a i t i n g - l i s t couples dropped in scores before receiving the booster sessions. It is possible that, in an t i c i p a t i o n of the booster sessions, w a i t - l i s t couples made attempts to implement the s k i l l s they had previously been introduced to and became increasingly d i s i l l u s i o n e d by their unsuccessful attempts to do so. This explanation was offered during the structured interview by two of the five couples in the group. This explanation seems plausible considering that the majority of these couples reported that they had not used the s k i l l s since the CT treatment had terminated. It is also possible that being unable to invoke their previous successes in communicating during the waiting period reduced their expectations of s e l f -e f f i c a c y and eventual mastery of the s k i l l s . Second, one of the couples in the DB group dropped out before providing booster post-test measures, requiring that the data by 120 analyzed using an average of their previous scores. Since no booster treatment gain was included in the averaging, the resulting post-booster mean for the DB group was reduced. D I S C U S S I O N O F W A I T - L I S T E F F E C T S Hypothesis 2, that couples' scores would not increase in the absence of treatment during the wait - l i s t condition, was confirmed by the s ta t i s t i ca l analyses. No significant differences were found between the booster pre-wait and post-wait occasions on any of the dependent measures. The established trend toward regression in the scores also supports the hypothesis. The positive magnitude of effect sizes presented in Table 10 confirm booster treatment gains from pre-test to post-test for a l l measures. The opposing negative magnitude of effect sizes for the untreated wait- l is t group, indicates regression. D I S C U S S I O N O F M A I N T E N A N C E E F F E C T S Hypothesis 3, that couples would maintain their booster treatment gains in the short term, over the four-month follow-up period is supported by results on a l l three measures. The data analysis revealed no significant differences between booster post-test and follow-up occasions in the FB group on any of the measures. Inspection of the group means in Table 4 121 seem to contradict t h i s finding as i t appears, at least for the DAS, that couples scores have regressed to below pre-treatment l e v e l s . This equivocal finding seems to contradict the s t a t i s t i c a l results supporting maintenance. The trend analysis is helpful in c l a r i f y i n g these apparently c o n f l i c t i n g outcomes. The finding of a quadratic trend in the data from James' (1988) pre-test occasion to the pre-test in the present study indicates that after the i n i t i a l EFT+CT treatment, couples' scores were on the decline. Extrapolating from the trend line seen in Figure 1 at 04 to the booster post-test occasion at 05, one would expect a continued decline in scores unless a s i g n i f i c a n t l y potent intervention caused a reversal. That is exactly what happened in t h i s study. The DB group' scores continued to decline during the w a i t - l i s t period in the absence of treatment, while the FB groups' scores increased. The decline in scores for the FB group in the follow-up period should be interpreted from the perspective of the overa l l trend in the data not just from inspection of the means. From the broader trend-based perspective, the decline in FB group scores at booster follow-up may not r e f l e c t a drop below pre-treatment levels i f the DB group's post-wait scores more accurately predict the booster pre-treatment baseline. Compared to the DB group's mean at post-wait, the mean of the FB group at booster follow-up remains higher. Glass and Hopkins (1984) contend that trend analysis results should be 122 interpreted independently of multiple comparisons as the trend analysis is usually more informative. Hypothesis 4 , that couples receiving booster treatments after termination of James'(1988) EFT+CT treatment would not d i f f e r in scores on the dependent measures between the EFT+CT post-test and the booster post-test occasions. The results of th i s analysis showed no s i g n i f i c a n t differences between the two occasions on the DAS, CS and TC. Booster