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A one year follow-up of the differential effects of experiential and systemic interventions in resolving… Rempel, Rosa 1986

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A ONE YEAR FOLLOW-UP OF THE DIFFERENTIAL EFFECTS OF EXPERIENTIAL AND SYSTEMIC INTERVENTIONS IN RESOLVING MARITAL CONFLICT by ROSA R E M P E L B.Ed., University of British Columbia, 1978 A THESIS SUBMITTED I N PARTIAL F U L F I L M E N T O F T H E REQUIREMENTS FOR T H E D E G R E E O F MASTER OF ARTS in T H E F A C U L T Y O F G R A D U A T E STUDIES Department of Counselling Psychology We accept this Thesis as conforming to the required standard T H E UNIVERSITY O F BRITISH C O L U M B I A July, 1986 ® Rosa Rempel, 1986 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . ) D e p a r t m e n t o f The U n i v e r s i t y o f B r i t i s h C o l u m b i a 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3 D a t e JXAJ^. . i i Abstract This study investigated the differential effects of two interventions in the treatment of marital discord one year following the termination of ten sessions of marital counselling on the dependent measures of conflict resolution (CRS), attainment of specified relationship goals (GAS), target complaint reduction (TC) and increased marital adjustment (DAS). The two treatments under investigation were an experiential intervention in which the goal is for partners to access and acknowledge, in both themselves and the other, previously unexpressed feelings underlying the reactive behaviour patterns and a systemic intervention in which the focus is on modifying patterns of communication. Twenty couples, ten from each treatment group, completed the standardized instruments as well as a qualitative follow-up questionnaire. The results of this study indicated that both treatment groups made significant gains at termination of active therapy on measures of goal attainment, marital adjustment, conflict resolution, and target complaints. The results also indicated that these gains were maintained over a one year period. Indeed, both treatments were effective in treating couples with problems of marital discord and have powerful components for changing the nature of relationships and maintaining those changes over a one year period. iii TABLE OF CONTENTS Abstract ii List of Tables v Acknowledgements vi CHAPTER I: INTRODUCTION 1 Background 1 The Problem 2 Definition of Terms 3 Hypotheses 4 Rationale For Hypotheses 5 CHAPTER II: REVIEW OF T H E LITERATURE 7 Outcome Research in Marital Therapy 7 Follow-up Research in Individual and Marital Therapy 9 Follow-up Research in Experientially-oriented Couples Therapy 12 Conceptual Models for Experiential and Systemic Marital Therapies 13 Experiential Theory 13 Family Systems Theory 17 Communication Theory 18 The Process of Change in Communication Theory 19 Milan Therapy 21 The Process of Change in Milan Therapy 21 Positive Connotations : 22 CHAPTER III: T H E M E T H O D O L O G Y OF T H E STUDY 27 Design of the Study 27 The Treatments 28 iv Research Procedures 29 Client Population and Sampling 31 Therapist Selection and Training 32 Instruments Used 32 Outcome Instruments 33 Data Analysis 38 Data Analysis Procedures 40 Limitations and Implications of the Study 41 CHAPTER IV: RESULTS 42 Implementation Check 43 Results: Quantitative Data 45 Results: Qualitative Data 50 Summary 52 CHAPTER V: DISCUSSION AND CONCLUSIONS 53 Limitation 60 Recommendations 61 References 63 APPENDIX 69 V LIST OF TABLES Table 1: Repeated Measures Analysis of Variance: Mean, (Std. Dev.), F-ratios (Between Groups) 46 Table 2: Repeated Measures One Factor Analysis of Variance Across 3 Occasions: Mean, (Std. Dev.), and F-ratios 47 Table 3: Qualitative Questionnaire—Frequency Table 51 vi Acknowledgements I would like to thank the members of my committee, Drs. Greenberg, Ratzlaff and Young, whose assistance, constructive feedback, and encouragement kept me motivated and helped make this project very special. My thanks are also extended to Audrey Goldman, who gave me her time and shared with me the information needed to conduct and complete this thesis. Finally, my deepest gratitude goes to my husband, Erwin, who has taught me the meaning of love, intimacy, and patience, through his own devotion to our marriage; also, for his invaluable support and encouragement which has led to the completion of this worthwhile endeavour. 1 CHAPTER I: INTRODUCTION Background Marriage is one of the primary vehicles for the satisfaction of intimacy needs. L'Abate (1977) defines intimacy as the sharing of fears or hurt feelings with someone who can be trusted, usually a mate. Bowlby (1969) maintains that attachment behaviour is an essential feature of our humanness, "to judge attachment behaviour in adults as inappropriate is to overlook the vital role that it plays in the life of man from the cradle to the grave" (Bowlby, 1969, p. 208). Evidence suggests that positive close relationships seem to help inoculate those involved against the stresses of life. In analyzing life histories, Lowenthal and Haven (1968) noted that the happiest and healthiest in later years were people who were or had been involved in one or more close personal relationships. If there is agreement with the generally accepted premise that marriage or sustained-couple relationships provide the best context for intimacy, it then becomes imperative for us to understand ways of facilitating its development, to gain a deeper understanding of ways to prevent marriage breakdown and/or to help repair and revitalize such relationships when they falter. A recent outcome study (Goldman, in press) addressed the issue of the effects of different interventions on couples' conflict resolution; the effects of two promising approaches to marital therapy which have not been adequately evaluated, experiential and systemic marital therapies, were studied. A set of different interventions specific to each of these approaches were defined and used to help the clients work through their conflicts in a ten week treatment program. 2 Short or long-term follow-up of clients after the administration of a treatment program of this sort is a vital component of any research study. This appears necessary in determining whether or not the change that has occurred as a result of therapy is lasting. Follow-up of clients is generally either omitted from psychotherapy research studies or is done inappropriately because adequate client testing is too demanding (Cross, Sheehan & Khan, 1982). According to Bergin (1971), follow-up needs to examine the client's situation on more than one occasion. Behaviour can vary over time, showing either improvement or deterioration, and multiple follow-up assessment isolates the patterning or configuration of effects, thereby providing detailed information on the specific consequences of treatment. Goldman (in press) assessed the treatment at termination as well as at the four month follow-up period. These same assessment procedures will be employed at the long-term follow-up. As Gottman and Markman (1978) commented, an important methodological consideration in psychotherapy research is "to include the same measures taken at pre and post-assessment in the follow-up assessment" (p. 54). The Problem Previous research, for the most part, has shown the lack of long term follow-up in treatment studies. Gottman and Markman (1978), for example, reviewed 55 studies done from 1970 to 1976 on systematic desensitization. Only 25 studies had any follow-up at all. Only six included retesting after periods of six months to one year. Goldman (in press) has conducted a study using an emotionally focused (experiential) therapy and an integrated systemically focused therapy. Neither of these approaches have had a great deal of research investigation. This study will attempt to 3 conduct a comparative investigation of the durability of these two promising broad approaches. This one year follow-up study should allow adequate opportunity for the effects of each treatment to emerge. Process and outcome in therapy concurrently will also be examined. In general, the literature tends to attribute therapeutic effects to such factors as the theoretical orientation employed, the therapist's experience and the duration of treatment. "Non-specific factors, e.g. therapist interest and client involvement, however, may also play an important role in inducing client change" (Cross, Sheehan & Khan, 1982, p. 104). Definition of Terms Emotionally Focused Therapy: (An experiential treatment.) A more detailed description of this treatment (Greenberg & Johnson, in press) can be found in Chapter II. The goal in experiential couples therapy is for partners to access and acknowledge, in both themselves and the other, previously unexpressed feelings underlying the reactive behaviour patterns. This can lead to a change in both the way partners are perceived by each other and how they communicate with one another. For example, if one member sees pain and sadness expressed by a partner who has previously been seen as demanding, this will most often lead to positive change and can evoke feelings of comfort and support instead of self-protectiveness against attachment (Greenberg & Johnson, in press). Strategic Couples Therapy: A systematic treatment which is specified in the systemic 4 manual designed and devised by Greenberg & Goldman (in press). A more detailed conceptual model for such an approach will be presented in Chapter II. The focus in systemic therapy is on modifying patterns of communication (Steinglass, 1978). Emotional experiencing plays little role in the process of change; the awareness and expression of feelings may or may not be a consequence of the therapeutic process, but they are not seen as necessary to the therapeutic process. Wile (1981) states, "the generating concept of systems is circular causality" (p. 27), traditional causal theory being linear. Each partner's behaviour is seen as a reaction or adjustment to the behaviour of the other. One partner withdraws because the second nags while the second nags because the first withdraws. Reframing of the marital interaction becomes the catalyst for change. Watzlawick (1976) has defined reframing: "to change the conceptual or emotional setting in relation to which a situation is experienced and place it into another frame that fits the 'facts' of the same concrete situation equally well or better and thereby changes its entire meaning" (p. 122). Interpretation is not used to foster either genetic or interactional insight; instead the negative interactional cycle is reframed in order to give it new meaning and then prescribed with the intent of creating recalibration or change in the system (Gurman, 1981). Hypotheses The hypotheses under investigation are that a systemic treatment and an emotionally focused treatment will not have differential effects in helping couples to resolve conflict goals, reduce target complaints and increase marital adjustment as measured at the one year follow-up. 5 H : There will be no differential effects between the two treatment o groups at the one year follow-up in helping couples to resolve conflict cycles, to reach specified relationship goals, reduce target complaints and increase marital adjustment, regardless of the therapy the couples have received. H : There will be no effects of time between an emotionally-focused o treatment and a systemic treatment as measured on two occasions: at termination of treatment and at the one year follow-up. There will be no change from one occasion to the other. Rationale For Hypotheses There is no comparative outcome research on the differential effects of emotionally focused (experiential) therapy and the systemic marital therapy. According to Jacobson (1978b, 1979), previous marital therapy has been focused predominantly on behavioural problem solving therapies; systems theory cannot claim a single outcome experiment investigating its effectiveness. Outcome research has as its basic purpose the elicitation of information regarding the effectiveness of a particular treatment. There is support in the literature for the notion that a technique for treating couples is of little value if the gains made during, and as a result of, treatment do not persist after the termination of active therapy. Follow-up data are the only way that one can be certain that treatment gains extend beyond the period of time when regular meetings with the therapist took place (Jacobson, 1979). It would seem crucial that research be generated to test kinds of therapies for the purpose of investigating the potency and continuing effect of various treatments in 6 effecting change. An important research question, "Do the effects of treatment hold?" addresses the issue of the lasting effects of different interventions of couples conflict resolution. If these ten week treatments do hold, then this study is highly significant because then we will have determined the effects that allow couples therapy to last If there is differential holding: one holds more than the other, this would also prove significant in determining which treatment is more lasting. If neither treatment holds, it may be assumed that these two treatments are not effective beyond the termination of active therapy. However, it cannot be assumed that these two treatments are less effective than other marital therapies, but it would generate tremendous possibilities for future investigations. 7 CHAPTER n: REVIEW OF THE LITERATURE This review will focus on outcome research and follow-up literature in marital therapy. Three areas will be emphasized: follow-up literature in marital therapy and certain research methodology issues, studies specific to experiential and systemic marital therapies, and finally, conceptual models for both the emotionally-focused and the strategic treatment approaches used in this study (Goldman & Greenberg, in press). Outcome Research in Marital Therapy A significant increase in research on outcomes of family and marital therapies has characterized the last decade. This is reflected in the contrast between a review of outcome studies in family therapy by Wells and Dezen (1978) where only 13 role-relevant reports could be identified with a review by Gurman and Kniskern (1978) where 500 reports were examined with total N approaching 5,000 (Gurman & Kniskern, 1981). Gurman and Kniskern (1985) note that whereas in 1973 only one journal in the field existed, there are now about two dozen journals published in English and in several other languages. In their more recent review, Gurman and Kniskern (1981) state that evidence suggests that both behavioural and non-behavioural treatments are effective beyond chance and conclude that, in the marital therapy reviewed, 65% of cases improved (Gurman & Kniskern, 1981). L'Abate (1983) in his review of individual and conjoint marital therapy found conjoint marital therapy to be superior to alternative treatments in 70% of comparisons and inferior in only 5%. Of Gurman and Kniskern's (1978, 1981 & 1985) overall conclusions on marital therapy studies, those that have relevance here are: 8 1. Nonbehavioral marital therapies produce beneficial outcomes in about two-thirds of cases. 