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DEPRESSION AND PERCEIVED MARITAL RELATIONSHIPS

BY

Paula C. McNitt

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1985

©1986

PAULA CHANLEY MCNITT

All Rights Reserved

ABSTRACT
DEPRESSION AND PERCEIVED MARITAL RELATIONSHIPS
BY

Paula C. McNitt

This study presents a family-systems conceptualization
of clinical depression and hypothesizes that depression is a
homeostatic mechanism in the marriages of depressed men and
women. Depressive symptoms preserve the marital status quo
and the relationship rules that govern interaction between
the depressed client and his/her spouse. The specific pre-
dictions tested were that depressed psychotherapy clients
would report less autonomy, higher levels of hostile auton-
omy, dominance and submission, less affectionate inter-
change, greater hostility, and more severely impaired
communication in their marriages than would either psychi-
atrically normal adults or other psychotherapy clients.

A group of 16 outpatient psychotherapy client volun-
teers who received a diagnosis of primary unipolar depres-
sion (Depressed Clients) was compared with a group of 16
psychotherapy clients who received some other diagnosis
and with 16 psychiatrically normal adults.

Each participant rated his/her marriage during the
past three months on Series A and B of the Structural
Analysis of Social Behavior (Benjamin, 1979), a modified
version of the Love Scale (Swensen and Gilner, 1968) and the

Marital Communication Inventory (Bienvenu, 1978).

The results of the study provide partial support for
its hypotheses. The Depressed Clients reported less overall
autonomy and friendly autonomy and more hostile autonomy,
dominance and submission, more hostility, and more impaired
communication than did the Normals. Contrary to prediction,
the Depressed Clients reported no less affection in their
marriages than did either the Normals or Nondepressed
Clients. Only on the self-ratings of overall autonomy,
friendly autonomy, hostile autonomy, and submission were the
differences between Clients groups statistically signifi-
cant. In rating their spouses' behavior the Depressed
Clients differed from the Normals, but not from the Non-

depressed Clients.

DEDICATION

For my daughters: Megan Elizabeth and Katherine Anne

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ACKNOWLEDGMENTS

There are literally dozens of people to whom I owe
thanks for their assistance and support in the conduct of
this study and the preparation of this dissertation.

First and foremost I must thank the participants, who
must remain anonymous. Their time, effort, and trust could
hardly be repaid by my modest "Thank you” payments. Next, I
must thank the clinical staff of the cooperating mental
health centers. A dozen or more therapists proved to be a
most interesting and colleagial referral source.

The members of my dissertation committee, Professors
Dozier Thornton, Bertram Karon, Robert Zucker, and Elaine
Donelson are as fine mentors as a student of psychology
could seek.

And there are those "on the home front" to be
thanked. My husband, Andrew McNitt, provided the moral and
financial support to see me through this long project.
Catherine Smith, my day-care provider, took such good care
of Megan and Kate, that I felt quite free to write this
dissertation. Terri Monnett has made the final preparation
of this manuscript seem almost effortless.

To all of these people I say "Thank you" for helping

me to achieve this goal.

iii

TABLE OF CONTENTS

CHAPTER

1.

INTRODUCTION 0 O O O O O O O O O O O O O

The Significance of the Marital
Relationship . . . . . . . . .
Systems Theory and Psychopathology. . .
Depression as an Interpersonal
Process. . . . . . . . . . .
The Depressed Patient and His/Her
Family . . . . . . . . . . . . . . .
Hypotheses. . . . . . . . . . . . . . .

METHODS O I O O O O O O O O O O O O O 0
subjects I O D O O O O O O O O O O O O 0

Client Participants. . . . . . . . .
Inclusion Criteria for the Depressed

Clients Group. . . . . . . . .
Inclusion Criteria for the Nondepressed
Clients Group. . . . . . . . . . .

Psychiatrically Normal Participants . .
Inclusion Criteria for Psychiatrically
Normal Participants. . . . . . . .
Matching Participant Groups . . . . .
Criteria for Matching Couples. . .
Procedure . . . . . . . . . .
Briefing Clinicians and Establishing
Diagnostic Agreement. . . . . . .
Contacting, Interviewing and Testing
Client Participants . . . . . . .
Orientation Protocol. . . . . . . . . .
Instructions for Participants (A) . . .
Recruiting and Testing Psychiatrically
Normal Participants. . . . . .
Instructions for Participants (B) . .
Feedback. . . . . . . . . . . . . . .
Instruments . . . . . . . . . . . . .
Validity Studies. . . . . . . . . . .
Organization and Analyses of SASB Data

The Love Scale. . . . . . . . .
Love Scale Scores and the Marital
Relationship . . . . . . . . .

A Modified Version of the Love Scale

iv

Page

PI

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CHAPTER

The Marital Communication

Dependent Measures. .
Predictions . . . . .

3. RESULTS . . . . . . .
4. DISCUSSION. . . . . .
Appendices

A. TARGET GROUPS . . . .

B. GUIDELINES FOR BRIEFING

PARTICIPANTS. . . .

CLIENT

Inventory . .

. DIAGNOSING PRIMARY UNIPOLAR DEPRESSION.

. DEPARTMENTAL RESEARCH CONSENT FORM. . .

C
D. SAMPLE CASE HISTORIES
E
F

. INFORMATION ABOUT:

THE MARITAL RELATIONSHIPS OF PERSONS
EXPERIENCING DEPRESSION AND ANXIETY .

G. GUIDELINES FOR INTERVIEWING THE

H. SUMMARY OF DIAGNOSTIC DATA.

I. GENERAL INFORMATION SHEET

. BECK'S DEPRESSION INVENTORY

CLIENTS

. A MARITAL COMMUNICATION INVENTORY

. SASB QUESTIONNAIRES .

J
K
L. SCALE OF FEELINGS AND BEHAVIOR OF
M
N

. INTRODUCTION TO PARTICIPANT COUPLES . .

O. SURVEY OF PROBLEMS. .

References 0 O O O O O O O O

A STUDY INVESTIGATING

Page
102
104
104
110

145

175

176
177
179
184

185
186
187
191
192
193
199
212
221
222

223

16.

17.

18.

LIST OF TABLES

Referral Sources of Client Participants

Characteristics--Depressed Clients.

Characteristics--Nondepressed Clients

Comparison of Groups on the Beck

Depression Inventory.

Referral Sources of Psychiatrically

Normal Participants .