sessions were ef f e c t i v e in maintaining the EFT+CT couples gains in marital adjustment, communication, and target complaint reduction. It is impressive to find that a b r i e f , four booster sessions maintained regressed couples scores at levels equivalent to those i n i t i a l l y attained after the 12 sessions of EFT+CT. This finding supports the long term maintenance of booster sessions because approximately one year had elapsed between the termination of EFT+CT and the commencement of the CT booster sess ions. CONCLUSIONS The preliminary analyses established that couples had s i g n i f i c a n t l y regressed in scores between the termination of the EFT+CT treatment and the commencement of the booster sessions. The trend results indicated that couples scores on the dependent measures would continue to decline in the absence of intervention. 123 In general, the results of the analyses of booster effects support the hypotheses in this study. The conclusions drawn from these analyses are: 1. Booster maintenance sessions after termination of James1 EFT+CT treatment s i g n i f i c a n t l y increased FB group scores on the measure of marital adjustment (p = .030) in comparison to the w a i t - l i s t control group. Strong non-s i g n i f i c a n t effects in the hypothesized d i r e c t i o n were found on the measures of communication and resolving target complaints . 2. Booster sessions were s i g n i f i c a n t l y more ef f e c t i v e than no treatment in maintaining the FB couples gains in resolving their main problem or target complaints (p = .049) during the booster four-month follow-up period. A non-s i g n i f i c a n t effect in the hypothesized d i r e c t i o n was evident on the CS indicating that couples increased and maintained their communication s k i l l s r e l a t i v e to the w a i t - l i s t control. Four months after the boosters, the FB couples did not maintain their gains on the measure of marital adjustment when compared to control couples. When the maintenance of short-term booster effects was tested in the FB group only, these couples maintained their gains on a l l measures with no s i g n i f i c a n t differences between booster post-test and follow-up occasions. 124 3. The u n t r e a t e d DB c o u p l e s d i d n o t i n c r e a s e i n s c o r e s on t h e d e p e n d e n t measures d u r i n g t h e w a i t - l i s t p e r i o d , r a t h e r t h e i r s c o r e s c o n t i n u e d t o d e c l i n e on a l l m e a s u r e s . 4. When b o o s t e r p r e and p o s t - t e s t s c o r e s were p o o l e d f o r b o t h g r o u p s , t h e b o o s t e r s e s s i o n s had a s i g n i f i c a n t e f f e c t on measures o f m a r i t a l a d j u s t m e n t (p = .026) and (p = .042) t a r g e t c o m p l a i n t r e d u c t i o n , and a s t r o n g but n o t s i g n i f i c a n t e f f e c t on t h e measure o f c o m m u n i c a t i o n . T h a t b o o s t e r e f f e c t s a r e r e p l i c a t e d i n t h e DB g r o u p s i n t h i s s t u d y a t t e s t s t o t h e p o t e n c y of t h e b o o s t e r s e s s i o n s i n p r o d u c i n g p r e - p o s t change w i t h e q u i v a l e n t g r o u p s . 5. On a l l t h r e e d e p e n d e n t m e a s u r e s , t h e magnitude of e f f e c t s i z e s f o r b o t h g r o u p s a t b o o s t e r p o s t - t e s t i s s u b s t a n t i a l l y l a r g e r and i n t h e o p p o s i t e d i r e c t i o n t h a n t h e e f f e c t s i z e s o f t h e u n t r e a t e d w a i t - l i s t . T h a t t h e t r e a t e d g r o u p means a r e l a r g e r and i n t h e o p p o s i t e d i r e c t i o n t o t h e u n t r e a t e d g r o u p means c o n f i r m s t h e f i n d i n g o f a s i g n i f i c a n t b o o s t e r t r e a t m e n t e f f e c t . 