2. Couples benefit most from treatment when both partners are involved in therapy conjointly rather than when only one is seen. 3. Short term therapies (8-12 sessions) seem to be at least as effective as treatments of longer duration. 4. Short term follow-up may minimize the detection of more impressive treatment outcomes. 5. Therapist relationship skills: the therapist's ability to convey an ultimate acceptance of each person's position, feelings and needs—growth inducing skills, have major impact on the outcome of marital and family treatment regardless of the "school" orientation of the clinician. 6. The only interventions which have received consistent positive empirical support as facilitating outcomes of marital therapy, regardless of the style of such therapies are those that increase couples communication skills. (Gurman & Kniskern, 1978; Jacobson, 1978b, 1979). 7. The assessment procedures used during the treatment phase should also be employed at each of the follow-up periods (Bergin, 1971). A number of research studies have been published in various journals over the last 25 years in which clients' evaluation of therapy has been the major outcome criteria (Feifel & Eells, 1963; Heine, 1953; Strupp, Wallach & Wogan, 1964). Despite the fears that self reports are not sufficiently objective measures of outcome, there is a long tradition of having clients evaluate therapy. Feifel and Eells (1963) point out that the client's viewpoint is a valuable contribution to our understanding of the therapy process and that, as well, non-standardized measures may sometimes provide very valuable information, "The involved parties in psychotherapy are still in the most favoured position to provide us with promising leads concerning what takes place" (p. 310). There would, of course, be problems with this approach if it was used to obtain accurate outcome data, but the 9 assumption is that careful wording of the inquiries, in non-standardized measures, as to what went on during therapy, can minimize distortion and allow constructive criticism of process to take place. Follow-up Research in Individual and Marital Therapy Previous research in individual and couples therapy, for the most part, has lacked long-term follow-up. Gottman and Markman (1978), for example, reviewed 55 studies of individual therapy carried out from 1970 to 1976 on systematic desensitization. Only 25 of those studies had any follow-up at all. Six included retesting after periods of six months to one year; and only six reassessed clients after periods of one year or greater. Similarly, for individually oriented psychotherapy, Luborsky, Singer and Luborsky (1975) reported that follow-ups were "either absent or too brief to catch the long-term benefits" (p. 1,005). Although this problem still exists, there have been some important studies on the issue of durability. Liberman's (1978) report on the results of experiments conducted by researchers at the Johns Hopkins Hospital following patients over time intervals of 5, 10 and 20 years suggest that patients receiving individual, group, or minimal therapy (1/2 hour biweekly) all improved over the initial treatment period. Continued improvement at each evaluation interval was also noted. In another major psychotherapy research project, Sloane, Staples Cristol, Yorkston and Whipple (1975) reported on a comparison of behavioural and psychodynamic psychotherapies. Initial improvements were found to be more pronounced than those found at the one-year and two-year follow-ups. However, the authors suggest that the effects obtained during treatment did persist in a sizeable percentage of patients. 10 Liberman, Yalom and Miles (1973) interviewed former participants who had benefited from encounter groups. Their results are interesting and appear to be consistent with other researchers' beliefs that maintenance of change is an active process engaged in by the client(s) and treatment results do not persist spontaneously. They found that gains were maintained mostly with participants who engaged in a continuing process of interpersonal "experiencing," practising the skills they had learned during their encounter groups. For comparative investigations, follow-ups need to allow adequate opportunity for the effects of the treatment forms that are employed in the therapy program to emerge. In fact, in couples therapy, little follow-up, short or long-term, has been done. Systemic marital therapy has not had a great deal of research investigation but Stanton (1981), on the basis of his review of the literature of family therapy, concluded that, depending on the kind of patient population, a strategic orientation to family therapy shows considerably better results and much promise when compared to standard forms of treatment. Stanton (1981) cited seven research studies investigating outcome using strategic-oriented family therapy and suggests that based on Gurman and Kniskern's (1978) scale of family research design quality, these studies utilized superior research designs in comparison with the average for studies of other family therapy approaches. While briefly reviewing a number of these studies, the emphasis will be on the follow-up results. Langley and associates (1968) investigated family crisis therapy using techniques similar to models that share a systemic root—communications-oriented theories such as Milan therapy and the work of Selvini Palazzoli, Boscolo, Cecchin, & Prata (1978) and the strategic therapy of Haley (1963). These therapies are characterized by the following: emphasis on the present rather than on the past, brief problem focused therapy, small 11 changes as the goal, refraining, attention to family hierarchy, positive interpretation, giving firm directives and concrete tasks for homework. Half the families were randomly assigned to family crisis therapy without hospitalization and half to standard treatment. Results from an 18 month follow-up showed that family crisis therapy cut in half the number of days patients subsequently spent in the hospital. Alexander and Parsons (1973) compared a behavioural]y- oriented, crisis-centered family therapy based on strategic techniques and systems theory derived from Haley (1963) and Watzlawick, Beavin & Jackson (1967) with client-centered, eclectic dynamic approaches and a no treatment control group in treating delinquency. Recidivism was cut in half in the systems treatment group, suggesting the superiority of this treatment A three year follow-up by Klein, Alexander & Parsons (1977) showed the incidence of problems in siblings to be significantly lower for the family system treatment. According to Olson, Russel & Sprenkle (1980), Alexander and Parson's approach has elements of strategic therapy and uses a form of refraining that they refer to as relabelling. Garrigan and Bambrick (1975, 1977, 1979) conducted a six year research project investigating outcomes of Zuk's "go-between" therapy for families with disturbed children. Follow-up of the first and second study suggested that the treatment group showed more improvement in the identified patient's perception of family adjustment This study was notable in that it used one of the few measures of marital dyadic function available in the literature. Results suggest that family therapy enabled these couples to reestablish more meaningful and facilitative ways to communicate. It is important to note that the lack of research in the area of marital counselling has resulted in family therapy working with couples on interaction and communication skills. 12 Follow-up Research in Experientially-oriented Couples Therapy A significant contribution has recently been made by Johnson and Greenberg (1984) who have conducted an outcome study in which a cognitive behavioural marital therapy, teaching problem solving skills and Emotionally Focused Couples' Therapy, focusing on emotional experiencing were compared with a control group. After eight sessions, both treatment groups showed significant gains over untreated controls on measures of goal attainment, marital adjustment, levels of intimacy and target complaints reduction. The effects of the experiential treatment were superior, at termination, to those of the cognitive behavioural marital treatment (CBMT) on marital adjustment, some aspects of intimacy, and reduction of target complaints. At the eight week follow-up, marital adjustment scores for the experientially treated couples remained higher than for the cognitive behaviourally treated couples. Thus, the general difference between groups found at treatment termination held at follow-up. According to Jacobson and Follette's (1985) report, Johnson and Greenberg's (1984) eight week follow-up period may have minimized the detection of more impressive cognitive behavioural marital therapy outcomes since communication/problem-solving training may be expected to have relatively weaker short-term effects, but more powerful long-term effects than behavioural exchange training (Jacobson, 1984; Jacobson & Follette, 1985). It seems necessary that long-term follow-up be conducted to allow for delayed change and to analyze the effects of time. Goldman and Greenberg (in press) have taken the next step and compared the same experiential approach that was used in Johnson and Greenberg's (1984) study with a systemic approach to marital therapy. The experiential treatment investigated here is the emotionally-focused treatment delineated by Johnson and Greenberg (1984). A 13 description of the systemic therapy as exemplified by Greenberg and Goldman's manual will be discussed in the latter part of this chapter. Neither of these two approaches has had a great deal of research investigation. Goldman has conducted a four month follow-up (Goldman, in press) to investigate the differential effects of the above treatments. A more long-term follow-up is needed to allow adequate opportunity for the effects of each treatment to emerge. Conceptual Models for Experiential and Systemic Marital Therapies. Experiential Theory Experiential therapy is an outgrowth of humanistic-existential theory (Greenberg & Johnson, 1985). Although developed as an individual therapy, Gestalt therapy, one of the major experiential therapies, addresses the issue of organism/environment interactions and hence lends itself to looking at interpersonal issues (Greenberg & Webster, 1982; Perls, 1973). In its work with individuals, however, Gestalt therapy has focused more on the individual's awareness. With this emphasis on awareness, the focus of therapy has been on a person's current organization of the world. It is assumed that all behaviour stems from individuals' quests to actualize themselves in their currently perceived environments. Blocks to awareness and experiencing are seen as central to individual problems. Such blocks may result from "unfinished business" or current restrictions of awareness, due to avoidance and disowning aspects of current experience (Greenberg & Johnson, 1985). Experience that is not allowed is regarded as alien to the ego and is perceived as a threat to the person's integrity. In order to combat such threats, the person interrupts his or her need gratifying sequence. These disturbances, occurring without 14 awareness, distort the person's perception of reality and allow him or her to avoid direct and immediate contact with the "here and now." Two of these "alterations of the boundary" which are relevant to couples therapy are "projection" and "introjection." These are generally accepted as two of the major processes by which ego functions are altered and are considered pathological when they are maintained outside the person's awareness: 1) Projection is a process in which the individual attributes disowned and alienated aspects of the self to other; these are regarded as foreign to one's self. This often results in overconcern with what other people think because judgements of oneself are imagined to be occurring in the environment 2) Introjection is a process in which the excitations and interests of the self are not perceived. Aspects of the environment are identified with as if they were aspects of the self; this results in conflict (Greenberg & Webster, 1982). As applied to couples counselling, when a client consistently misinterprets or exaggerates some aspects of his or her partner's or therapist's personality that is denied in himself or herself, the above phenomenon, individually or a combination of both, are seen to be operating. The goal of therapy is to allow the client to re-experience both good and bad aspects of his or her personality, thus enabling him or her to reintegrate dissociated parts of the self (Segraves, 1982). Within an experiential framework which generally stresses individual awareness, Satir (1967) has emphasized the importance of congruent communication and closeness in relationships (Greenberg & Johnson, 1985). The essence of Satir's position is that there is a reciprocal interrelationship between communication difficulties and individual self-esteem. Healthy interpersonal relationships require those involved to have a sense of individuality and relatedness (Segraves, 1982). Satir emphasizes that people need to learn 15 to discriminate between internal feelings, images and introjects, and external reality. Although the emphasis on communication and interrelatedness places her approach in a communication and systems framework, the emphasis on affect also places her approach in an experiential framework (Greenberg & Johnson, 1985). Gurman (1981), Wile (1981) and Greenberg and Johnson (1985) all propose integrative theories of marital therapy which draw upon aspects of intrapsychic as well as interactional theory. Gurman supports this by stating: It is likely that treatment approaches which systemically consider and attempt to produce change on multiple levels of psychological experience will facilitate the development of interventions that are more flexible and responsive to [clients] and will . . . lead to more positive and enduring clinical outcomes, (p. 422) An overriding goal, in an experiential marital therapy, is to achieve change in each partner as well as in the marital interaction. Contrary to notions in the family therapy field, while change in one spouse changes the marital system, system change is not necessarily required in order for change to occur in one or the other partner (Gurman, 1981a). In an experiential approach, partners are encouraged to share their points of view with mutual caring but in addition, the fulfillment of