Matching Couples Across Groups.

Comparison of Couples/Groups on Age,
Length of Marriage, and Social

Class . . .

Operationalization of Dependent Measures.

Comparison of
Comparison of
Comparison of
Comparison of
Comparison of
Comparison of

Comparison of
Affection .

Comparison of
Affection .

Comparison of

Comparison of

MCI Scores - C

Groups on Interdependence .

Groups on Friendly Autonomy

Groups on
Groups on
Groups on
Groups on

Groups on

Groups on

Groups on

Groups on
1 O O 0

vi

Dominance

Submissiveness.

Hostile Autonomy.

Affiliation

Expression of

Expression of

Hostility .

Communication-

Page
44
51
53

57

59
64

66
105
111
112
113
114
115

120

121

122

123

126

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Table Page
19. Correlations - Severity of Depression
and Autonomy, Affiliation, and
commication O O O O O O O O O O O O O O O O 127

20. Correlation Matrix - 18 Dependent
Measures. . . . . . . . . . . . . . . . . . . 129

21. Summary of Step-wise Discriminant
Function Analysis . . . . . . . . . . . . . . 132

22. Comparison of Standardized Dis-

crimination Coefficients and

Structure Coefficients. . . . . . . . . . . . 136
23. Classification of Cases . . . . . . . . . . . . 140

24. Assignment of Cases to Groups According
to Discriminant Scores. . . . . . . . . . . . 141

vii

mu.

RI.

LIST OF FIGURES

Figure Page
1. Map of SASB Model . . . . . . . . . . . . . . . 87
2. Map of SASB Octants . . . . . . . . . . . . . . 89

viii

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on.

CHAPTER 1
INTRODUCT ION

This study examines several aspects of the marital
relationships of depressed men and women. Specifically, it
focuses on autonomy vs. dependency, expression of affection
and of anger, and quality of communication in these mar-
riages. The study's theoretical underpinnings are to be
found in the family systems theorizing of Jackson (1968),
Haley (1963a), and Satir (1967). A family-systems con-
ceptualization of psychopathology defines a disorder as an
expression of disturbance not merely in the identified
patient's intrapsychic functioning, but also in his/her
family system. Psychiatric symptoms are homeostatic mechan-
isms insofar as they preserve the family members' roles and
relationship rules. The fundamental hypothesis of this
study is that clinical depression is a homeostatic mechanism
in the marital relationship of depressed men and women.
Depressive symptoms are congruent with these couples'
general interaction processes.

A family-systems conceptualization differs importantly
from genetic and biochemical (Akiskal & McKinney, 1975),
psychoanalytic (Gaylin, 1968), cognitive (Beck, 1972),

operant-behavioral (Lewinsohn, 1974), and learned

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helplessness (Seligman, 1974) theories of clinical depres-
sion. These otherwise diverse theories agree that the prime
cause of depressive pathology is to be found within the
individual. A person responds to life's stresses and dis-
appointments with depressive symptoms because there is some-
thing wrong with him/her: his/her body chemistry is askew,
s/he has directed hostility against him/herself rather than
against a disappointing love object, s/he is excessively
dependent on others, s/he systematically misinterprets
events in an egocentric and negativistic fashion, s/he lacks
the social skills necessary’ to {elicit the reinforcement
which would maintain his/her self-esteem and self-confi-
dence. Generally, these theories assume that the depressed
patient's current social environment is, at most, a precipi-
tating or secondary factor in the emergence of his/her
disorder. The depressed person is a relatively closed
system, impervious to his/her sane and rewarding environ-
ment. S/he is, however, unable to acquire the available
support and gratification s/he so desperately needs (Coyne,
1976a). A family-systems conceptualization, though, assumes
that an individual's depression is an index of disturbance
in a relationship system in which his/her intrapsychic and
physiological processes are but sub-systems. This concep-
tualization does not repudiate the significant contributions
of biochemical, psychodynamic, cognitive and social learning

theories of depression. Rather, the family systems

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orientation offers an additional conceptual level from which
to examine the phenomena of clinical depression.

It is, perhaps, an oddity' of contemporary psycho-
pathology research that only a few scattered investigators
[the Hogans in the United States (Hogan & Hogan, 1975),
Hinchliffe and her colleagues in England (Hinchliffe, Hooper
& Roberts, 1978), and Heins in Australia (Heins, 1978)] have
adopted a family systems approach to the study of depres-
sion. While this theoretical orientation has been widely
heralded as a nmjor advance in clinical research, the vast
majority of depression research has remained focussed on
intra-individual variables. This focus may be due in part
to the behavior of the depressed patient him/herself
(Hinchliffe et al., 1978). The depressed person tends to be
self-absorbed. and. egocentric in, his/her' view' of his/her
predicament. The very language in which s/he expresses and
describes his/her feelings and problems diverts his/her, and
at times the researcher's, attention from the depression as
an interpersonal process. A shift in focus from the identi-
fied patient to his/her family system can be difficult for
patient, therapist, and researcher.

Yet there is ample justification for a systems ori-
ented study of the depressed patient's family relationships.
First, this orientation promises further understanding of
depression. because it Ihas enhanced. our understanding of
other psychiatric disorders, notably schizophrenia.

Secondly, clinicians, both published (Deykin, Jacobson,

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Klerman & Solomon, 1966; Feldman, 1976; Forrest, 1969; Hogan
& Hogan, 1975; Jacobson & Klerman, 1966; Rashkis, 1968;
Rubinstein & Timmons, 1978) and unpublished (this author)
have concluded that a comprehensive assessment and treatment
of the depressed patient must address itself to his/her
family and to the function his/her depression serves for
that family. Klerman and his colleagues (Deykin et al.,
1966; Jacobson & Klerman, 1966) observed that depression in
some middle-aged women both stemmed from and served to mask
conflicts over changes in relationships with their grown
children. Rashkis (1968) concluded that the emergence of an
adolescent child's identity crisis can elicit similar
unresolved conflicts and consequent depression in his/her
parent. Forrest (1969) describes a pattern of shared
underlying pathology in the marriages of several of her
severely depressed patients. Several behavioral (Lewinsohn
& Shaffer, 1971; McLean, Ogston & Grauer, 1973) and
cognitive-behavioral (Rush, Shaw & Khatami, 1980) therapists
have reported that their treatment efforts ‘were greatly
enhanced by enlisting the active participation of a
depressed patient's spouse.