6. C o u p l e s who r e c e i v e d b o o s t e r s e s s i o n s a f t e r t h e t e r m i n a t i o n o f t h e EFT+CT t r e a t m e n t m a i n t a i n e d t h e i r EFT+CT g a i n s on a l l t h e d e p e n d e n t measures o v e r t h e l o n g t e r m . T h a t Is t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between t h e FB g r o u p s c o r e s as a s s e s s e d a t EFT+CT p o s t - t e s t i n t h e James (1988) s t u d y and b o o s t e r p o s t - t e s t i n t h i s s t u d y . The r e s u l t s o f t h e s t r u c t u r e d i n t e r v i e w p r o v i d e q u a l i t a t i v e s u p p o r t f o r t h e e f f i c a c y o f t h e b o o s t e r s e s s i o n s 125 i n e n h a n c i n g c o u p l e s r e l a t i o n s h i p s and m a i n t a i n i n g t h e i r g a i n s . Most of t h e c o u p l e s r e p o r t e d t h a t t h e s e s s i o n s i m p roved t h e i r s k i l l s and i n c r e a s e d t h e i r c o n f i d e n c e i n and commitment t o use t h e s k i l l s i n t h e i r d a i l y l i f e . A number of c o u p l e s a s s e s s e d t h e f a d i n g p r o c e d u r e as h e l p f u l i n a l l o w i n g more a t -home p r a c t i c e and g r a d u a l l y i n c r e a s i n g t h e i r i n d e p e n d e n c e from t h e r a p y . By t h e end of t h e f o u r t h b o o s t e r , a m a j o r i t y o f c o u p l e s f e l t t h e y had b e t t e r i n c o r p o r a t e d t h e c o m m u n i c a t i o n s k i l l s i n t o t h e i r d a i l y l i v e s t h a n t h e y had a t t h e end o f t h e i n i t i a l CT t r e a t m e n t component. T h i s f i n d i n g i s p a r t i c u l a r l y e n c o u r a g i n g b e c a u s e t h e main r e a s o n t h a t c o u p l e s gave f o r d i s c o n t i n u i n g use o f t h e i r n e w l y a c q u i r e d c o m m u n i c a t i o n s k i l l s a f t e r t h e i n i t i a l CT s e s s i o n s , was t h a t t h e s k i l l s seemed awkward and u n n a t u r a l t o u s e . F i n a l l y , a l l b u t one c o u p l e s a i d t h e CT b o o s t e r s had c o n s i d e r a b l y i m p roved t h e i r r e l a t i o n s h i p s . The s e n t i m e n t s t h e s e c o u p l e s h e l d i n common were t h a t t h e s e s s i o n s had: i n c r e a s e d t h e i r a w a r e n e s s o f s e l f and o t h e r , h e l p e d them r e l a t e b e t t e r , and made them more h o p e f u l a b o u t t h e f u t u r e o f t h e i r r e l a t i o n s h i p s . LIMITATIONS The most o b v i o u s l i m i t a t i o n o f t h i s s t u d y i s t h e s m a l l number o f s u b j e c t s ; 10 c o u p l e s w i t h f i v e p e r g r o u p . W h i l e a l a r g e r number o f c o u p l e s i n e a c h g r o u p would have g e n e r a t e d a more a c c u r a t e e s t i m a t e o f t h e p o p u l a t i o n v a l u e and t h e r e f o r e 126 had more external v a l i d i t y , this sample does represent an adequate rate of response from James' (1988) EFT+CT group as 10, or the o r i g i n a l 14 couples agreed to p a r t i c i p a t e . The small N in this study may also mitigate against finding a s i g n i f i c a n t difference between the two experimental groups on some of the dependent measures. A related concern was how the sample was selected. Because this was a sample of convenience, not randomly selected from a target population of distressed couples, external v a l i d i t y is reduced and i t is d i f f i c u l t to generalize the findings to distressed couples in the general population. The problem of a t t r i t i o n has hindered researchers e f f o r t s to conduct follow-up studies. Of the 14 EFT+CT couples, 10, or 71%, agreed to participate in the current study. These subject a t t r i t i o n rates are less than reported in most booster studies, e s p e c i a l l y considering that couples maintained involvement for approximately 18 months after commencement of the i n i t i a l EFT+CT treatment. A t t r i t i o n presented some concern in this study as one couple in the DB group dropped out just prior to receiving treatment. This couple consented to the researcher using the data they had already provided, however, and the missing data point was estimated by averaging their other scores. A t t r i t i o n of the therapist population was a greater concern than subject a t t r i t i o n in t h i s study. Two of the four therapists were unable to continue after the FB group had been 127 t r e a t e d , r e q u i r i n g t h e r e m a i n i n g two t h e r a p i s t s t o a d m i n i s t e r t h e b o o s t e r s e s s i o n s f o r t h e DT g r o u p . I t i s u n l i k e l y t h a t t h i s f a c t c o n f o u n d e d t h e r e s u l t s of t h e s t u d y b e c a u s e a l l of t h e t h e r a p i s t s were e q u i v a l e n