individual needs is seen as a priority. Wile (1981) sees psychological symptoms as emanating from the deprivation of needs that people are currently experiencing. The result is a lack of satisfaction and control that is necessary to make conditions and life worthwhile. The major premise of this view is that it is people's inability to have their wishes and needs respected as well as not being the most important person to an important other that cause problems in a marriage. Disowning of these universal human needs leads to ineffective communication and escalating interactional cycles (Greenberg & Johnson, 1985). These authors note that some major needs in couples are for closeness, 16 contact/comfort and intimacy. Intrapsychic fears of being close and interactional patterns which prevent closeness are, then, goals for change. In this model of couples therapy, change occurs within the individual as well as within the context of the relationship. Intrapsychic change or growth in the individual involves developing a broader range of experiential awareness, including an awareness of unmet needs for closeness and intimacy and the acknowledgement of feelings of vulnerability or deprivation (Greenberg, 1984; Greenberg & Johnson, 1985; Wile, 1981). Cognitive change at a purely conceptual level will not necessarily produce change at a feeling level in a person; but acknowledging emotions not in the clients' current awareness provides people with adaptive, affective responses which aid problem solving. "These affective change processes occur in each individual during the process of successful experiential couples therapy" (Greenberg & Johnson, in press). When couples relive their emotions by recreating a situation, the cognitions governing these behaviours become available for further inspection, clarification and modification (Greenberg & Johnson, 1985). Interventions range from reflection of feelings and non-verbal expression to clear and vivid responses. Once clients are in this state, experiential procedures from Gestalt therapy (Perls, Hefferline & Goodman, 1951) or client centered therapy such as empathic reflection and evocative responding (Rice, 1974) could be used to encourage emotional experiencing. These authors suggest that an important mechanism in the change process is the change in interpersonal perceptions in which the expression of feelings plays an important role. The expression of underlying, previously unexpressed feelings leads to a change in each partner's perception of the other. When a blamer expresses underlying vulnerability or a withdrawer expresses underlying resentment and this is heard and accepted by the other partner then change occurs in the cycle. The receptive partner begins to see his 17 or her spouse in a new way—no longer blaming but vulnerable and no longer uninvolved but angry. The expressive partner experiences that he or she can disclose, be accepted and have his or her needs responded to by the other. This process enables each partner to appreciate the other's position and become more accepting of their spouse's previously unacceptable behaviours (Greenberg & Johnson, 1985; Wile, 1981). This type of sharing builds intimacy and emotional bonds; it invokes deeper understanding and acceptance of their partners, leading to change and resolution of conflict in the relationship. Family Systems Theory Steinglass (1978) points out that the essence of a systems approach, from which marital systems theory has emanated, is defined as "attention to organization, to the relationship between parts, to concentration on patterned rather than linear relationships and to a consideration of events in the context in which they are occurring rather than in isolation from their environmental context" (p. 304). The principle of "wholeness" is important to an understanding of the development of marital systems therapy. Weeks and L ' Abate (1982) note that "the behavior of a system is the product of a complex series of transactions" (p. 25). A marital-family disturbance is often the cause of individual problems. Marital conflict is seen as a result of interaction; intrapsychic, especially unconscious, forces are considered irrelevant. This notion is in contrast to the experiential theorists' notion that emotional experiencing is pivotal to the process of change in marital therapy. The system-oriented therapists show some similarity to cognitive therapists (Beck, 1976; Ellis, 1973: Meichenbaum, 1977) in their beliefs that awareness and expression of feelings may or may not be a consequence of the 18 therapeutic process; such processes are not seen as necessary for change in therapy. Gurman (1981) notes that a symptomatic individual cannot be expected to change unless his or her family system changes. It appears that treating an individual, alone, for a marital problem may produce deterioration in the marriage. There are varying "schools" or orientations within the broad framework of family and marital systems theory. Emphasis will be placed here on elaboration of communications-oriented theories as well as the Milan group because they have had considerable influence upon the development of the techniques and interventions that are associated with the systemic marital therapy used in the Goldman and Greenberg (in press) study. Communication Theory Communication theory is a systems model of marital interaction and therapy in which the central focus is on interaction and communication and on the rules that govern human behaviour. Thoughts and feelings, internal processes, of the individual are not perceived as being relevant Steinglass (1978) notes that the above focus also applies when considering marital disorders. Fisch, Weakland and Segal (1982) note, "a focus on communication and interaction within the family leads to much more emphasis on actual behaviors, what is observably going on in the present rather than on the past, the internal and the inferential" (p. 8). If a series of negative exchanges occurred regularly in a marriage, it might be concluded that a "describable" pattern of communication existed (Steinglass, 1978). Jackson (1965) points out that such a pattern of communication reflects a rule about the nature of a marital relationship. If the rules are flexible, the couple might do well but 19 if the agreements are too rigid, the couple might be at risk from the pressures that require change in the communicational patterns (Steinglass, 1978). Similar to a social learning view, communication theorists view marital conflict, in people who marry, as a result of their interactions and not as stemming from any existing psychopathology in these people. Haley (1963) sees relationships and marital conflict as largely a process of the struggle for power and control. In these interpersonal systems, rules are rigid and partners have fewer options for processing information and resolving their conflicts. The Process of Change in Communication Theory The ways clients try to alter a problem often contribute most to the problem's maintenance or escalation (Fisch, Weakland & Segal, 1982). This is one of the key principles of the MRI group, while Haley's (1963) emphasis, in marital conflict, is on the power struggle between spouses, the element of rules on boundaries and the management of power and authority (Sluzki, 1983). Problem formation and maintenance are seen as part of a vicious circle process by the communication theorists. Well-intended solution-behaviours tend to maintain the problem. If this vicious circle process was interrupted by altering these behaviours then this interruption of the cycle should initiate resolution of the problem. The therapist's primary aim, then, is to initiate a reversal. For this to occur, the therapist must get "a clear view of the problem behaviors and the behavior that functions to maintain it; he [or she] must also consider what the most strategic change in the 'solutions' might be and take steps to instigate these changes . . . in the face of the client's considerable commitments to maintaining them" (Fisch, Weakland & Segal, 1982, p. 19). 20 Haley (1976) comments, ". . . the main goal of therapy is to get people to behave differently and so to have different subjective experiences" (p. 49). Gurman (1978) adds, The basic assumption of communicationists in this regard is that when change has been achieved in one domain of experience, it radiates to all other domains, from the behavioral-interactional to the subjective. This assumption also appears in analogous form in the standard contention by systems-oriented therapists that a therapeutic focus on process is superior to a focus on content. This assumption is explained by reference to the general systems notion of equifinality, that is, that no matter where one begins, the conclusion will be the same. (p. 529) In a communications approach to marital and family therapy, the mechanisms for change stem from a paradox paradigm and involve reframing or positively connoting the couple or family's symptoms and/or system. This is followed by making interventions centering around a suggestion of "no change"; the therapist would prescribe the symptom or negative interactional pattern and enable the clients to see it as a strength. The therapist needs to understand what purpose the symptoms have been serving in the marital or family system. Weeks and L'Abate (1982) note, once the positive function of the symptom has been identified it can be seen as a vehicle for change. Reframing and relabelling are seen as ways of facilitating positive therapeutic outcomes. Watzlawick (1976) has defined reframing as: "to change the conceptual or emotional setting in relation to which a situation is experienced and place it into another frame that fits the 'facts' of the same concrete situation equally well or better and thereby change its entire meaning" (p. 122). Effective reframing consists of a successful change of second order frame of reference and is based on the communicationist idea that there is not some "true" underlying problem but that the problem lies in how people view things. Relabelling is seen as changing the label attached to the person or problem without changing the frame of reference. 21 During therapy, an injunction is given that creates "paradox"—the client is told to change by remaining unchanged. The client is put into an untenable situation: if he or she complies, he or she no longer "can't help it," the client gains control of the symptom, which is the purpose of therapy. If there is resistance to the injunction, the client does so only by not behaving symptomatically, which is also the purpose of therapy. Haley (1976) suggests that these types of interventions are meant to influence the client to change. Milan Therapy Although the Milan group's focus has been on whole families, many of their principles are adaptable and have been central to the marital systems therapy manual applied in Goldman's (in press) comparative outcome study. Selvini Palazzoli, Boscolo, Cecchin and Prato (1978) emphasize circular causality and believe that clinicians who use a circular orientation, allowing implicit information to become more explicit, think more broadly in terms of content and, therefore, facilitate constructive change with clients. To facilitate constructive change, the therapist must understand and point out how the symptom, e.g. hostility, has been useful for both husband and wife. Similar to a communications approach, the therapist focuses on the clients' strengths and the positive rather than the negative aspects of the problem. The Process of Change in Milan Therapy This process is similar to the. systemic process of change, as outlined in Goldman and Greenberg's Integrated Systemic Marital Therapy manual (in press). The main 22 catalyst for change in Milan Therapy seems to be the intervention which represents the conclusions of the team, who, having been behind the mirror during the session, notes the system's reaction to the message delivered by the therapist as a message from the team. The team bases its conclusions on brainstorming, where the emphasis is on elaborating a systemic understanding, i.e. What effect is the hostile behaviour of Father having on Mother and the children? The message may be in the form of an opinion, a prescription for "no change," a declaration of impotence, etc. (Selvini Palazzoli et al., 1978). Positive Connotations. Positive Connotations is an important technique used in Milan Therapy which corresponds to the reframing process in other systemic therapies (Selvini Palazzoli et al., 1978). When the behaviours of the family members are connoted positively, as beneficial, they are more easily accepted. Positive connotation legitimizes the prescription of "no change" and allows new ideas to be acknowledged by the family system. This is analogous to the sequence of reframing negative interactional cycles and then prescribing the symptom "no change" which is followed by the Palo Alto group. The premise is that intervention will suggest change at some deeper level of meaning, comparable to the Watzlawick (1976) notion of second order change, as opposed to the concrete or content level. When a task is prescribed, it is the reaction of the family members to the instructions that is the change agent It has been suggested by the Milan group that the basic paradox presented by the family to the therapist is, "Our family is fine and does not need to change . . . but here is the individual who has a problem and needs to change." The therapist needs to counter the family's paradox. Systems theory postulates that change in one part requires some complementary change in the whole; within a marital dyad, symptoms of husband and wife are assumed always to have interpersonal meaning and function as 23 communicative acts, so that the symptomatic individual cannot be expected to change unless his OT her partner changes. The therapist's response is often paradoxical but may not be, depending on the severity of the problem. Rorbaugh, Tennen, Press & White (1981) see paradoxical strategies as being least applicable in situations of crisis. In summary, Sluzki (1983) has proposed that "models that share a systemic root are. those that focus primarily on process, primarily on structure and primarily on world views" (p. 470). Symptomatic behaviours can be said to be anchored in circular interactional patterns. Process and structure are seen as a dialectic pair, whereas the construction of reality refers to a different logical level. "However, each level of analysis allows the description of a recursive loop that accounts for the maintenance of a symptomatic . . . behavior" (p. 474). Conceptual models of an experientially-oriented marital therapy treatment as specified in the emotionally-focused marital therapy manual (Greenberg & Johnson, in press) and a specific integrated systemic marital therapy treatment, as