Ideally, one would examine all of the depressed
person's important family relationships. Practical and
empirical-theoretical considerations, however, have limited
this study to an investigation of the marital relationships

of currently married depressed outpatients.

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The Significance of the Marital Relationship

Epidemiological and life history research suggest that
the marital relationship plays a central role in the onset
and persistence of depressive disorders. With most psychi-
atric disorders it is the unmarried who are at higher risk.
The reverse is true for depression; it is the married who
are at higher risk (Hinchliffe et al., 1978). Overall's
(1971) study indicates that. depressive symptomatology is
characteristic of psychiatric patients who have been married
once. This group includes currently married patients as
well as divorced patients who have not remarried. Those
patients who had never married were more likely to present
schizophrenic symptoms, and those who had married more than
once were unlikely to present high levels of any one cluster
of psychiatric symptoms. From this Overall (1971) argues
that depression is related to dependency relationships in
less than adequate social settings.

Several lines of research have demonstrated an associ-
ation between marital unhappiness and clinical depression.
Conflict and change in the depressed patient's marriage have
often been cited as stressful events preceding the onset of
a depressive episode. Paykel and colleagues (Paykel,
Meyers, Dienelt, Klerman, Lindenthal & Pepper, 1969) found
that among 185 psychiatric patients receiving a diagnosis of
primary depression, an increase in arguments ‘with one's

spouse was the most frequently mentioned source of stress

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occurring during the six months prior to symptom onset. The
number of depressed patients reporting increased marital
conflict was statistically higher than the number of matched
normal controls reporting this problem. In this study
marital separation. was the second. most frequently cited
stressful event. Leff, Roatch and Bunney (1970) in their
intensive long-term. study’ of 40 severely' depressed
inpatients noted that 19 patients reported a change in their
marital relationships during the six months prior to their
depressions.

The emergence of depressive symptoms hardly eliminates
marital dissatisfaction and discord. Depressed persons
often report continuing stress and ‘unhappiness in their
marriages. In a study of the general population Ilfield
(1977) found that of all social stressors, it is marriage
stressors which correlate highest with depressive symptoms.
Coleman and Miller's (1975) study of 154 couples who
requested help at an outpatient mental health clinic yielded
a significant correlation between self and clinicians' rat-
ings of depression and ratings of marital maladjustment.
The correlation was significant only for the husbands,
although the wives were more depressed and more often the
identified patient. An extensive investigation of the
social adjustment of 40 depressed women (Weissman & Paykel,
1974) revealed high levels of friction and hostility between
these patients and their husbands which persisted months

after symptomatic recovery.

7

Of the 76 depressed women participating in another
Yale study (Rounsaville, Weissman, Prusoff & Heiceg-Baron,
1979) over half reported serious disputes with their
husbands, and of this half only one-fourth reported improve-
ment in their marriages during eight months of maintenance
treatment. The women who reported no marital improvement
were significantly more symptomatic at treatment's end than
were all of the other participants. All of the women in
this study had initially shown marked symptomatic improve-
ment following four to six weeks of anti-depressant medica-
tion. At the beginning of subsequent maintenance treatment
there was no relationship between symptom severity and
marital discord. The patterns of marital discord were
remarkably stable at 48 months follow-up. Few of the women
who initially reported no marital disputes later reported
such problems. Most of the women who had initially com-
plained of disputes with their husbands did so 48 months
later. The between group differences on severity of depres-
sive symptoms was evident at 20 months, but not at 48 months
follow-up (Rounsaville, Prusoff & Weissman, 1980). These
researchers (Rounsaville et al., 1979) suggest that the
marital conflicts of depressed women are chronic sources and
exacerbators of depressive episodes rather than transient
by-products of the latter.

The evidence suggesting that the marital relationship
often figures significantly in the development of depression

prompts the further, rather difficult question of the

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specific nature of the relationship between the depressed
person's mood and behavior and the dynamics of his/her
marriage. To argue that depression is simply one partner's
reaction to a disappointing or conflict ridden marriage
leaves much unexplained, for the question remains as to why
that partner becomes depressed rather than develops other
psychiatric symptoms, seeks consolation in an extra-marital
liaison, becomes abusive, or quits the marriage. It must be
noted. as well that the co-occurrence of depression and
marital dysfunction is not universal. Not all of the
depressed women in the Yale studies (Rounsaville et al.,
1979, 1980) reported marital disputes. In Coleman and
Miller's (1975) study the correlation between depression and
marital maladjustment proved statistically significant only
for the husbands. Perhaps an answer to this quandry can be
found in a somewhat different conceptualization of the rela-
tion. .between. interpersonal. relations and. psychiatric
symptoms.

This conceptualization posits depression as the out-
come of basic, underlying marital processes and rules when
these are subjected to stress, rather than as one partner's
idiosyncratic response to marital dysfunction. The under-
lying marital roles and rules which give rise to depression
are the same ones which may give rise to overt conflict and
unhappiness. A marital relationship which is not obviously
unhappy or conflicted may nonetheless be depressogenic.

Hinchliffe and her colleagues (Hinchliffe et al., 1978)

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argue similarly that the depression prone marriage. may be
superficially adequate and supportive. On the surface there
are few, if any, signs of conflict or poor communication.
At a deeper level, though, there may be a far more disturbed
level of experience which is quite negatively toned. Family
systems theory provides a vocabulary with which to elaborate
and elucidate the relationship between marital processes and

the emergence of clinical depression.
Systems Theory and Psychopathology

General systems theory (von Bertalanffy, 1974) pro-
vides the conceptual framework for a family-systems study of
psychopathology. The theory has as its basis the concept of
the self-regulating, goal directed biological organism. A
system is a complex of parts and processes in mutual inter-
action. Causal connections within the system are circular
rather than linear. Any component acting within the system
will ultimately be acted on by other components in response
to its original action. This process is called a feedback
loop. Organisms are self-regulating and maintain a state of
internal dynamic equilibrium, or homeostasis. Systems are
error activated and self-correcting. If any component or
subsystem diverges from its appropriate path or level of
activity, other components will act on it so as to bring it
back into line. Such error correcting processes are

referred to as negative, or deviation reducing, feedback

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loops. Implicit in the concept of homeostasis is that
organisms resist fundamental, system incongruent change.