t i n t h e amount of t r a i n i n g , s u p e r v i s i o n and e x p e r i e n c e t h e y had w i t h t h e CT and CT b o o s t e r - t r e a t m e n t m o d e l s . In a d d i t i o n , t h e i m p l e m e n t a t i o n c h e c k c o n f i r m e d t h a t t h e t h e r a p i s t s had c l o s e l y f o l l o w e d t h e p r o c e d u r e s as o u t l i n e d i n t h e CT b o o s t e r manual. I t s h o u l d a l s o be n o t e d t h a t random a s s i g n m e n t o f t h e t h e r a p i s t s t o c o u p l e s i n e a c h t r e a t m e n t c o n d i t i o n m i t i g a t e d a g a i n s t d i f f e r e n t i a l t h e r a p i s t e f f e c t s . I t would have a l s o been p r e f e r a b l e i f t h e r e s e a r c h e r had n o t been one o f t h e t h e r a p i s t s , however t h e r e were o n l y a l i m i t e d number of t h e r a p i s t w i t h t h e CT t r a i n i n g who were w i l l i n g t o v o l u n t e e r f o r t h i s s t u d y . F u t u r e r e s e a r c h e r s a r e a d v i s e d t o have a s u f f i c i e n t p o o l o f t r a i n e d t h e r a p i s t s t o o f f s e t any a t t r i t i o n d u r i n g t h e e x p e r i m e n t a l p e r i o d . I n f u t u r e s t u d i e s i t would a d v i s a b l e t o c o n d u c t a f o r m a l i m p l e m e n t a t i o n c h e c k u s i n g i n d e p e n d e n t r a t e r s t o r e l i a b l y e n s u r e t h a t a l l c o u p l e s r e c e i v e d t r e a t m e n t c o n s i s t e n t w i t h t r e a t m e n t p r o t o c o l and e l i m i n a t e p o s s i b l e e x p e r i m e n t e r b i a s . I n t h i s s t u d y e f f o r t s were made t o e n s u r e r e l i a b i l i t y , by t r a i n i n g t h e r a p i s t s , p r o v i d i n g a w r i t t e n manual o f t h e t r e a t m e n t p r o c e d u r e s , p r o v i d i n g s u p e r v i s i o n , and o b t a i n i n g t a p e d r e c o r d i n g s o f a c t u a l s e s s i o n s f o r i n f o r m a l e v a l u a t i o n . 128 The f a c t t h a t t h e r e s e a r c h e r , who was a l s o a t h e r a p i s t , may a l s o be c o n s i d e r e d a l i m i t a t i o n of t h i s s t u d y . E f f o r t s were made t o e n s u r e c o n f i d e n t i a l i t y and i m p a r t o b j e c t i v i t y i n t h e a d m i n i s t r a t i o n o f t h e d e p e n d e n t measures t h e r e f o r e making i t u n l i k e l y t h a t s u b j e c t s r e s p o n s e s were a f f e c t e d . The measures were s e l f - r e p o r t q u e s t i o n n a i r e s t h a t were f i l l e d out i n • p r i v a t e f r o m r e s e a r c h e r and s p o u s e , number c o d e d , and r e t u r n e d s e a l e d i n e n v e l o p e s . F o l l o w - u p measures were s e n t t o c l i e n t s f o u r months a f t e r t h e i n i t i a l b o o s t e r t r e a t m e n t w i t h I n s t r u c t i o n s t o f i l l them o u t as b e f o r e and r e t u r n i n t h e e n v e l o p e s p r o v i d e d . S i n c e c l i e n t p e r c e p t i o n o f t h e t h e r a p e u t i c r e l a t i o n s h i p i s s e e n as an i m p o r t a n t f a c t o r i n t r e a t m e n t outcome, i t would have been w o r t h w h i l e t o e v a l u a t e whether c o u p l e s i n b o t h g r o u p s p e r c e i v e d e q u a l l y p o s i t i v e a l l i a n c e s w i t h t h e i r t h e r a p i s t s . The r e s u l t s o f t h e s t r u c t u r e d i n t e r v i e w i n d i c a t e d t h a t a l l c o u p l e s p e r c e i v e d t h e i r t h e r a p i s t s as i n v e s t e d i n t h e i r w e l l - b e i n g , s k i l l e d and e f f e c t i v e . W i t h o u t e x c e p t i o n , c o u p l e s j u d g e d t h e t h e r a p y t o have improved t h e i r r e l a t i o n s h i p s . A f i n a l l i m i t a t i o n o f t h i s s t u d y i s t h a t i t employed a n o n - p r o b a b i l i t y sample o f a v a i l a b l e s u b j e c t s which a f f e c t s e x t e r n a l v a l i d i t y . B e c a u s e no s t a t e m e n t of c o n f i d e n c e c a n be a t t a c h e d t o e s t i m a t e s f r o m s u c h s a m p l e s , c a u t i o n must be used i n g e n e r a l i z i n g f r o m t h e f i n d i n g s . In t h i s s t u d y , t h e f i n d i n g s a r e l i k e l y g e n e r a l i z e a b l e t o m i l d l y t o m o d e r a t e l y d i s t