specified in the integrated strategic marital therapy manual (Greenberg & Goldman, in press) are discussed below: The Emotionally-Focused treatment outlined in Greenberg and Johnson's marital therapy manual (in press) represents an integrated affective systemic approach to marital therapy. The emphasis on the role of affect and intrapsychic experience in change is based upon the experiential tradition of psychotherapy (Greenberg & Safran, 1984: Perls, Hefferline & Goodman, 1951; Rogers, 1951). This treatment therapy is also based on the systemic tradition which stresses the role of communication and interactional cycle in the maintenance of problem states (Sluzki, 1978; Watzlawick, Beavin & Jackson, 1967). In this model, it is not partners' feelings and wants which are considered the problem, but rather the disowning or disallowing of these experiences that lead to ineffective 24 communication and interactional cycles. Problems are seen as being maintained by self-sustaining, mutually interchangeable, negative interaction patterns, which are predominantly pursue-distance or attack-withdraw patterns. These types of patterns serve to maintain each partner's distress level and negative perceptions of the other. The therapist, in this approach, identifies the negative interaction cycles and guides the couple in bringing into awareness the unacknowledged feelings underlying each person's position in this cycle. Attention is paid to underlying vulnerabilities, fears and unexpressed resentments. This process of accessing and expressing previously unacknowledged feelings involves a synthesis of new emotional experience in the present (Greenberg & Safran, 1984). The therapist uses the methods of Gestalt therapy and client centered therapy (Rice, 1974) to access and emphasize specific underlying responses. This treatment addresses what Gurman (1978) refers to as the "felt needs" of the couple directly. The therapist reframes the problem in terms of these emotional responses, encouraging clients to acknowledge their disowned feelings and needs, and to accept and respond to their partner's needs. Finally, the therapist aids the couple in consolidating their new positions in relation to their partner and focuses upon the strengthening of trust and intimacy which arises from this process. New emotional experience is seen as an important and necessary treatment goal in order to promote new interactional positions. The Strategic couples therapy outlined in Greenberg and Goldman's therapy manual (in press) represents an integrated systemic approach to marital therapy where intrapsychic, especially unconscious, forces are considered irrelevant (Weeks & L'Abate, 1982) and is based upon the systemic tradition that a symptomatic individual cannot be expected to change unless the couple (system) changes (Gurman, 1981) and the communications tradition which emphasizes the role of communication and interaction on actual behaviour (Fisch, Weakland & Segal, 1982). Similar to a social learning view, in 25 this model, marital conflict is viewed as a result of a couple's existing negative interaction patterns, the most basic of which appears to be an attack-withdraw or a dominant-submissive pattern. Haley (1963) sees relationships and marital conflict as largely a process of the struggle for power and control. The interventions in this treatment tend to occur in a circular fashion within sessions and emphasize "attention to organization, to the relationship between parts, to concentration on patterned rather than linear relationships and to a consideration of events in the context in which they are occurring rather than in isolation from their environmental context" (Steinglass, 1978, p. 304). The therapist, in this approach, aims to resolve the negative cycle by restructuring the manner in which the couple communicate to each other. The therapist identifies sequences of problematic reactions and prescribes them to the couple; the couple is encouraged to have an argument deliberately. This follows a communications approach to marital therapy in which the mechanisms for change stem from a paradox paradigm and involve reframing or positively connoting the couple's symptoms. Interventions are centred around a suggestion of "no change." Positive connotations is an important technique used in Milan Therapy which corresponds to the reframing process in other systemic therapies (Selvini Palazzoli et al., 1978) and legitimizes the prescription of "no change" which allows new ideas to be acknowledged by the couple. The therapist attempts to get a clear view of the problem behaviours which are operating in the relationship, to stabilize them and maintain them at their present "safe" level. Weeks and L'Abate (1982) note, once the positive function of the symptom has been identified it can be seen as a vehicle for change. In this treatment approach, restraining is also used to support the notion of "no change." The couple is encouraged to "go slow" which carries the message, "you 26 probably shouldn't change" (Greenberg & Goldman therapy manual, in press, p. 16). Through this process of reframing and restraining, the therapist uses the methods of communications theory where an injunction is given that creates "paradox"—the couple is told to change by remaining unchanged. If the couple comply, they no longer "can't help it," the couple gains control of the symptom, which is the purpose of therapy. If there is resistance to the injunction, the couple does so only by not behaving symptomatically, which is also the purpose of therapy. The intent of therapy is to set a frame far beyond the treatment time so that the fighting that will occur, once treatment is terminated, will be covered by the reframe. The couple is advised to respect an important aspect of their relationship, the arguing, and to keep it, as it may occasionally be useful. Reframing and relabelling are powerful therapeutic tools; they attach different labels or change the conceptual or emotional viewpoint in order to generate change in the couple, making more response alternatives open to them. 27 CHAPTER III: T H E M E T H O D O L O G Y OF T H E STUDY This chapter includes the method and other details for conducting this study. The design of this study is outlined; the client population and sampling, and therapist selection and training are discussed. Instrumentation and proposed methods of data analysis are described. Design of the Study The study investigates the differential effects of two independent therapies: experiential couples therapy and systemic couples therapy on the dependent measures of conflict resolution, attainment of specified relationship goals, target complaint reduction and increased marital adjustment one year after the termination of ten sessions of marital counselling. The original study took the following form: R o, T i o 2 o 3 R o. T 2 o 2 o 3 R o. T 3 o 2 The data involved in this study took the following form: O, 0 2 On O, 0 2 O a In this design, treatment 1 is the experiential treatment, treatment 2 is the systemic treatment. In the original study, T 3 represented the wait-list control. Summaries of the two treatments and the essential characteristics which differentiate them follows. More detailed descriptions of both the emotionally focused (experiential) 28 treatment and the integrated systemic treatment were discussed in Chapter II. The Treatments Emotionally-focused therapy: Emotionally-focused therapy is directed toward the experience and expression of underlying affective experience in an interactional context. Change is seen to occur in each partner as well as in the marital interaction. Partners are regarded as active perceivers who construct meanings and organize perceptions and responses on the basis of current emotional states, disowning aspects of present and past experience because of blocks to awareness or because of perceived requirements in the present relationship. The therapist helps partners to recreate situations and relive underlying emotions in order to make the cognitions governing behaviours available for clarification and modification. Therapeutic techniques include methods of Gestalt therapy (Perls et al., 1951), empathic reflection, evocative responding (Rice, 1974) and reframing the problem and responses in terms of underlying feelings. In summary, then, the essential characteristics which differentiate the emotional treatment from other treatments is the focus on the present experience and expression of underlying emotions to change interactional positions. The assumption is that when different aspects of the self are accepted by both partners, deeper level relationship changes, underlying levels of intimacy and emotional closeness will occur and be manifested in changes in conflict cycles. 29 Interactional Systemic Marital Therapy: The systemic marital therapy was derived from family and marital systems therapy and was based on an integration of process, structure and world views—orientation within the systemic framework. In this view, changing repetitive, self-perpetuating, negative interactional cycles are believed to lead to change in the system—change not only in behaviours but in rules governing interactions in relationships. Problem behaviours and negative interactional cycles are seen as serving a purpose or function in the marital system and change needs to occur around points at which the system seems to be stuck. The essential characteristics which differentiate the systemic marital treatment suggested here from other treatments is the exclusive focus on the current interactions between partners and the reframing of the negative interactional patterns prescribing the symptom and using restraining tactics. The therapists' and/or team's adoption of a position of "no change" and their ability to respond to clients in such a way as not to oppose their positions or perceptions of reality was believed to be a critical variable in the change process. In this approach, a team operating behind a one-way mirror consulted with the therapist during treatment by telephone and by calling the therapist out of the room. Messages from the team were frequently sent through the therapist to the couple. Research Procedures In the original study there were 14 couples in each treatment group and 14 couples in a wait list control group. Couples in the treatment groups received 10 one-hour weekly therapy sessions in the period December, 1984 to May, 1985. 30 After an initial screening, including the DAS measure, selected subjects received an induction session. At that time, pre-measures were taken. Subjects were then randomly assigned to treatment and therapist and received treatment; however, there was an attempt to match treatment groups in terms of the severity of couples' distress as indicated by DAS scores. They were assessed at termination and at the four month follow-up using the four standardized instruments listed below. The four month follow-up showed a reduction of three couples in each treatment group. These couples did not meet the follow-up criteria; they had either separated or were unwilling to complete the four month follow-up measures. As a result, this study had a pool of 11 couples in each treatment group who were available and who agreed to a one year follow-up. These 22 couples were contacted by telephone eleven months after the termination of therapy. They were informed of the mailing procedure that allowed them to complete instruments given to them at termination of therapy and at the four month follow-up: 1. The Dyadic Adjustment Scale (DAS) 2. Target Complaints (TC) 3. Goal Attainment Scaling (GAS) 4. Conflict Resolution Scale (CRS) The couples were also asked to complete a non-standardized questionnaire which was used to analyze their perceptions of the therapeutic change process operating during the previous year. Further contact was made two weeks after the initial mailing of instruments. The couples were reminded of the completion deadline and encouraged to complete the instruments, if they had not been completed. Arrangements were made to pick up the completed instruments from couples who did not return them within one month of the initial mailing. 31 Client Population and Sampling The clients for the original study (Goldman, in press) were recruited by means of newspaper, radio and T.V. advertisements. Respondents who were eligible were offered a minimum of eight and a maximum of twelve free sessions designed to help them break recurrent conflict cycles. Before counselling, clients had an orientation interview and were screened according to the following criteria: 1. Clients must have been living together for a minimum of eighteen months. 2. Clients should not have immediate plans for divorce or separation. 3. Clients should not have received psychiatric treatment/hospitalization within the two year period previous to treatment 4. Clients should not be addicted to alcohol or drugs. 5. Clients should not report any incidences of physical violence in the relationship. 6. Clients should fall into the "distressed" range on the Dyadic Adjustment Scale (Spanier 1976), that is, they should score below 95 but not below 60. 7. Clients should be willing to consent to research procedures, testing and video-taping. A set of similar criteria were adhered to for the one year follow-up: 1. Clients must still be living together (not separated or divorced). 2. Clients should not have immediate plans for divorce. 