The application of systems theory to the study of
psychopathology has utilized family homeostasis (Jackson,
1957) as its pivotal concept. The family is a self-
correcting system in which all members act to maintain its
steady state. Homeostasis entails a balance in the intra—
familial relationships (Satir, 1967). If any member trans-
gresses either the behavioral limits imposed by his/her role
in the family or the family's rules for interaction with
outsiders, other family members will act so as to rescind or
reduce that transgression. Family' members behave as if
governed by rules (Jackson, 1965). Family rules usually
remain unstated, but can be inferred from the members'
habitual interaction patterns and their responses to devia-
tion from these. All family members govern each other's
behavior, although they may not be aware that they do so
(Haley, 1963a). Governing includes far more than straight-
forward domination; the processes of interpersonal control
entail a complex and subtle array of overt and covert,
active and passive, concrete and symbolic, rewards, threats,
and punishments.

Psychiatric disorders are homeostatic mechanisms.
Symptoms are not simply senseless, maladaptive behaviors,
but rather the system's response to internal and external
threats to its equilibrium. As painful and distressing as

these symptoms may be for the patient and his/her relatives,

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they may be necessary for the family's survival. The family
needs to have one of its members serve as "identified
patient.” This seemingly counterintuitive conclusion has
been drawn from two classes of clinical observation. First,
families frequently attempt, whether consciously or uncon-
sciously, to sabotage the identified patient's treatment and
recovery (Kohl, 1962; Satir, 1967). Perhaps the most
startling instance of such sabotage is the unwitting
abetting of their husbands' drinking observed in some wives
of alcoholics. Ewing (Ewing, Long & Wenzel, 1961) noted
that some of these women's sense of strength and effective-
ness was contingent on the husband's remaining dependent and
incapacitated by his drinking. A husband's sobriety was so
threatening as to prompt some wives to ”accidentally“ serve
their otherwise sober husbands alcoholic beverages.
Secondly, in some families, members alternate in playing the
role of identified patient. Many clinicians have observed
the emergence of psychiatric symptoms in another family
member consequent to the identified patient's improvement.
Kohl (1962) found that of the 39 spouses of hospitalized
psychiatric patients, five resumed excessive drinking, and
21 became depressed following the first signs of the
patient's symptomatic recovery. Jackson (1957) noted
several instances of symptom exchange, including the case of
a husband's sexual impotence which emerged consequent to his

wife's improvement in her treatment for frigidity. These

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12
cases are cited as examples, not as proof of the universal-
ity, of symptom exchange within families.

Psychiatric symptoms are homeostatic in two senses.
First, symptoms can maintain the family as a unit when it
might otherwise disintegrate under stress. Symptoms pre-
serve unstable and unrewarding relationships within the
family, especially the marital bond. Children, it seems,
possess an uncanny proclivity to develop emotional,
behavioral, and academic problems which deflect their
parents' attention and energy away from their own marital
discord (Satir, 1967). In a sense, a sick child can
preserve a bad marriage. Should the child's difficulties be
resolved, his/her parents would again be faced with disap-
pointments and conflicts in their marriage. Similarly, a
husband's or wife's anxiety, depression, agoraphobia,
alcoholism, etc., can save a couple from confronting their
relationship problems and thereby from risking a complete
disruption of their marriage (Haley, 1963b). Husbands and
wives have been known to collude in the myth that they would
be quite happy together if only he or she were not plagued
by this or that symptom. The symptom, they will protest, is
strictly the individual's problem, and has nothing to do
with their marital relationship.

Psychiatric symptoms are homeostatic in that they are
congruent with the family's relationship and communication
rules. For example, Haley's (1959) model of the family

communication and relationship rules of the schizophrenic

13
patient makes sense out of his/her psychotic behavior. Com-
munications within the schizophrenic's family are such that
family members constantly negate or disqualify their own and
each other's statements. Such communications entail an
incongruence between the message, or content, level and the
meta-message level, which indicates how the message content
is to be understood. Because all communications define the
relationship between the sender and his/her audience (as
well as convey content) incongruous messages deny or confuse
this relationship. Consequently, the schizophrenic experi-
ences extreme difficulty discerning his/her relationships to
other and thus his/her own identity as well. Moreover, the
schizophrenic's family invokes prohibitions on his/her
attachments both in and outside of the family. Such pro-
hibitions become unbearable as he/she confronts his/her own
maturational needs and the larger society's demands that
he/she individuate from his/her family. Psychotic behavior
is the schi20phrenic's way of simultaneously infringing and
not infringing these prohibitions. The patient withdraws
into his/her private reality, but remains dependent on his/
her family's care and support. He/she denies his/her
identity and his/her relationship to others, but does so in
a manner consistent with the only communication rules he/she
has ever learned. That is, his/her delusions and his/her
"word salad" statements are messages which are incongruent
at all levels. In short, he/she has reduced his/her

family's mode of interpersonal transaction to an absurdity.

14

Homeostasis as a first principle of family process is
both limited and pessimistic (Speer, 1970). It cannot
account for the normal, healthy growth of the individual or
of the family as a relationship system. Secondly, the
principle implies the imminent capacity for psychiatric dis-
order in any family. Redefining the family as an open, but
relatively stable system can, however, enhance understanding
of both normal and disturbed families. The family is
governed by both deviation reducing and deviation amplifying
feedback mechanisms (Speer, 1970; Wender, 1968). As such it
is both self-regulating and. open to change and growth.
Families whose internal organization is complex and flex-
ible, and whose processes are limited by a minimum of rigid
constraints change and grow in response to the demands of
both its members' maturational needs and its changing
environment. This capacity for adaptation and growth is
what differentiates healthy from pathogenic families. Only
sick, symptom-generating families are in homeostasis (Speer,
1970). Satir (1971) has similarly argued that the rules of
dysfunctional families interfere with the growth and
development of their members. Given such rules, these
families are bound to respond to the challenges and stresses
imposed by maturational and environmental forces with
symptoms. Such families can maintain their status quo only
if at least one member becomes dysfunctional.

The fundamental hypothesis of this study is that

clinical depression, as opposed to periods of normal grief,

15
or of reality based discouragement, is a homeostatic mechan-
ism in each of the two senses discussed. First, depressive
symptomatology can maintain the marital unit when it might
otherwise disintegrate. Secondly, depressive symptoms are
congruent with the couple's special mode of interaction.
Depression, insofar as it is a passive, dependent, whiny,
reproachful, manipulative, and indirect plea for care and
attention, is consistent with a couple's relationship rules.
That depression, or any other psychiatric disorder, serves
to keep a marriage or family intact cannot be directly
observed, but can only be inferred. Similarly, relationship
rules can only be inferred from observed patterns of
behavior. A couple's interaction pattern can, though, be
observed or reported on directly, and thus it is to the
interactions reported by depressed men and women that this
study addresses itself. Specific hypotheses are based on
the case study and research literature on the marital and

family treatment of depression.