r e s s e d 129 v o l u n t e e r c o u p l e s from t h e G r e a t e r V a n c o u v e r a r e a who s h a r e t h e c h a r a c t e r i s t i c s of t h e c o u p l e s i n James* (1988) s t u d y . N o n - p r o b a b i l i t y s a m p l e s a r e o f t e n used i n c l i n i c a l n u r s i n g r e s e a r c h and a r e deemed a p p r o p r i a t e f o r e x p l o r a t o r y s t u d i e s , s u c h as t h i s one. IMPLICATIONS T h i s s t u d y i s t h e f i r s t i n v e s t i g a t i o n of t h e use of b o o s t e r s e s s i o n s as a s t r a t e g y f o r m a i n t a i n i n g c hange' b r o u g h t a b o u t i n a n o n - b e h a v i o r a l m a r i t a l t h e r a p y . The r e s u l t s s u p p o r t e d t h e e f f i c a c y o f b o o s t e r s e s s i o n s i n i n c r e a s i n g and m a i n t a i n i n g m a r i t a l t r e a t m e n t g a i n s one y e a r a f t e r t e r m i n a t i o n of t h e i n i t i a l t r e a t m e n t . More f u n d a m e n t a l l y , t h i s s t u d y adds t o t h e s m a l l number o f e x i s t i n g s t u d i e s t h a t p r o v i d e e v i d e n c e t h a t m a i n t e n a n c e i s p r o b l e m i n m a r i t a l t h e r a p y . One i m p l i c a t i o n o f t h e r e s u l t s of t h i s s t u d y i s t h a t b o o s t e r s e s s i o n s may be an e f f e c t i v e way f o r c l i n i c i a n s t o enhance t h e m a i n t e n a n c e o f t r e a t m e n t g a i n s a f t e r m a r i t a l t h e r a p y . C a l l s f o r a c c o u n t a b i l i t y f r o m t h e p u b l i c s e c t o r t o g e t h e r w i t h i n c r e a s i n g p r e s s u r e from government f u n d i n g s o u r c e s f o r and c o s t e f f e c t i v e m e n t a l h e a l t h s e r v i c e s have made i t incumbent upon r e s e a r c h e r s and c l i n i c i a n s t o d e v e l o p t h e r a p y p r a c t i c e s t h a t p r o d u c e d u r a b l e g a i n s . B o o s t e r m a i n t e n a n c e s e s s i o n s , whether d e l i v e r e d t o i n d i v i d u a l c o u p l e s or i n a g r o u p , a r e c o s t - e f f e c t i v e f o r b o t h 130 c l i e n t and t h e r a p i s t , r e q u i r i n g o n l y a b r i e f i n t e r v e n t i o n t o r e t u r n c o u p l e s t o p o s t - t r e a t m e n t l e v e l s o f f u n c t i o n i n g . B o o s t e r s e s s i o n s c a n p r o t e c t t h e f i n a n c i a l , e m o t i o n a l and t i m e i n v e s t m e n t s made by c o u p l e s a t t e n d i n g t h e r a p y and p r o v i d e c l i n i c i a n s and r e s e a r c h e r s w i t h e f f i c i e n t ways t o back-up and e v a l u a t e t h e s e r v i c e s t h e y p r o v i d e . A s e c o n d i m p l i c a t i o n o f t h i s r e s e a r c h i s t h a t i t may promote change i n t h e t r a d i t i o n a l model m a r i t a l t h e r a p y , where an i n t e n s i v e t r e a t m e n t p e r i o d i s f o l l o w e d by t e r m i n a t i o n . J a c o b s o n e t . a l . (1986) have p r o p o s e d a new model of t h e r a p y w h i c h f e a t u r e s a b o o s t e r m a i n t e n a n c e phase as an i m p o r t a n t component. In t h i s model, " t h e m a r i t a l t h e r a p i s t o p e r a t e s more l i k e an a c c o u n t a n t or a d e n t i s t , t h a n a p h y s i c i a n , t o f orm r e l a t i o n s h i p s w i t h t h e i r c l i e n t s , s o l v e t h e i r most p r e s s i n g p r o b l e m s , and t h e n meet w i t h them p e r i o d i c a l l y t o p r o v i d e . . . f u r t h e r c o n s u l t a t i o n " ( p . 6 7 ) . The p r i n c i p l e a u t h o r a s s e r t s t h a t t h i s model i s more c o n s i s t e n t w i t h e v i d e n c e t h a t , more t h a n any f a c t o r r e l a t e d t o t h e r a p y , n e g a t i v e l i f e e v e n t s and s t r e s s e s o c c u r r i n g s u b s e q u e n t t o t h e r a p y u l t i m a t e l y d e t e r m i n e whether c o u p l e s m a i n t a i n t h e i r t r e a t m e n t g a i n s ( J a c o b s o n e t . a l . , 1 9 8 7 ) . Assuming t h i s e x p l a n a t i o n o f t h e m a i n t e n a n c e p r o b l e m i s v a l i d , i t seems u n r e a l i s t i c t o e x p e c t b r i e f m a r i t a l t h e r a p y i n t e r v e n t i o n s t o have permanent e f f e c t s on m a r i t a l r e l a t i o n s h i