3. Clients should be willing to complete the follow-up instruments. Demographic data on clients was collected and included—age, length of time together, number of children, education level of partners, occupation, previous therapy experience, previous marriage and income level—in order that it would be possible to describe the population. After screening, appropriate clients attended clinics of the 32 University of British Columbia for counselling. Therapist Selection and Training There were 16 therapists, eight conducting each treatment. Therapists professed orientations in the treatment they represented. Al l of the therapists had at least a Master's degree in counselling psychology, clinical psychology or social work and some were doctoral candidates in the counselling psychology program at The University of British Columbia. Each therapist had at least two years' experience in couples counselling and were matched as to prior training and experience. Therapists were trained in a group setting, approximately twelve hours of training for each group, to implement the procedures in the therapy manuals. Group supervision of therapists took place regularly. Implementation checks were made during and following the therapy sessions. An "Implementation Checklist" enabled trained raters, three hours of training, to determine if the interventions stipulated in the treatment manuals occurred. The raters studied two ten-minute samples of therapy taken from the second and final third of randomly selected sessions. The 25 item checklist was comprised of 20 categories of therapist interventions taken from the treatment manuals, ten categories of interventions from each treatment, plus five additional categories not assignable to either treatment, namely, information gathering. Instruments Used This one year follow-up study utilized the same standardized measures that were administered to couples at pre-treatment, termination, and four month follow-up. A 33 qualitative follow-up questionnaire was developed for the purpose of determining the clients' perceptions of therapy and the change process one year after the termination of therapy. Outcome Instruments 1. The Dyadic Adjustment Scale (DAS) (Spanier, 1976). This scale was used for screening and as a general measure of outcome at termination and the four month follow-up. As well, it was used at the final follow-up. The DAS is comprised of 32 items arranged into four subscales measuring dyadic satisfaction (10 items), consensus (13 items), cohesion (5 items) and affectional expression (4 items). It is, at present, the preferred instrument for the assessment of marital adjustment in relation to reliability (.96), Cronbach's Coefficient Alpha, and validity. Validity data suggest correlation between the DAS and the Locke Wallace Marital Adjustment Scale (1959) of .86. Distress level as measured on this instrument correlated with satisfaction concerning conflict outcomes and objective conflict resolution in Koren, Carlton & Shaw (1980). Spanier points out that the scale can be considered to be a measure of the adjustment of the dyad as a functioning group rather than a measure of individual adjustment to the relationship. The scale has a theoretical range of 0 to 151. The mean total score in the norming sample for married and divorced couples was 114.8 (S.D. 17.8) and 70.7 (S.D. 23.8) respectively. The reliability of each subscale is Consensus .90, Satisfaction .94, Cohesion .86 and Affectual Expression .73. The majority of items involve a five or six-point Likert-type scale defining the amount of agreement of 34 the frequency of an event A rating measure for global happiness and for commitment is included in the Satisfaction subscale. 2. Target Complaints (TC) (Battle, Imber, Hoehn-Saric, Stone, Nash & Frank, 1966). This measure was completed by each partner in conjunction with his or her therapist during the initial interview and given at the end of the sessions as well as at the four month follow-up. This measure is recommended in Waskow and Parloff (1975) as a core battery instrument for use in psychotherapy outcome research. It is comprised of three five-point scales on which the client is asked to rate the amount of change on three different complaints. In this study, clients were asked to rate the amount of change on three complaints related to the main conflict in the relationship. Numerical values can be assigned to each rating point. The client's score on the instrument then becomes a mean value consisting of the sum of the ratings for all target complaints divided by the number of complaints rated. Battle et al. (1966) provide evidence as to the validity of this measure; it showed significant correlations with four other outcome measures. In particular, the main complaints derived from a target complaint interview were congruent with complaints obtained In intensive psychiatric interviews. The authors state that, as an outcome measure, Target Complaints was informative, made good clinical sense and responded differentially to experimental manipulation. With regard to reliability or consistency of clients' initial definitions of problems, clients' rankings of problems. between pre-post psychiatric interviews showed a correlation of .68. Jacobson, Folette and Elwood (1985) suggest that measures which tap couples' presenting problems most directly, as do Target Complaints and Goal Attainment Scaling, are preferred instruments in assessing 35 marital therapy. 3. Goal Attainment Scaling (GAS) (Kiresuk & Sherman, 1968). This measure was filled out by each client in the assessment interview as well as at the termination of the sessions and the four month follow-up. The clients were asked to set specific behavioural goals in relation to their main presenting concern and the attainment of these goals were evaluated using this procedure. In this study, one year after the termination of therapy, clients were asked to focus upon the main goal in relation to their marital issues and to define five levels of attainment of that goal: "expected or most likely results," "somewhat better than expected results," "much better than expected results," "somewhat less than expected results," and "much worse than expected results." For each level the client was asked to list three observable and quantifiable behaviours with emphasis on specifying the frequency, i.e. "I would like my husband to listen to me and give me feedback at least three times each day", as well as an affective indicator, i.e. how would he or she feel or want to feel if this happened? Clients were asked to indicate at which level of attainment they were at pre-treatment, post-treatment and at the four month follow-up. They were asked at which level of attainment they were during the one year follow-up. The treatment goal was for the level of attainment to improve. It is possible that the level of attainment at the one year follow-up could be lower than the post-treatment and the four month follow-up assessment. A spouse might describe the "somewhat better than expected" level of goal attainment as 1) being able to reach consensus on decisions 75% of the time, 2) being able to discuss issues openly when consensus was not reached and as a 36 result, 3) only having had one escalating conflict cycle a month. This could lead to the spouse feeling more content and secure in the relationship. The GAS scores are based on a standard score system, T scores, having a mean of 50 and a standard deviation of 10. The range for goal outcomes is -2 for "much worse than expected" to +2 for "much better than expected." Outcome data can be grouped for analysis without losing the import of individual client goals. A standard score may be generated for each client to evaluate his or her position before therapy, at termination and at the one year follow-up. Essentially, the GAS has the following characteristics: 1) a set of statements of goals for an individual; 2) a system of weights for those goals; 3) a set of expected outcomes for these goals ranging from "most unfavourable" to "most favourable"; 4) a follow-up scoring of these outcomes; and 5) a score summarizing the outcome across all goals. The one year follow up allowed clients to review their goals and rate their present level of attainment on an independent basis, individually. 4. Conflict Resolution Scale (CRS): Subscale of Enriching and Nurturing Relationship Issues, Communication and Happiness (ENRICH) (Fournier, Olson & Druckman, 1983). This measure was completed by each client in the assessment interview, at the termination of sessions and, as well, at the four month follow-up. In this study, clients completed this form one year after the termination of therapy. The ten items were specifically developed to identify interpersonal processes that become problematic for many couples. To determine construct validity, the relationship between new measures and existing measures that are consistent with theoretically 37 derived hypotheses relevant to the construct were assessed. The CRS is significantly correlated with the Locke-Wallace Marital Adjustment Scale. The Alpha coefficient for the CRS (ENRICH) is .75 and Test-Retest reliability is .90. Al l items are answered on a five point Likert-type scale: 1) Strongly agree, 2) Moderately agree, 3) Neither agree nor disagree, 4) Moderately disagree and 5) Strongly disagree. Raw scores on the CRS are converted into percentile scores so that each individual can be compared to national (U.S.) norms. Individual percentile scores are calculated for both male and female partners as well. One methodological feature of the CRS is the assessment of social desirability, modified Marital Conventionalization Scale (Edmonds, 1967), and the subsequent correction of individual percentile scores. The individual revised scores adjust each category percentile score according to 1) each individual's relative amount of "idealistic distortion," 2) the empirical relationship between each scale. The couple scores provide a summary of the convergent or divergent opinions that couples have about their relationships. The couple scores were designed to tap the four main dimensions of 1) differences or disagreements in partner responses, 2) potentially negative agreements in partner responses, 3) indecisive responses and 4) similar responses or agreements, that appear to be positive for the relationship. The four dependent variables used in this study contain items which are answered on Likert-type scales. The Likert-type scale involves assigning numbers to objects in such a way that equal differences in the numbers correspond to equal differences in the amounts of the attribute measured. Measurement of these four variables does riot fall neatly into one of the four levels of measurement: nominal, ordinal, interval or ratio; however, they do appear to achieve a level of 38 measurement known as quasi-interval. A quasi-interval scale represents a measurement that falls somewhere between the ordinal and the interval levels of measurement Interval scales represent a more highly refined measurement than nominal or ordinal scales (Glass & Hopkins, 1984). Therefore, the use of parametric statistics, i.e. F-ratios, is supported. Parametric statistics are used with more highly refined measurements and are more efficient; non-parametric statistics methods make fewer assumptions but are also less efficient 5. Change Maintenance Questionnaire: This questionnaire assesses the degree to which the clients changed over the one year period following the termination of therapy as well as the factors which helped them to maintain those changes. It is intended to provide clients with the opportunity to express their perceptions of the therapeutic and change process. There are nine items, five of which are answered on a three point Likert-type scale: 1) Yes, 2) Maybe and 3) No. The remaining four items are asked as open ended questions to elicit more detailed responses that probe clients' experience during the past year. Data Analysis The present study is a comparative outcome study to investigate the differential effects of two treatments, an experiential, emotionally-focused, marital therapy and a systemic marital therapy on the dependent measures of conflict resolution, specified relationship goals, target complaint reduction and increased marital adjustment at the one year follow-up. 39 There is little evidence to suggest which treatment might be superior and what the effects of each treatment wil be one year after the termination of therapy. Therefore, the hypotheses will be stated as null hypotheses: H 1: It is hypothesized that couples exposed to emotionally-focused o therapy and systemic therapy will not be significantly different on the mean Dyadic Adjustment Scale score, a measure of marital satisfaction at the one year follow-up. H 2: It is hypothesized that couples exposed to emotionally-focused o therapy and systemic therapy will not be significantly different on resolving conflict, as measured by the Conflict Resolution Scale at the one year follow-up. H 3: It is hypothesized that couples exposed to emotionally-focused o therapy and systemic therapy will not be significantly different on target complaints reduction, as measured by the Target Complaints Instrument at the one year follow-up. H 4: It is hypothesized that couples exposed to emotionally-focused o therapy and systemic therapy will not be significantly different on goal attainment, as measured by the Goal Attainment Scale at the one year follow-up. H 5: It is hypothesized that couples exposed to emotionally-focused o 40 therapy and systemic therapy will not be significantly different on the Dyadic Adjustment Scale, the Conflict Resolution Scale, the Target Complaints Instrument and the Goal Attainment Scale when couples' pre-treatment mean scores are compared to their one year follow-up mean scores. H 6: It is hypothesized that couples exposed to emotionally- focused o therapy and systemic therapy will not be significandy different on the Dyadic Adjustment Scale, the Conflict Resolution Scale, the Target Complaints Instrument and the Goal Attainment Scale when couples' termination mean scores are compared to their one year follow-up mean scores. Data Analysis Procedures The data collected on the four standardized measures were analyzed. In addition, the clients' perceptions of the therapeutic change process as detected by the final follow-up questionnaire were analyzed. An overall repeated measures analysis of variance was conducted to test for differential effects on both treatment groups as well as on the pre-treatment, post-treatment and one year follow-up occasions. A one factor repeated measures A N O V A was then conducted on each treatment group, separately, so that the Newman-Keuls method of pair-wise comparisons could be used to compare couples' mean scores across three occasions: 1) pre-treatment, 2) post-treatment and 3) one year follow-up on the Dyadic Adjustment Scale and on the Conflict Resolution Scale. The Newman-Keuls method was also used, across each treatment, to compare couples' 41 post-treatment mean scores to their one year follow-up mean scores on the Target Complaints Instrument and on the Goal Attainment Scale. The Newman-Keuls method of pair-wise comparisons was an important component of the data analysis; it allowed for the examination of the difference between all possible pairs of means on the three/two time occasions. Limitations and Implications of the Study The number of couples, a minimum of eleven in each group, could be considered limited in power to find differential effects and thus limit external generalizability. The time of follow-up, one year, might be considered a limitation. It is difficult to control the effects of therapy and possible attrition of clients. It is also difficult to control what the clients do after treatment. Will they seek further counselling? Will they separate? Although variables such as further treatment or separation may be perceived as confounding variables and as limiting the generalizability of the results, they can also be perceived as effects of therapy, i.e. decisions made as a result of therapy and therefore not detracting from demonstrations of effectiveness. Regardless of what occurred in the intervening period, it was the purpose of this study to investigate the long-term effects of the two treatments on the twenty-two couples. 