Depression as an Interpersonal Process

 

The interpersonal characteristics of depression can be
discussed from two viewpoints. One approach focuses on the
depressed patient's interpersonal needs and style: on his/
her dependency, hostility and uncommunicativeness. The
psychoanalytic tradition has emphasized the depressive's
excessive and unresolved dependency needs (Arieti &

Bemporad, 1978; Chodoff, 1970, 1974). The depression-prone

 

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16
person requires an inordinate amount of attention and praise
from others in order to maintain his/her precarious self-
esteem and self-confidence. S/he lacks that stable sense of
self-worth which enables most adults to weather life's
frustrations and disappointments with relative equanimity.
The depressive's dependency needs become most obvious during
symptom episodes. Beck (1972, p. 32) observes that the
depressed patient expresses a craving for help that exceeds
even his/her perceived need of help. The 40 depressed women
of Weissman and Paykel's (1974) study reported that they
relied on their husbands to help with household chores and
child care and make decisions for them while they were
depressed. Once their depressive symptoms lifted, however,
they no longer relied on their husbands so extensively.
Cohen et a1. (1954) described the manic depressive patient
as maintaining one or a few highly dependent relationships.
His/her need to be cared for and relieved of adult responsi-
bility dominates all of his/her interpersonal transactions
during depressive episodes. During symptom-free periods,
the manic-depressive maintains an easy, though superficial,
social adjustment. Even during his/her healthy periods s/he
operates from the premise that life's rewards are to be won
via ingratiation and manipulation of powerful others, rather
than to be earned by one's own imperfect skill and effort.
The manic depressive patient fears abandonment above all,

and thus avoids any competition or conflict with significant

17
others. In short, there are two aspects of the depression-
prone person's dependency needs: the reliance on the good
opinion of others to maintain his/her sense of worth and the
need to be cared for and absolved of responsibility. This
latter aspect apparently comes to the fore during clinical
episodes.

The relationship between depression and hostility has
been extensively discussed and researched. Abraham (1911)
was one of the first psychoanalytic theorists to note the
depressive's ambivalence and repressed hostility. Freud
(1917) postulated an aetiological link between depression
and introjected hostility. He noted that the depressed
patient's self-denigration and self-blame are devoid of the
humility one :might expect. of a ‘truly self—effacing and
repentant person. From this, Freud inferred that the
depressive's apparently self-directed anger has, in fact, a
different target. This target is a lost or frustrating love
object. whom. the depressive has introjected rather than
relinquished. Freud's insight introduced the maxim widely
held among clinicians that depression is associated with a
maximum of self-directed hostility and a minimum of other
directed hostility.

Other clinicians point to hostility as a prominent
feature of depression, but question the aetiological link
Jbetween introjected hostility and depression. The research-
ers from the Washington School of Psychiatry (Cohen et al.,

1954) conceptualized the manic-depressive's hostility as a

18

product of his frustrated attempts at manipulating others
into meeting all of his/her narcissistic needs. Hostility
is a by-product, rather than a cause, of the depressive
process. Chodoff (1970) comments that the impact on others
of the depressive's behavior belies its unconscious hostile
intent. That contact with a depressed patient can leave one
feeling tense, vexed, guilty and depressed is attested to by
clinical (Cohen et al., 1954) and laboratory (Coyne, 1976b)
observations. Bonime (1960) may be the least sentimental of
clinicians in his assessment. of the depressed patient's
angry, sadistic manipulativeness. He contends that depres-
sive symptoms entail two pathological goals: satisfaction
of’ manipulating others to provide care and concern and
enjoyment of the tyranny of dependency in the exploitation
of others. Those who try to alleviate the depressive's
misery usually find themselves ”walking on egg shells" from
fear of further upsetting the patient. More often than not,
the would-be helper ends up feeling impotent in the face of
the depressive's stubborn misery. The patient's covert
goal, Bonime (1960) contends, is to hurt and defy his/her
significant others.

The studies designed to systematically confirm clini-
cal observations and intuitions of the depressed patient's
overt and covert hostility have yielded varied results.

Wessman, Ricks and Tyl's (1960) study of normal
college women found that periods of normal low mood were

associated with an increase of extrapunitive rather than

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19
intropunitive responses to frustration. These psycho-
analytically oriented researchers suggest that it is
precisely the response to frustration which differentiates
normal lOW' mood from pathological depression, and that
pathological depression is associated with increased intro-
punitiveness.

A mmlti-trait, multi-method study (Zuckerman et al.,
1967) of anxiety, depression and hostility yielded mixed
results. Anxious and depressed psychiatric patients
reported significantly' more .hostility' on the Buss-Durkee
Hostility Inventory (Buss & Durkee, 1956) than did normal
controls; however, these groups did not differ on inter-
viewers' ratings or Multiple Affect Adjective Check List
(MAACL) (Zuckerman & Lubin, 1965) self-ratings of hostility.
The correlation between MAACL ratings of depression and
Buss-Durkee hostility scores was significant for the normal
subjects only.

Gershon, Cromer and Klerman (1968) examined levels of
"hostility-in" and "hostility-out" in the free association
content of six depressed female inpatients. "Hostility-in"
correlated positively with ratings of severity of depression
for all six women. For only two of the women did "hostil-
ity-out'I correlate significantly (and positively) with
severity of depression. These two 'women. were rated as
significantly lower on depressive affect, though not on

overall symptom severity, than the other four. These two

 

 

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20
were also the only two described as presenting hysterical
personality feature.

The 190 depressed patients in Friedman's (1970) study
reported significantly less verbal hostility and signifi—
cantly more resentment on the Buss-Durkee Hostility
Inventory (Buss & Durkee, 1956) than did the 98 normal
control subjects. The depressed patients reported no
greater internalization and somaticization of anger than did
the normal subjects. Clinical improvement was associated
with a significant decrease in all aspects of hostility.
Friedman remarks that the patients' decrease in verbal
hostility is curious as one would have expected a regression
to the norm, and thus an increase in verbal hostility with
clinical improvement. He speculates that the depressed
person usually inhibits overt expression of anger, but this
defense breaks down during depressive episodes. Friedman
(1970) cites his previous finding that depressed patients
were much less likely than nondepressed subjects to agree
that sometimes it is quite right to be angry. He concludes
that the inability to freely verbalize anger is an integral
aspect of the predisposition to depression.