p s as i n t e r v e n i n g l i f e s t r e s s e s become s a l i e n t . F r a n k (1968) s u g g e s t s t h a t t h e c o n c e r n a b o u t t h e l o n g - t e r m e f f e c t s of p s y c h o t h e r a p y d e r i v e s 131 from the tradit ional cr i ter ion in medicine and surgery of the 5-year cure. It remains to be seen whether future research wi l l endorse booster maintenance sessions as an integral part of marital treatment regimens. One argument that has been advanced against boosters is that they serve only to delay regression, not prevent i t . Even i f improvement proves temporary, a respite from marital distress can reinforce a couple's belief in therapy and engender motivation and commitment to continue to work on their relationship. Hence, even just delaying relapse can be an important step in generating durable change. A f inal implication of this study is that i t may stimulate future research in a largely uncharted area of marital therapy; namely the maintenance of treatment gains. FUTURE RESEARCH Since this study is the f i r s t to investigate and support the use of booster maintenance with a non-behavioral therapy, one of the main recommendations for future research is that a study be conducted to replicate the current findings. In conducting such a study, i t is suggested that both short and long term follow-up measures be taken. Lebow (1981) asserts that treatment effects may be masked or misinterpreted i f either proximal or d is ta l follow-up data are omitted. No systematic long-term follow-up studies have been conducted on 132 the effects of booster sessions in of non-behavioral marital therapy. One of the major methodological problems in previous studies of booster sessions is the small number of subjects in each treatment condition, which often results in i n s u f f i c i e n t power to detect between-group differences (Whisman, 1990). The current study is no exception, although treatment effects were detected despite the small number of couples in each group. A second recommendation for future research is that prospective studies involve s u f f i c i e n t l y large numbers of subjects to ensure adequate power. An appropriate strategy for this purpose would be to perform power analyses of the number of subjects necessary to i d e n t i f y between-group differences (Cohen, 1969). Another methodological flaw in existing studies of booster sessions is the f a i l u r e to specify a rationale for how the boosters were scheduled. Whisman (1990) contends that to enhance the e f f i c a c y of maintenance sessions, scheduling should be based on empirical grounds. In p a r t i c u l a r , this author suggests that the relapse rates for a given therapy f i r s t be determined and then maintenance sessions be scheduled during the i d e n t i f i e d high-risk period rather than at some ar b i t r a r y point in time. For relapse rates to be determined in a meaningful way, there must be some standardized method for quantifying rates of change in marital therapy. One method that shows promise employs a r e l i a b l e change index based on 133 the standard error of measurement (Jacobson et a l . , 1984) to assess c l i n i c a l l y s i g n i f i c a n t change. Current rates of per-couple improvement and relapse could be established quite e f f i c i e n t l y by applying these c r i t e r i a to existing outcome and follow-up data. A further suggestion as to the scheduling of booster sessions is that c l i e n t - i n i t i a t e d sessions be offered in addition to those scheduled by the therapist, thus extending the maintenance phase of treatment. Whisman (1990) suggests that "the t y p i c a l approach of scheduling three or four post-treatment sessions may not be s u f f i c i e n t to sustain behaviour changes whereas extending the contact with the therapist may serve to maintain treatment gains for a longer period of time" (p. 166). In the structured interview, spouses responded almost unanimously in favour of the fading procedure indicating that t h i s strategy would be worth r e p l i c a t i n g . Another suggestion for future studies is that the booster strategy be reserved for couples who experience i n i t i a l success in treatment. Not to do so may create the u n r e a l i s t