42 CHAPTER IV: RESULTS This study compared the long-term effects of two interventions in the treatment of marital discord: an experiential intervention, focusing on emotional experiences underlying interaction patterns, and a systemic intervention, focusing on couples' problematic reactions in communication and relationship problems. The focus of tire follow-up was to determine whether the treatment effects found at the termination of therapy, for both the emotionally-focused (EF) and the systemic couples, would also be found one year later. The 22 of the 28 couples who received treatment in the original study (Goldman, in press) were contacted by telephone 11 1/2 months after each couple's termination of therapy. At that time they were informed of the mailing procedure and encouraged to complete the instruments as soon as they received them. The packaged standardized instruments as well as a qualitative, non-standardized one year follow-up questionnaire were mailed to each of the remaining 22 couples, two weeks after the initial phone contact Two weeks after mailing the instruments, the couples were, again, contacted by phone and reminded of the completion deadline. Eighteen of the 22 completed instruments were returned by mail. The four packages that were not returned within one month of the initial mailing were picked up from each of the remaining couples' homes. During my visit to these couples' homes, it was determined that one couple from the Emotionally-focused treatment group and one couple from the systemic treatment group were in the process of separating. They were still living together, but they had emotionally withdrawn from their spouses and refused to complete the instruments. Thus, these two couples' scores were not available for the overall analysis in this one year follow-up study. They chose not to report follow-up data and therefore, did not meet the follow-up criteria. Also, the instruments used in 43 this study are not applicable to people who have decided to separate. The focus, on each instrument, is on the marital/dyadic relationship. The growth and development of the marital relationship was no longer a goal of these two couples. Implementation Check Before analyzing the follow-up data, the implementation check will be discussed. In the original study (Goldman, in press), an implementation check was conducted to determine if the treatments were implemented according to the treatment manuals. This implementation check was conducted by two trained, independent raters, blind to the treatment conditions they were observing, who rated segments from video and audiotapes of the therapists. Approximately three of each couples' series of ten sessions, a total of 93 out of 280, were chosen at random and observed by the raters. Two segments of ten minutes each were taken from the middle and final third of these 93 sessions. In this way, each couple was observed for a total of 60 minutes of their therapy. The Implementation checklist is comprised of 25 coding categories, five of which were general categories or problem definition categories descriptive of interventions common to both therapies. The remaining twenty categories were made up of ten which described interventions typical of the Integrated Systemic therapy and ten which described interventions typical of the Emotionally-focused therapy. An intervention was defined as "a complete therapist statement," of which the beginning and end were noted by the raters to ensure that they were both evaluating the same units. A total of 2,268 interventions were evaluated by the raters. Of the 2,268 interventions coded, 64 or 2.8% were coded as to be inappropriate to the treatment condition being observed. Of these inappropriately coded, 42 occurred in 44 the Emotionally Focused treatment condition and 22 in the Integrated Systemic treatment The more cognitive, structured and clearly specified nature of the Integrated Systemic treatment may tend to make it more clearly identifiable. According to Goldman (in press), in the Emotionally Focused treatment, the Systemic interventions most often mistakenly applied were those relating to "restructuring," where the therapist either forms a temporary coalition with one partner or redefines partners' positions in a way that emphasizes complementarity, i.e. "When did you give up trying to be close to Dennis?" Therapist interventions in the EF treatment which are directed toward validating or developing partners' underlying feelings might more easily be misinterpreted as belonging in such systemic categories; they may use similar phraseology and be perceived as somewhat more emotionally evocative than other systemic interventions, such as "reframing" and/or "prescribing the symptom." In the Integrated Systemic treatment, the Emotionally Focused intervention most often mistakenly applied was one in which the therapist explores partners' blocks to accepting the other's position in terms of underlying feelings. Inter-rater reliability was calculated on 624 interventions taken from 25 randomly chosen sessions—26.9% of the total sessions observed. The two raters agreed on 594 of the interventions rated—95% agreement Inter-rater reliability was then calculated using Cohen's (1960) statistic Kappa. This statistic is a conservative estimate of agreements, corrected for the proportion of agreement to be expected by chance alone. The 30 disagreements that occurred between the raters were comprised of five cross-treatment (n=5) disagreements and 25 cross-intervention (n = 25) disagreements. The Kappa statistic for inter-rater agreement regarding treatment was computed at .982. The Kappa statistic for inter-rater agreement regarding interventions was computed at .95. These results suggest that treatments were implemented according to the manuals and that both the 45 overall treatments and the interventions within treatments can be reliably differentiated. Results: Quantitative Data A repeated measures analysis of variance (ANOVA) was conducted using the DAS and CRS scores respectively over three occasions: pre-treatment, post-treatment and the one year follow-up for the two treatment groups. No significant differences were found between the two treatment groups on DAS (F = 0.188, p>.05) or on the CRS (F = 3.859, p>.05) (refer to Table 1). Also, there was no significant Time x Group interaction on either the DAS (F = 0.391, p>.05) or on the CRS (F = 0.279, p>.05). Hypotheses one and two were accepted: couples exposed to emotionally-focused therapy and systemic therapy were not significantly different on the Dyadic Adjustment Scale, a measure of marital satisfaction, and on resolving conflict, as measured by the Conflict Resolution Scale at the one year follow-up. The repeated measures analysis of variance showed a significant difference for the time factor (pre-treatment, post-treatment and follow-up) on both the DAS (F = 24.977, p<0.001) and on the CRS (F = 27.519, p<0.001). Thus, the two treatments, over time, did have an effect For both treatments, there was a significant difference among the three occasions in terms of the total DAS and CRS mean scores of the couples. To determine where the differences lay, a one factor repeated measures A N O V A was conducted (refer to Table 2) for each treatment group. The Nev/man-Keuls method (Winer, 1971) of pair wise comparisons was used to examine the difference between all possible pairs of means on the three occasions (pre-treatment, post-treatment and one year follow-up) for each treatment group. 46 Table 1: Repeated Measures Analysis of Variance: Mean, (Std. Dev.), F-ratios (Between Groups) Pre-Treatment Post-Treatment Follow-up Variable Treatment X X X F p EF 89.30 105.85 100.2 (7.89) (9.33) (13.02) DAS 0.188 0.670 S 86.85 103.15 101.35 (8.53) (6.60) (9.29) EF 25.05 32.35 32.85 (2.44) (3.74) (5.25) CRS 3.859 0.065 S 27.85 35.15 34.20 (2.83) (3.19) (5.12) EF — 4.38 3.65 (0.51) (1.00) TC item 0.401 0.535 S — 4.10 3.65 (0.57) (0.71) EF — 4.27 3.42 (0.68) (1.11) TC average 0.021 0.886 S — 4.00 3.62 • (0.52) (0.70) EF — 5.70 5.19 (0.68) (0.78) GAS 1.265 0.276 S — 5.50 4.88 (0.53) (0.94) Note: 1. n = 20 2. Statistics (F, p) represent the BETWEEN TREATMENTS Analysis. 3. EF = emotionally- focused treatment; S = systemic treatment 4. DAS = Dyadic Adjustment Scale, CRS = Conflict Resolution Scale, TC = Target Complaints, GAS = Goal Attainment Scaling. 47 Table 2: Repeated Measures One Factor Analysis of Variance Across 3  Occasions: Mean, (Std. Dev.), and F-ratios Pre-Treatment Post--Treatment Follow-up Variable Treatment X X X F •P EF 89.30 105.85 100.2 7.478 0.004 (7.89) (9.33) (13.02) DAS S 86.85 103.15 101.35 33.109 0.001 (8.53) (6.60) (9.29) EF 25.05 32.35 32.85 12.62 0.001 (2.44) (3.74) (5.25) CRS S 27.85 35.15 34.20 15.844 0.001 (2.83) (3.19) (5.12) EF 4.38 3.65 3.944 0.078 (0.51) (1.00) TC item S 4.10 3.65 2.359 0.159 (0.57) (0.71) EF 4.27 3.415 3.831 0.082 (0.68) (1.11) TC average S — 4.00 3.615 2.22 0.170 (0.52) (0.70) EF 5.70 5.19 2.381 0.157 (0.68) (0.78) GAS S 5.50 4.88 3.151 0.110 (0.53) (0.94) Note: 1. n = 10 (for each treatment) 2. Statistics (F, p) represent the ACROSS TIME Analysis 3. EF = emotionally-focused treatment; S = = systemic treatment 4. DAS = Dyadic Adjustment Scale, CRS = = Conflict Resolution Scale, TC = : Target Complaints, GAS = Goal Attainment Scaling. 48 The results of the pair-wise comparisons were similar for both treatment groups on both the DAS and the CRS measures. Hypothesis five, which states that couples exposed to emotionally-focused therapy and systemic therapy will not be significantly different on the Dyadic Adjustment Scale and the Conflict Resolution Scale when couples' pre-treatment mean scores are compared to their one year follow-up mean scores, was rejected. There was a significant difference found between the DAS (F = 3.16, p<0.05) and CRS (F = 3.16, p<0.05) pre-treatment mean scores and the post-treatment mean scores as well as the pre-treatment and the one year follow-up mean scores for both the Emotionally-focused and the Systemic couples (Table 2). These results indicate that both treatments were effective in the treatment of marital discord and showed no differential effects at the termination of therapy nor one year after the termination of therapy (Table 1). The Newman-Keuls method was again used to determine if there was a difference between post-treatment and one year follow-up mean scores for both the EF and the Systemic group on the measures of DAS and CRS. The focus of the follow-up was to determine whether the treatment effects found at the termination of therapy, for both the EF and the Systemic couples, would also be found one year later. Indeed, hypothesis six which states that couples exposed to emotionally-focused therapy and systemic therapy will not be significantly different on the Dyadic Adjustment Scale and on the Conflict Resolution Scale when couples' termination mean scores are compared to their one year follow-up mean scores, was accepted. There was no significant difference found between the DAS (F = 3.55, p>0.05) and the CRS (F = 3.55, p>0.05) post-treatment mean scores and the one year follow-up mean scores. 49 A Repeated Measures Analysis of Variance was also conducted on the total TC variables and the total GAS scores over two occasions, post-treatment and follow-up, and between the two treatment groups (refer to Table 1). Hypotheses three and four were accepted: couples exposed to emotionally-focused therapy and systemic therapy were not significantly different on target complaints reduction, as measured by the Target Complaints Instrument and on goal attainment, as measured by the Goal Attainment Scale at the one year follow-up. No significant differences were found between the two treatment groups on the TC item scores (F = 0.401), on the TC average scores (F = 0.021), and on the GAS, (F = 1.265). There was also no significant Time x Group interaction demonstrated on the TC item (F = 0.355), on the TC average (F = 0.858), and on the GAS (F = 0.057). There was a significant difference demonstrated for the two treatments over the two occasions on TC item (F = 6.302, p<0.05), TC average (F = 5.969, p<0.05), and GAS (F = 5.524, p<0.05). To determine where the difference was, a one factor Repeated Measures A N O V A was conducted and the results indicate that although between time the two treatments did differ on the overall Repeated Measures A N O V A , each treatment, by itself, did not have a significant effect from post-treatment to follow-up, as demonstrated on the one factor Repeated Measures A N O V A (Table 2). The Newman-Keuls method of pair-wise comparison was again used to examine for differences over occasions for each treatment group and to check the above differences. The results of this comparison were similar for both the EF and the Systemic couples on the TC variables and the GAS. Hypothesis six, which states that couples exposed to emotionally-focused therapy and systemic therapy will not be significantly different on the Target Complaints Instrument and the Goal Attainment Scale when couples' termination mean scores are compared to their one year follow-up mean scores, was accepted. There was no significant difference between the post-treatment and 50 one-year follow-up mean scores for both treatment groups on the TC item (F = 4.26), on the TC average (F = 4.26) and on the GAS (F = 4.26). Thus, the general treatment effects, for both treatment groups, found at termination of treatment held at the one year follow-up. Results: Qualitative Data The main results of the one year follow-up questionnaire which encouraged couples to focus on and discuss the change that occurred as a result of therapy as well as the change agents that helped them to maintain those changes over a one year period are discussed. The clients in the Systemic group wrote and spoke of having more communication skills and using them more often in relationship problems while those in the EF group indicated that the sharing of innermost feelings led to more open and honest communication and a greater awareness of self and partner's needs. Questions such as, "If change occurred after treatment to what do you attribute this change?," "Since counselling ended, how have you maintained these changes?" and "Was counselling a major factor in helping you to get to where you are now? If so, what was it about counselling that was helpful to you during this past year?" probed clients' experience after the termination of treatment and encouraged them to indicate the treatment components which they perceived as being particularly helpful in motivating them to improve and to maintain the effects of treatment over a one year period. The frequency table on the next page was formed according to each client's response to these three questions. 