Weissman and Paykel (1974) assessed the amount. of
friction, defined as overt fighting, depressed women
experienced with their children, husbands, relatives,
friends, and co-workers. Compared to psychiatrically normal
women, these patients reported significantly more friction

during' both the symptomatic period and the twelve-month

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recovery period. Friction correlated with the intimacy of
the relationship. The women argued most with their children
and husbands and least with their friends and co—workers.
weissman and Paykel (1974) conclude that the expression of
hostility varies according to the depressed woman's social
setting. The amount of anger she manifests or alludes to
during an assessment interview may be a very poor indicator
of the kind and amount of friction she is experiencing at
home. These authors also comment that their clinical obser-
vations revealed no impairment in the depressed woman's
overt expression of hostility, but noticeable impairment in
her direct communication of her needs, wishes, and feelings.

In a methodologically sophisticated study, Schless et
a1. (1974) were able to divide 37 depressed inpatients into
two groups: internalizers and externalizers of hostility.
Among internalizers severity of depression correlated posi-
tively with degree of internalization. Externalization of
hostility was associated with hysterical personality
features and resentment. Schless et a1. (1974) suggest that
hostility serves as a defense against experiencing depres-
sive affect. In severe cases of depression this defense has
broken down. On a semantic differential measure severely
depressed patients described their own anger as impotent but
other people's anger as quite potent.

Fava and his colleagues (Fava, Kellner, Munari, Pavan
& Pesarin, 1982) compared a sample of 40 outpatients who

were experiencing a first depressive episode sufficiently

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22

severe to warrant treatment with antidepressant medication
with a sample of psychiatrically normal controls. The
former group scored significantly higher on hostility as
assessed by the Kellner Symptom Questionnaire (Kellner,
1981). Among the depressed patients, the correlation
between ratings of hostility and of severity of depressive
symptoms proved statistically reliable only for those
patients who had suffered no losses or exits from the social
field during the several months prior to symptom onset.
Presumably those patients who had lost a significant other
had no (one to blame for their unhappiness, whereas those
patients who had not lost a significant other were both
angry and depressed as a result of ongoing interpersonal
conflicts (Fava et al., 1982).

Although results of these studies provide no single
unequivocal statement about the relationship between
hostility and depression, they do suggest that the depressed
person is less able to express his anger verbally, in a
straightforward manner. Anger expression may be a defense
against the experience of depressive affect. Depressed
patients whose anger is expressed in the form of resentment
and hysterical complaints experience less severe feelings of
depression. Patients who turn their anger against them-
selves experience more severe depressive feelings.

A third feature of the depressed patient's inter-
personal transactions is his/her impaired communication

(Coyne, 1976; Spiegel, 1965; Stuart, 1967). Any therapist

23
who has attempted to engage a severely depressed patient in
talking therapy can testify to the extreme difficulty of the
task (Spiegel, 1965). Impaired communication is hardly
limited to the consultation room; rather it appears to be a
prominent feature of the depressed patient's family rela-
tionships.

McLean, Ogston and Grauer (1973) observed that their
depressed patients' intimate relationships were marked by a
coercive style of communication which precluded effective
problem solving. These patients and their spouses proffered
each other predominantly negative feedback when discussing
interpersonal issues. Moreover, they were often unaware of
the impact such feedback had on their partners. Their case
histories also indicated that this negative mode of communi-
cation was chronic and not limited to one partner's
symptomatic periods.

Weissman and Paykel's (1974) study of depressed women
revealed an abnormal degree of reticence in their relation-
ships with their husbands, children, other relatives,
neighbors, and co-workers. This reticence was not limited
to the depressive episode, but persisted during the twelve-
month symptom-free follow-up period. The. content of the
depressives' messages was also constricted. For the most
part, depressed patients talked about their symptoms and
their general unhappiness.

Wasli's (1977) study of 16 hospitalized depressed

women and their husbands revealed that these couples'

24

conversations were brief, infrequent, and most often
centered on the wife's feelings. These depressed women and
their husbands reported difficulty perceiving, understanding
and discussing each other‘s needs, discussing problems, and
expressing disagreement without losing their tempers. The
patients often complained that their husbands did not mean
what they said. On a standardized instrument, the Marital
Communication Inventory (Bienvenu, 1978), the couples
reported significantly impaired communication.

Hinchliffe, Hooper, and Roberts (1978) examined the
patterns of communication between 20 depressed inpatients
and their husbands and wives. Their discussions of hypo-
thetical interpersonal and family problems videotaped during
the acute depressive period were compared with discussions
taped at symptomatic recovery, discussions between the
depressed patient and a stranger, and discussions between
psychiatrically normal surgical patients and their spouses.

The depressed patient couples were generally more
expressive than were the surgical control couples. This
differenoe was most pronounced for negative expressiveness
in the messages of the depressed men at the acute sympto-
matic stage. At recovery these patients had reduced
negative expressiveness to the same levels as the surgical
controls. The depressed women and their husbands made no
such shift. Their conversations were highly negatively
toned at both the symptomatic and recovery periods. The

depressed patients and their spouses were more formal in

25

their conversational style, given to more "turn taking." In
discussing solutions to problems the depressed patients and
their spouses were more egocentric and less objective than
were the psychiatrically normal couples. The depressed
couples' conversations had a negative uneven flow, often
disrupted by pauses and negative emotional outbursts. In
contrast, the conversations of the surgical couples were
leavened by laughter and other positive tension releasors.
During the acute symptomatic period the depressed patients
attempted to exert greater control by means of interruptions
and direct eye gaze. Yet these deviant patterns of communi-
cation were not apparent in the depressed patients' conver-
sations with strangers. This suggests that the depressed
patient's impaired communication does not necessarily
generalize to all of his/her relationships.

Hautzinger, Linden, and Hoffman (1982) compared the
communication. patterns of two groups of’ couples seeking
marital therapy. In the first group one partner was
diagnosed as depressed; in the second group neither partner
was so diagnosed. The depressed partner couples expressed
more dysphoric mood, talked more about their well being, and
offered each other more help than did the other couples.
The nondepressed spouses of the depressed clients, compared
to both spouses in the second group, expressed fewer nega-
tive and more positive self-evaluations, evaluated their
spouses less positively, seldom agreed with them and offered

them more help. Such help was ambivalent as it was usually

26
accompanied by negative evaluations of the depressed part-
ner. The communication in the distressed couples without a
depressed partner proved to be more positive, reciprocal and
supportive.