i c expectation that a b r i e f booster intervention could achieve gains that more intensive therapy could not; leaving couples fee l i n g even more d i s i l l u s i o n e d with therapy and their r elationships. It makes sense to attempt to maintain gains only where gains have been achieved. The following recommendation relates s p e c i f i c a l l y to the content of the CT boosters sessions. The effectiveness of the 134 CT b o o s t e r s may be i m p r o v e d by i n c l u d i n g more m a i n t e n a n c e e n h a n c i n g component t o t h e CT p a c k a g e . In a d d i t i o n t o t h e t h r e e s k i l l s i n c l u d e d i n t h e CT b o o s t e r component, G u e r n e y has d e v e l o p e d s e v e r a l o t h e r s k i l l s t h a t c o u l d be i n c o r p o r a t e d i n t o t h e CT b o o s t e r p a c k a g e . These i n c l u d e s k i l l s i n : (a) c o n f l i c t / p r o b l e m r e s o l u t i o n , (b) g e n e r a l i z a t i o n / m a i n t e n a n c e , ( c ) f a c i l i t a t i o n o f c h a n g e . T h e r e i s a need f o r f u t u r e r e s e a r c h t h a t examines t h e mechanisms t h r o u g h w h i c h b o o s t e r s e s s i o n s m a i n t a i n c h a n g e . C l i n i c a l p r a c t i c e may b e n e f i t from t h e r e s u l t s of p r o c e s s -o r i e n t e d s t u d i e s t h a t b e g i n t o s p e c i f y how change i s i n d u c e d and m a i n t a i n e d . Whisman (1990) c l a i m s t h a t t h e r e i s no r e a s o n t o i n f e r t h a t t h e p r o c e s s e s t h a t p r o d u c e change r e s e m b l e t h e p r o c e s s e s by w h i c h change i s m a i n t a i n e d . One f a c t o r , t h a t has been a s s o c i a t e d w i t h t h e m a i n t e n a n c e p r o c e s s i s t h e c l i e n t ' s e x p e c t a t i o n s o f s e l f - e f f i c a c y . An i n d i v i d u a l ' s s e n s e o f c o n t r o l or m a s t e r y seems t o i n f l u e n c e t h e p e r s i s t e n c e o f t h e r a p e u t i c e f f e c t s . I n f u t u r e s t u d i e s of b o o s t e r s e s s i o n s i t would be i m p o r t a n t t o p r o v i d e r a t i o n a l e and i m p l e m e n t a t i o n p r o c e d u r e s t h a t enhance c l i e n t s ' p e r c e p t i o n s o f s e l f - e f f i c a c y . I n t h i s s t u d y , p r o s p e c t i v e c o u p l e s were t o l d t h a t CT b o o s t e r s would h e l p them d e v e l o p t h e i r c o n f i d e n c e i n u s i n g t h e s k i l l s t o enhance t h e i r r e l a t i o n s h i p s t o r e s o l v e t h e i r own c u r r e n t and f u t u r e p r o b l e m s . 135 F i n a l l y , f u t u r e r e s e a r c h i n c o u p l e ' s t h e r a p y might a d d r e s s t h e p r o b l e m o f i n t r a - c o u p l e d i f f e r e n c e s . I n s p e c t i o n of i n d i v i d u a l ' s s c o r e s i n t h i s s t u d y r e v e a l e d t h a t some s p o u s e s had q u i t e d i f f e r e n t p e r c e p t i o n s of t h e i r r e l a t i o n s h i p s . A l s o , of i n t e r e s t t o f u t u r e r e s e a r c h would be a s t u d y t h a t e x p l o r e d m a l e / f e m a l e d i f f e r e n c e s i n r e s p o n s e t o t r e a t m e n t s e m p h a s i z i n g c o m m u n i c a t i o n and g e n e r a t i n g i n t i m a c y . The i n t e n t o f t h i s s t u d y - t o s t i m u l a t e e m p i r i c a l i n t e r e s t i n t h e m a i n t e n a n c e p r o b l e m - i s a p t l y e x p r e s s e d i n t h e s e n t i m e n t s of t h e l e a d i n g c o n t e m p o r a r y r e v i e w e r of b o o s t e r m a i n t e n a n c e s e s s i o n s : I t i s hoped t h a t by i m p r o v i n g t h e c o n t e n t o f b o o s t e r s e s s i o n s and t h e r e s e a r c h m e t h o d o l o g y u s e d t o e v a l u a t e them, as w e l l as i d e n t i f y i n g f a c t o r s a s s o c i a t e d w i t h t h e change p r o c e s s , t h e i m p a c t o f b o o s t e r m a i n t e n a n c e s e s s i o n s i n m a i n t a i n i n g t r e a t m e n t - i n d u c e d change w i l l be e n h a n c e d (Whisman, 1990, p . 1 6 8 ) . 