51 Table 3: Qualitative Questionnaire—Frequency Table I. Emotionally-Focused Couples Therapy Category Frequency 1. Open and honest communication of innermost 16 feelings, needs, etc. 2. Greater awareness and understanding of self and 6 partner's strengths and weaknesses. 3. Greater awareness of self and partner's feelings 6 and needs/desires. 4. Instilled confidence in client 4 5. Caring therapist 2 II. Systemic Couples Therapy Category Frequency 1. Greater communication of feelings and relationship 13 problems. 2. Greater understanding of self and partner's 7 concerns and differences. 3. Clarification and other techniques that helped 7 couples get through an argument. 4. Greater respect for each other's opinion. 4 5. Greater awareness of our love and commitment to 3 one another. The Systemic couples identified three main areas which they felt motivated them to improve and to maintain the effects of treatment over a one year period. These areas were. 1) greater communication of feelings and relationship problems, 2) a greater understanding of self and partner's concerns and differences and 3) clarification and other techniques that were helpful in working through arguments. The EF couples also 52 identified three main areas of growth which helped them to maintain the effects of treatment over a one year period: 1) more open and honest communication of needs, feelings and concerns, 2) sharing of innermost feelings, and 3) greater awareness of self and partner's feelings and needs. The indication is that couples' experience of therapy was consistent with the two therapy manuals and that the gains that were made as a result of therapy were maintained due to each therapy's claimed method of operation. Although both treatment methods differed, couples' perceptions of what they saw as contributing factors to change and maintenance of that change appear similar. Couples from both treatments stressed the importance of an open and honest communication system as well as having gained a greater understanding of self and partner's concerns and differences. Summary The analyses clearly demonstrated that the EF treatment and the Systemic treatment were both effective at termination and after a year in treating couples with problems in conflictual relationships as indicated by post-treatment measures. The focus of this one year follow-up study was to determine whether there were differential effects of treatment and to determine whether the treatment effects found at termination of therapy were lasting. Indeed, one year later, no significant difference was found between the post-treatment mean scores and the follow-up mean scores on all four measures, for both treatment groups. Thus, maintenance effects operating during and after therapy have persisted over the one year period following the termination of treatment and support the main question asked throughout this study, "Does therapy last?" 53 CHAPTER V: DISCUSSION AND CONCLUSIONS In the literature, the importance of evaluating maintenance of psychotherapy outcomes has been stressed although research in the area has been relatively neglected. Follow-up of clients is generally either omitted from psychotherapy research studies or done inappropriately because adequate client testing is too demanding (Cross, Sheehan & Khan, 1982). For the most part, evaluating maintenance of psychotherapy has not been pursued except over limited periods of time. This study investigated the differential effects of two marital therapy treatment interventions one year following the termination of treatment. The two treatments under investigation were 1) an experiential intervention in which the goal is for partners to access and acknowledge, in both themselves and the other, previously unexpressed feelings underlying the reactive behaviour patterns and 2) an integrated systemic intervention in which the focus is on modifying patterns of interaction and communication. The implementation check results indicated that these two treatments were implemented according to the manuals and that both the overall treatments and the interventions within treatments can be reliably differentiated. There was no evidence to suggest that either treatment was superior nor what the effects of each treatment would be one year after the termination of therapy. The dependent measures of conflict resolution, attainment of specified relationship goals, target complaints reduction and increased marital adjustment were completed by twenty couples one year after the termination of ten sessions of marital counselling. A qualitative questionnaire which probed the client's experience after therapy and the changes that occurred as a result of therapy was also completed by each couple. 54 It should be noted that couples' mean scores were used to analyze the follow-up data as opposed to each individual's score. This is consistent with other marital therapy outcome studies, i.e. Goldman (in press), Johnson (1984), Jacobson and Follette (1985), Jacobson (1978b, 1979), etc. O'Leary and Turkewitz (1978) note, "Since the members of a dyad influence one another, they should not be regarded as independent units in analyses of variance" (p. 755). According to Jacobson (1978a), significance may be found when spouses' mean scores are analyzed as individual scores. However, "this type of analysis violates one of the prerequisites for the use of analysis of variance—the independence of each observation in the sample" (p. 419). In his review of the research on the effectiveness of marital therapy, Jacobson (1978a) indicates that those studies which analyzed spouses' mean scores as individual scores did not add significantly to confidence in the effectiveness of a behavioural approach to marital therapy. Jacobson (1978a) also notes, when couples' scores are analyzed as individual scores, non-parametric statistics should be used. This follow-up study made use of parametric statistics because they are more highly significant and are used with more highly refined measurements (Glass & Hopkins, 1984) such as the four standardized measurements used in this study. For the follow-up, couples were screened according to the following criteria: 1. Clients must still be living together (not separated or divorced). 2. Clients should not have immediate plans for divorce or separation. 3. Clients should be willing to complete the follow-up instruments. Surveys of existing work on long term effects indicate that relatively few studies demonstrate persistent results following treatment Goldstein, Lopez and Greenleaf (1979) reviewed 192 controlled psychotherapy studies conducted from a variety of theoretical perspectives. It appears that the rate of positive outcomes, though high at termination of therapy, was much lower at follow-up: 85 percent of studies reported positive results at 55 termination, only 14 percent reported transfer or maintenance effects. These authors note that maintenance is the exception rather than the rule. The focus of this study was to examine the effects of two treatment interventions one year following the termination of treatment: to determine if there was a significant difference between the two treatments across the time occasions and, also, to determine whether the treatment effects found at termination of .therapy were maintained. The six null hypotheses of this study are examined and discussed below: Hypotheses one to four were accepted; couples exposed to the EF therapy and couples exposed to the Systemic therapy were not found to be significantly different as measured by the DAS, CRS, TC, and GAS one year after the termination of treatment Hypothesis #5 was rejected; couples exposed to both the EF and the Systemic treatments significantly increased their DAS, CRS, TC, and GAS mean scores from pre-treatment to follow-up. Hypothesis #6 was accepted; couples exposed to both treatments maintained the effects of each therapy over a one year period. This was demonstrated by the Newman-Keuls method of pair-wise comparisons which showed that treatment termination mean scores were not significantly different from follow-up mean scores on all four measures. Thus, this study strongly supported the occurrence of positive outcomes at follow-up and clearly established the power of both the EF therapy and the Systemic therapy in the treatment of marital discord and the maintenance of change over a one year period. The results of this study demonstrated the effectiveness of both the EF treatment and the Systemic treatment which increased and maintained the total DAS and CRS levels; facilitated improvement and maintained that improvement in TC and GAS. Indeed, both treatments have powerful components for changing the nature of relationships and maintaining those changes. This suggests that for the EF treatment, focusing on inner experience as it is translated into relationship events during interaction, thus enabling 56 the client to reintegrate dissociated parts of the self (Segraves, 1982) may be a powerful technique. For the Systemic treatment, focusing on the couple's negative interactional cycle and dysfunctional communication pattern is an important component of therapy. Interrupting the vicious cycle using reframing and positive connotation of the couple's symptoms, followed by making interventions centering around a suggestion of "no change," i.e. prescribing the symptom, may well be a powerful tool for changing the nature of relationships and helping to maintain those changes beyond the termination of treatment Weeks and L'Abate (1982) note, once the positive function of the symptom has been identified it can be seen as a vehicle for change. The gains and maintenance demonstrated by the EF couples may reflect the fact that this treatment attempts to address what Gurman (1978) referred to as the felt needs of the couple, especially if positive affect is considered the most important characteristic of a good marriage, as Broderick (1981) has suggested. The Systemic couples' treatment gains and maintenance may be a result of the fact that this treatment places more emphasis on actual behaviour through the avenue of communication and interaction. The premise is that the system has transforming potential and that the intervention has suggested change at some deeper level of meaning, comparable to the Watzlawick (1976) notion of second order change, as opposed to the concrete or content level, and this supports positive long-term outcome. It is important to note that the EF couples' improvement on GAS was comparable with that made by the Systemic couples even though this variable might be expected to be more responsive to the Systemic treatment "in which the main goal of therapy is to get people to behave differently and so to have different subjective experiences" (Haley, 1976, p. 49). This would seem to suggest that the EF treatment also had an effect on a couple's ability to negotiate and change specific behaviours and 57 to maintain those behaviours over a one year period in spite of the fact that these areas were not focused on during treatment. It may be that the increase in trust and responsiveness, which is the goal of the EF treatment, had an effect on behaviour change. The results of the qualitative questionnaire indicate that greater communication of feelings and relationship problems were perceived as significant processes of change by couples in both treatment groups. This would seem to suggest that there may be processes operating in both treatments which allow for this type of open and honest communication to occur and which encourage change in the system to persist over time. The EF treatment emphasizes the importance of the "therapeutic alliance." Luborsky and his colleagues, in discussing individual dynamic therapy (Luborsky, Mintz, Auerbach, Cristoph, Bachrach, Todd, Johnson, Cohen & O'Brien, 1980), contend that clients were helped most if "a working alliance was developed as well as . . . mastery over the main conflictual relationship themes that were identifiable initially" (p. 480). This may be notable using the EF therapy. The Systemic treatment, as well, appears to stress the importance of a similar kind of working alliance, with the therapist in which the emphasis is for couples to work through main conflictual relationship themes with the help of the therapist who initially identifies the negative interactional cycle (Fisch, Weakland & Segal, 1982). Positive connotation of the negative interaction cycle probably helped create a good alliance. Both the EF and the Systemic treatment encouraged the clients to become committed and productively involved in therapy. Strupp and his colleague (Strupp & Hadley, 1979) note the importance of the clients' ability to become involved in therapy. Parloff (1980) contends that many of the common ingredients that lead to positive treatment outcomes are related to therapist qualities: the ability to establish a therapeutic 58 alliance; clinical intuition, judgement and sensitivity; and plausible explanations of the causes of distress. Imber (1978) notes, persistence or maintenance processes seem likely to involve factors shared by different treatment forms. It would appear that the aforementioned strengths of the EF treatment and the Systemic treatment combined with the common ingredients operating across treatments support the results of this study. It should be noted that the two couples whose scores were not available for this follow-up study were in the process of separating, chose not to report follow-up data and, therefore, did not meet the follow-up criteria. According to Jacobson (1984), couples who do not report data could be counted as "unimproved" at follow-up. Thus, in this study, those couples who did not report data at follow-up have been classified as "unimproved." As one would expect, none of the changes that occurred with the couples who chose not to report data are clinically significant because no scores were available to measure any change. Spanier (1976) notes, on the DAS, the mean total scale scores for the married and divorced samples in his study were 114.8 and 70.7. It is of interest to note that the two couples whose follow-up scores were not available for this study both had post-treatment mean scores of 72.5 and 81.5 that remained "unimproved" when compared to their pre-treatment mean scores of 73.5 and 80.5 on the DAS. These couples' DAS scores easily classify them as severely distressed. Similar "unimproved" scores were found across the remaining three measures. Since they did not improve during the course of therapy, there was no way they could be classified as "deteriorated" during the follow-up period. According to Jacobson (1984), separated couples can be classified as "deteriorated" only if they showed improvement during the course of therapy. These results raise a question as to whether or not these two treatment interventions are effective with severely distressed couples. 