A. second. approach to the interpersonal aspects of
clinical depression defines depressive symptoms as inter-
personal behaviors. Bonime (1960) emphasizes that depres-
sion is an active, though manipulative, way of relating to
others. Although the depressed person is often withdrawn
and uncommunicative, s/he nonetheless broadcasts his/her
misery to all around him/her. Depressive symptoms are
messages demanding action (McPartland & Hornstra, 1964).
These are pleas for others to provide support and meaning.
Symptoms are, however, oblique and strident pleas, and thus
usually fail to elicit the desired response. Each failure
only intensifies the depressed person's pleas. His/her
messages become ever more strident, reproachful and
unanswerable. The patient's audience, which may at one time
have been specifiable, becomes increasingly diffuse. Should
this depressive drift continue unchecked, the patient may
abandon all hope of having his/her pleas met and retreat
into a psychotic state (McPartland & Hornstra, 1964).

The depressed patient's uncommunicativeness is itself
a message. The depressed person uses behavior rather than
words to convey his/her meaning (Stuart, 1967). His/her
communication is paradoxical insofar as it is a plea that

denies it is a plea. Because all relationships are defined

27

through communication processes, the depressive's symptom
messages can be construed as attempts at revising his/her
relationships. The essence of the depressive's message is
"you must treat me differently, but, I am not telling you to
do so, because I do not control my depressive behavior"
(Stuart, 1967). The depressed person can dominate his/her
entire social field, yet remain convinced of his/her utter
helplessness.

Because it is an active way of relating to others,
depression both influences and is influenced by its inter-
personal context. Several authors have commented on how the
depressed individual's social environment elicits and rein-
forces his/her symptoms. Operant behavior theorists,
notably Lewinsohn and his colleagues (Lewinsohn, 1974; Libet
& Lewinsohn, 1973) contend that depression is a response to
a low rate of response contingent positive reinforcement. A
real or imagined loss of a significant source of positive
reinforcement can account for both the depressive's low rate
of adaptive behavior and his/her depressive affect. The
sympathy which depressive symptoms normally elicit inevit-
ably reinforces these maladaptive behaviors. Lewinsohn's
group argues that the depressed individual's lack of social
skills is a critical antecedent to his/her loss of social
reinforcers. Libet and Lewinsohn's (1973) study of
depressed college students' participation in small group

discussions revealed that these students addressed

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28
themselves to fewer fellow group members and offered fewer
positive responses to them than did non-depressed students.

Lewinsohn's group has also investigated the role
played by the patient's home environment in the emergence
and maintenance of clinical depression. Lewinsohn and
Shaffer's (1971) home observations of the marital inter-
action of several of their depressed clients revealed that
these clients received more negative and less positive
reinforcement from their spouses than they in turn offered.
In several cases the interaction, whether positive or nega-
tive, between client and spouse was minimal. Liberman and
Raskin (1971) applied a functional analysis of depressive
symptoms to their family-based treatment of depression.
They noted that family members habitually focus their
attention on a patient's dysphoria, guilt, and fatigue, and
overlook the patient's adaptive behaviors. Thus they
advised families to ignore the patient's depressive com-
plaints and attend to and praise all of his/her adaptive,
constructive behaviors. This strategy proved effective in
alleviating depressive symptoms.

Coyne (1976a) presents a sophisticated model of the
interaction between depressed persons and their significant
others. The depressed person engages others, but in such a
way as to lose their support. Depressive symptoms are a
call for help; they demand restoration of a valued source of
reinforcement and reassurance of the depressed person's role

and value in his/her social space. Typically these messages

29

of need, pain and helplessness elicit another's attempt to
answer these demands directly and literally. Yet the
depressed person cannot decide whether the proffered
reassurance is a statement of genuine concern or merely a
response to manipulation. S/he therefore intensifies his/
her complaints and demands for assurances and validations of
his/her worth. This prolonged intensification of symptoms
is both frustrating and guilt inducing for the would-be
helper. S/he may overtly deny his/her anger and resentment
at being imposed on, but s/he is likely to express these
feelings nonverbally. The ambiguity of the helper's
messages reinforces the depressed patient's belief that s/he
is not truly loved and cared about. This belief further
intensifies his/her symptom pleas for love and understand-
ing. Thus emerges a pattern of mutual manipulation in which
each participant denies that the manipulation is in fact
occurring. Eventually, more would-be helpers drop out of
the depressive's social field. As his/her social space
contracts, the depressed patient's pleas grow increasingly
ambiguous and diffuse.

Coyne .(1976b) tested. the hypothesis that. depressed
persons induce hostility and depression in those with whom
they interact and thereby court rejection. In his study,
college women conducted telephone conversations with
depressed clinic clients, nondepressed clinic clients, or
normal women. The students who conversed with the depressed

women subsequently felt more depressed, anxious and hostile,

30
described their conversation partners less favorably, and
expressed less interest in further contact with these women
than did the students who conversed with the other two
groups. These results provide experimental confirmation of
the common clinical observation (Cohen et al., 1954;
Spiegel, 1965) that the depressed client can be a most
trying, irritating, and fatiguing person with whom to
interact. The question which now presents itself is how and
why the depressed person's close friends and relatives con-
tribute to an apparently difficult and unrewarding relation-
ship to the extent that they do. The literature on the
family treatment of depression suggests answers to this

question.
The Depressed Patient and His/Her Family

Several authors (Hogan & Hogan, 1975; Rubinstein &
Timmons, 1978) emphasize that the exaggerated dependency
characteristic of the depressed patient entails a two-person
system and that this dependency relationship is the core
feature of the families of these patients. Hogan and Hogan
(1975) note that these families promote and prolong the
infantile polarity of powerlessness to act directly on the
environment, on the one hand, and omnipotence to get others
to meet all of one's needs, on the other. Powerlessness is
manifest not only in inadequate task performance, but also
in the inability to perceive and express needs and feelings

directly. Infantile omnipotence involves the expectation

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that one will be viewed as special and rewarded without
one's effort, the tendency to uuhimize efforts not crowned
by perfect success, and the belief that mistakes cannot be
corrected. Such dependency entails a two-person relation-
ship in that it includes an omnipotent other who will
spontaneously recognize and meet all of the dependent one's
needs. The omnipotent other is supposed to decipher all of
one's covert and inarticulate requests.