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M a i n t e n a n c e s t r a t e g i e s f o r t h e t r e a t m e n t o f o b e s i t y : An e v a l u a t i o n o f r e l a p s e p r e v e n t i o n t r a i n i n g a n d p o s t t r e a t m e n t c o n t a c t by m a i l a n d t e l e p h o n e . J o u r n a l o f Consulting and C l i n i c a l Psychology, 5_2_, 404-413. R o s s , E . R . , B a k e r , S . B . , & G u e r n e y , B . G . , (1985). E f f e c t i v e n e s s o f R e l a t i o n s h i p E n h a n c e m e n t t h e r a p y v e r s u s t h e r a p i s t ' s p r e f e r r e d t h e r a p y . Amer i c a n J o u r n a l Of M a r i t a l a n d F a m i l y T h e r a p y , i l , 11-21. R e l i n g e r , H . , B o r n s t e i n , P . H . , B u g g e , I . D . , C a r m o d y , T . P . & Z o h n , C . J . (1977). U t i l i z a t i o n o f a d v e r s e r a p i d s m o k i n g i n g r o u p s : E f f i c a c y o f t r e a t m e n t and m a i n t e n a n c e p r o c e d u r e s . 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The occurrence of behavior disorders in children: The in t e r -dependence of Attention D e f i c i t Disorder and Conduct Disorder. Journal of the American Academy o£ C h i l d and Adolescent P s y c h i a t r y , 25_, 809-819 . G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family. 28_, 15-2. Steffen, J.J. & Karoly, P. (1980). Toward a psychology of therapeutic persistence. In P. Karoly & J. Steffen (Eds.) Improving the long-term effects of  psychotherapy, (pp.3-24.) New York: Gardiner Press. Stuart, R. B. (1967). Behavior control of overeating. Behavior Research and Therapy, 5_, 357-365. Vogler, R. E., Lunde, S.E., Johnson, G. R., & Martin, P. L . (1970). E l e c t r i c a l aversion conditioning with chronic alcoholism. Journal of Consulting and C l i n i c a l Psychology. 2A, 302-307. Wallersteln, J. (1988). Second chances: Menr women and children ten years after divorce • New York: Tickmore & F i e l d s . Wieman, R. J. (1973). Conjugal relationship modification and reciprocal reinforcement: A. comparison of. treatments Loz m a r i t a l d i s c o r d , unpublished doctoral d i s s e r t a t i o n , Pennsylvania University. Shapiro, Spanier, 145 Whisman, M. A. (1990). The efficacy of booster maintenance sessions in behavior therapy: Review and methodological cri t ique. C l in i ca l Psychology  Review, 1H, 155-189. Wilson, G . , & Brownell, K. (1980). Behavior therapy for obesity: An evaluation of treatment outcome. Advances in Behavior Research and Therapy, 3_, 49-86 . Z ie l insk i , J . (1978). Maintenance of therapeutic gains: Issues, problems, and Implementation. Professional P s y c h o l o g y , 5_, 353-359. 146 APPENDIX A Demographic D a t a f o r t h e Ten C o u p l e s i n t h e B o o s t e r S t u d y . 1. Mean number o f y e a r s l i v i n g t o g e t h e r - 13.0. 2. Mean number o f c h i l d r e n i n t h e f a m i l y - 2.3. 3. P e r c e n t a g e o f c o u p l e s who had r e c e i v e d p r e v i o u s m a r i t a l c o u n s e l l i n g o f b r i e f d u r a t i o n - 50% (mean d u r a t i o n 2.4 m o n t h s ) . 4. P e r c e n t a g e o f i n d i v i d u a l s who were p r e v i o u s l y m a r r i e d -20%. 5. Mean age of p a r t n e r s - 40 y e a r s . 6. M e d i a n a n n u a l f a m i l y income was between 45,000 and 50,000 d o l l a r s . 7. Mean number o f y e a r s of e d u c a t i o n f o r i n d i v i d u a l was 13.2. 1 4 7 APPENDIX B INTERVIEW SCHEDULE 1. What was i t like to participate in these four C T . sessions several months after your last C T . Ski l l s training sessions ended? 2. Prior to receiving these four sessions, had you been using the expression and listening s k i l l s that you were introduced to in your f i r s t four C T . sessions? What reason do you give for this? 3. What did you find most helpful about the C T . sessions this time around? Consider things like the session format, timing, contents or the s k i l l s themselves. 4. What effect do you think these four C T . sessions has had on your relationship with your partner? Improved No effect Deteriorated Not sure Why do you think this is so? 5. How often were you able to complete the homework practice sessions? Never Rarely Sometimes Most Times Always 6. How helpful were the homework practice sessions in helping you learn the sk i l l s? Very Somewhat Not At A l l Not Sure Why do you think this is so? 148 

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