59 This follow-up study is a component of a larger body of work (Goldman & Greenberg, in press) providing extensive research and support for the positive and enduring effects of two treatment interventions, the EF treatment and the Systemic treatment, both of which have had little research investigation. Although the question of whether or not these two treatment interventions are effective with severely distressed couples has been raised, one cannot overlook the positive outcomes discussed in this study. Hopefully, researchers will recognize the value of this investigation, however different this may be from their own favoured theoretical position. Some exciting implications are that both treatments are indeed effective and enduring in the treatment of marital discord. In addition to the theoretical contribution, there are implications for clinical practice. A consideration for practising therapists would be to become familiar with the identified clinical strategies specific to both of these treatment approaches. A therapist is not simply an aide in problem solving, but a guide in accessing new information; he or she is in a position to access new and successful strategies, which have been proven, to help couples change the nature of their relationships and to maintain those changes beyond the termination of active therapy. Hopefully the results of this study will encourage therapists to employ and experience the dynamic effects of these two treatment interventions. This may lead therapists to deliberately incorporate directly in their treatment techniques certain procedures specifically designed to ensure long-term maintenance. The results of this study underscore the importance of continued research in the area of long-term follow-up. Durability should come to be recognized as a significant aspect of treatment outcome and researchers should be encouraged to be accountable for the efficacy of the treatments they conduct 60 Limitation One limitation of this study was the decline in the number of couples that met the follow-up criteria. In the original study, (Goldman, in press) there were 28 couples, 14 treated by the EF treatment and 14 treated by the Systemic treatment. All 28 couples were assessed at termination of treatment. In the four month follow-up there were 22 couples assessed. In this study, 12 months after the termination of active therapy, there were 20 couples assessed (n = 10 for the EF treatment and n = 10 for the Systemic treatment). These 20 couples represent those couples who stayed together; this is a particular sub-sample of the 28 couples who first entered therapy. The mean level of distress for the couples in this study (M = 88, SD = 8.21, range = 71-105) on the pre-treatment total DAS score suggests that this sample may be considered as moderately to severely distressed and the results apply only to this population. Three couples from each treatment group were found to have separated at the four month follow-up; a discussion of these findings are in Goldman's (in press) study. From the four month follow-up to the one year follow-up, there was a further reduction; one couple from each treatment group were in the process of separating and unwilling to complete the follow-up instruments. It may be that the majority of the couples who did not separate could be considered moderately distressed rather than severely distressed. However, it is argued that since the remaining couples did improve during the course of therapy, almost all of them were candidates for deterioration during follow-up (Jacobson & Follette, 1984). Deterioration did not occur with these 20 couples. Although the purpose of marital therapy is to help couples strengthen their relationship and not to separate, there are instances where separation is inevitable. In marital therapy it is difficult to determine which is worse: a couple who stay together and are alienated 61 from one another or a couple who choose to separate. The decision to separate may be seen as an effect of treatment and should not be judged as necessarily negative. This may have been a decision made by couples as a result of the awareness, understanding and lack of change in their relationship after the termination of active therapy. Another limitation could be the effects of environmental influence or events over the one year following therapy. These occurrences may be seen as obscuring the results of treatment and findings may have been confounded if clients participated in additional formal treatments subsequent to the original psychotherapy. In fact, it is known that two couples had further treatment This, however, can also be seen as an effect of treatment; a decision made as a result of treatment In this study, all measures were self-report. This could be viewed as being limited. However, this type of measurement appears to be appropriate because marital satisfaction or well-being is a subjective factor rather than an externally quantifiable phenomenon. The Goal Attainment measure could be viewed as objective; it was specifically tied to observable behaviours. According to Jacobson and Follette (1984), self-report measures will continue to be- used until it has been demonstrated that objective measures, i.e. observational coding systems which are relatively insensitive to relationship changes, quantify constructs that are not adequately measured by the less expensive self-report instruments. Recommendations Future long term follow-up research should be conducted for both the EF couples therapy and the Systemic couples therapy to examine in depth the components contributing to the persistence of change during and following the termination of 62 treatment Clients could then be prepared for specific future relationship problems which are inevitable in any marriage. The essential structure in this study can be expanded upon in a number of different ways. It would be useful to replicate this study with a larger number of couples in each treatment group. An alternate and/or more detailed description of couples' experience during and following therapy may be provided by interviewing each couple. Another possibility would be to present the data in a way that shows, subject by subject, what happened from post-treatment to follow-up. Both qualitative and quantitative measures are needed to test for the effectiveness of marital therapy. Finally, it would be both interesting and useful to conduct a two year follow-up study on these same twenty couples to clarify and confirm the lasting effects of these two treatment interventions over a longer period of time. Hopefully no other couples will have separated, but if some do this would be seen as a limit on sample size. However, the information would still be useful and would generate tremendous possibilities for future investigations. 63 References Alexander, J., & Parsons, B. (1973). Short-term behavioural intervention with delinquent families: Impact on family process and recidivism. 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E., & Parloff, M . B. (1975). Psychotherapy change measures. Rockville, M D : National Institute of Mental Health. Watzlawick, P. (1976). The psychotherapeutic techniques of "reframing." In J. L. Claghorn (Ed.), Successful psychotherapy. New York: Brunner/Mazel. Watzlawick, P., Beavin, J. H. , & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies and paradoxes. New York: W. W. Norton. Weeks, G., & L'Abate, L. (1982). Paradoxical psychotherapy: Theory and practice with individuals, groups and families. New York: Brunner/Mazel. Wells, R. A., & Dezen, A. E. (1978). The results of family therapy revisited: The nonbehavioral methods. Family Process, 17, 251-274. Wile, D. E. (1981). Couples therapy: A non-traditional approach. New York: John Wiley & Sons. 69 APPENDIX Name Circle one: Hale Female DYADIC ADJUSTMENT SCALE Most persons have disagreements tn their relationships. Please Indicate below the approximate extent of agreement or disagreement between you and your partner for each Item on the following l i s t . (Place a checkmark / to Indicate your answer.) Almost Occa- Fre- Almoat Always Always sionally quently Always Always Agree Agree Disagree Disagree Disagree Disagree 1. Handling family finances 2. Matters of recreation 3. Religious matters 4. D&fiuMfftratlons of affection 5. Friends 6. Sex relations 7. Conventionality (correct or proper behavior) 8. Philosophy of l i fe 9. Ways? of dealing with parents or In-laws 10. Alms, goals, and things believed important 11. Amount of time spent together 12. Making aajor decisions 13. Household tasks 14. Uilsurtj timo Inter-ests and activities '3. Caraax decisions 7« More Al l Most of Often Occa-the Tine the Tine Than Not sionally Rarelv Never 16. How often do you dis-cuss or have you con-sidered divorce; sep-aration, or terninat-_ng your relationship? 17. Row often do you or your aate leave the house after a fight? IS. In general, how often do you think that things between you and your partner *rc going well? 19. Do you confide in your mate? _ _ _ _ _ _ 20. Do you ever regret that you married (or lived together)? __. 21. How often do you And your partner quarrel? 22. How often do you and your mate "get on each others' nerves"? Almost Every Every Occa-Day Day sionally Rarely Never 23. Do you kiss your mate? A l l of Most of Sorae of Very Few Hone of Them Them Then of Them Them 14. Do you Jrvd your mdte engage In outside interests together? few often would you Say the -following events occur between yon and your mate'! Le»s Than One© Or Once or Ortce & Twice a Twice a Once a More Kever Month Month Meefc Pay Often 25.- Wave a stimulating exchange of ideas-12 Less Than Oncg or Once or Once a Twice a Twice a Once a More Never Month Keneh Week Day often 26. Laugh together 27. Calmly discuss something 28. Work, together on a project These are some things about which couples sometimes agree and sometimes disagree. Indicate If either item below caused differences of opinions or were problems In your relationship during the past few weeks. (Check yes or no.) Yes No 29. _ _ _ _ _ _ _ _ _ _ _ _ Being too tired for sex. 30. Not showing love. 31. The dots on the following line represent different degrees of happiness in your relationship. The middle point, "happy", represents the degree of happiness of most relationships. Please circle the dot which best describes the degree of happiness, a l l things considered, of your relationship. Extremely Fairly A Litt le Happy Very Extremely Perfect . Unhappy Unhappy Unhappy Happy Happy 32. Uhich of the following statements best describes how you feel about the future of your relationship? I want desperately for my relationship to succeed, and would go to almost any length to see that it does. I want very ouch for my relationship to succeed, and will do a l l I can to sec that It <Ioo;i, I w/inc very much for my relationship to S U C C C B I I , nnd will do ray fair share to sec that it does. _ _ _ _ _ _ It would be nice i f my relationship succeeded, but I can't do much more than I am doing now to help it succeed. It would be nice i f it succeeded, but I refuse to do any more than I am doing now to keep the relationship going. My relationship can never succeed, and there Is no oore that I can do Co keep the relationship going. CONFLICT RESOLUTION SCALE IS In thinking about your relationship, please c irc le the response that best describes your level of agreement with each statement. 1. In order to end an argument, I usually give up too quickly. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 2. My partner and I have very different ideas about the way to solve our disagreements. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 3. When discussing problems, I usually tel l my partner what is bothering me. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 4. When we are having a problem, I can always tel l my partner what is bothering me. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 5. Sometimes we have serious disputes over unimportant issues. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 6. I would do anything to avoid conflict with my partner. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree .11 7 * 7. I sometimes feel that our arguments go on and on and never get resolved. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 8. When we have a disagreement, we openly share our feelings and decide how . to resolve our differences. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 9. I usually feel that my partner does not take our disagreements seriously. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree 10. When we argue, I usually end up feeling that the problem was al l my fault. 1 2 3 4 5 strongly moderately neither agree moderately strongly agree agree nor disagree disagree disagree C O A L A T T A I K H E V T roLLo:.-up cui?z H A M E : D A T S : DESCRIPTION OF CONFLICT YOU HAVE BEEN UORXINC ON. MUCH W0R33 ?ni)l EXPECTED RESULTS: SOM_",(RAT LESS THAN EXPECTED RESULTSi EXPECTED OR HOST LIKELY RESULTS: SOMEWHAT BETTER THAII EXPECTED RESULTSi XUCH BETTEH THAU EXPECTED RESULTSi (p lao» a»tarin_ (•) n»xt to leva! whort you _• • now) QUESTIONNAIRE I (at follow-up) Wo are interested In how much the following complaint is) of yours has (have) changed since you started the program. Please c i rc l e the words that describe your position. (a) worse . . . suae.. . s l ightly bet ter . . . soiaevhat bet ter . . . & lot better (b) worse . . . same... s l ightly bet ter . . . somewhat bat ter . . . a lot better (c) worse . . . sajne... s l ightly better . . . somewhat bet ter . . . a lot better 11 month follow-up Couple # Please check the appropriate box: MALE | | FEMALE | | To answer, please c i r c l e YES, MAYBE or NO below each question (where a p p l i c a b l e ) . For the remaining items, please f e e l free to elaborate on any of your wri t ten answers. We appreciate your co-operation and response. It i s important to the re su l t s of th i s study. 1. At the end of counsel l ing d i d you change as a r e s u l t of counsel l ing? YES MAYBE NO a) If change had not occurred by the end of counse l l ing , has i t occurred since then? YES MAYBE NO b) If change occurred a f ter treatment, to what do you a t t r i b u t e th i s change? c) I f change d i d occur at the end of counse l l ing , have these changes been maintained? YES MAYBE NO d) Since counse l l ing ended, how have you maintained these changes? 2. Has your r e l a t i o n s h i p improved s ince you ended counsel l ing? YES MAYBE NO 3 . Was counse l l ing a major factor i n helping you to get where you are now? YES MAYBE NO a) If not, was there anything since counse l l ing that you saw as being p a r t i c u l a r l y helpful? b) If so, what was i t about the counse l l ing that was he lp fu l to you during th i s past year? 

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