This dependency relationship between mother and infant
is a normal but brief developmental stage. Most mothers and
children progress beyond it as the child acquires those
skills which enable him/her to negotiate the world on his/
her own. Some parents, however, out of their need to be
indispensable, perfect, all-giving, parents, subtly and not
so subtly, discourage and punish the child's self-assertion
and independence. In such families the child learns that to
assert his/her wants and needs and to make his/her own deci-
sions is to impugn his parents' caretaking ability. S/he is
taught that one makes requests of strangers, not of loved
ones, for loved ones are supposed to know one's needs with-
out being told. Consequently, the child learns to devalue
any praise or rewards or affection not offered spontane-
ously. The prohibition against self-assertion also places
severe constraints on the child's experiencing and express-
ing his/her strong feelings, especially his/her anger.
Expression of anger is felt to be quite dangerous because it

belies the belief that others in the family will meet one's

32

needs ‘without. being asked. Anger thereby threatens the
family's symbiotic bonds. Suppression of anger not only
reinforces the child's feelings of powerlessness, but also
instills the belief that. his/her emotions are extremely
destructive forces. The family interaction processes which
discourage autonomy and self-assertion can be discerned in
both the family of origin and the current immediate family
of the depressed patient. This is no accident: in adult
life, men and women often find partners with whom they can
replicate the relationship patterns of their childhood
(Hogan & Hogan, 1975; Jackson, 1957; Rubinstein & Timmons,
1978). That the depressed adult patient maintains the
position of infantile polarity of powerlessness and
omnipotence implies the s/he is abetted by a significant
other who assumes the role of omnipotent parent or rescuer.

This is precisely the observation made by clinicians
(Rubinstein & Tummons, 1978) who argue that every case of
depression involves a depressive dyad consisting of the
patient and his/her caretaker. The caretaker’ may' be a
parent, child, spouse, friend, or therapist, but typically
is the patient's spouse. Partners in such dyads have been
known to exchange roles as well. The underlying dynamic in
the relationship is anger. In cases of severe depression,
the patient is enraged at not having all of his/her needs
met, and the caretaker is enraged by his/her failure to meet
the patient's extreme dependency needs. This anger must be

transformed though, because it threatens the relationship.

33

The patient's anger is transformed into helplessness and
depression; the caretaker's anger is transformed into even
more solicitous care. Rubinstein and Timmons note a
similar dyadic pattern in cases of neurotic depressive
disorders. In these cases the hostility is more overt and
dissatisfactions are verbalized. Some couples are caught in
a continual, though perhaps unconscious, struggle over who
will be the one cared for by the other.

Pathological elements in the marital relationship are
evident even during symptom-free periods. These elements
provide the basis for episodes of depression. Rubinstein
and Timmons (1978) characterize these marriages as disallow-
ing personal growth or autonomy. Neither partner can feel
free as this would threaten the other's security. Each
partner monitors and supervises the other's behavior. The
relationship is over-close and over-warm, but the partners
are unable to share responsibility for problem solving or to
collaborate in professional or leisure interest. In this
sort of relationship, warmth and closeness have become forms
of bribery and coercion.

Feldman (1976) comments similarly on the patient-
rescuer marital pattern in depression. He describes a
circular interaction. pattern. in.*which the husband's and
wife's complementary cognitive structures trigger repetitive
reciprocal stimulation and reinforcement. Operationally,
this means that the nondepressed partner's overprotective-

ness elicits and reinforces the depressed partner's sense of

34

helplessness, inadequacy and resentment. The depressed
partner's symptoms, in turn, elicit and reinforce the
caretaker's overprotectiveness. The nondepressed partner
unwittingly undermines the depressed one's autonomy and
self-esteem. Each partner may resent his/her role in a
relationship which s/he nonetheless needs. The depressed
spouse needs to be cared for and reassured of his/her
wealth; the caretaker needs to be needed. The caretaker may
initially welcome his/her depressed spouse's recovery, but
may also respond negatively to any changes which challenge
the basic marital bargain. Feldman (1976) cites the case of
a husband who was at first delighted by his wife's recovery
from depression, but who grew extremely jealous and resent-
ful of her increasing independence and involvement in her
new job.

The caretaker's need to be needed. may ‘well. be a
transformation of his/her own unmet dependency needs.
Tabachnik's (1961) study of the interpersonal relationships
formed by suicide attemptors (who are likely to be
depressed) found that these typically include a unique
relationship with a single significant other. This signifi-
cant other assumes responsibility for meeting the suicide
attemptor's inordinate dependency needs, even to the point
of being imposed on. Tabachnik speculates that in doing
this the rescuer is covertly and vicariously meeting his/her
own dependency needs, which s/he otherwise must defend

against. The suicide-rescuer relationship is not, however,

 

 

 

35

unambivalent. The suicide attemptor may need to be punished
so as to alleviate his/her guilt over his/her inordinate
needs and his/her rage at not having these met. From either
his/her anger at being imposed on or his/her envy of the
attemptor's dependency, the rescuer may eventually punish
the suicide attemptor. This punishment may assume the form
of criticism, anger, neglect or insensitivity. In short,
this is a highly symbiotic relationship, but one punctuated
by ambivalence.

Forrest (1969) in her long-term intensive treatment of
five cases of severe depression, observed a somewhat differ-
ent pattern of underlying pathology in her patients' mar-
riages. These couples interact so as to perpetuate their
mutual feeling of grief and deprivation. Each partner main-
tains an inordinate .need. for help and. support. and. each
appeals to the other's grandiosity in attempting to persuade
him/her to assume the role of the all-good provider. They
battle constantly for the dependent role. Neither partner
can, of course, meet the other's needs, the caretaker role
notwithstanding. The depressed partner neither trusts nor
values the care and concern his/her spouse does offer as
these were gotten by manipulation. The relationship is, to
say the least, emotionally impoverished. Yet the partners
collude in denying and suppressing their mutual anger and
frustration.

A picture of the depressed patient's marital relation-

ship emerges. This is a tentative composite, which does not

 

 

 

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36
purport to mirror every married patient's relationship with
his/her spouse. This is a marital relationship constrained
by excessive interdependency. This interdependency becomes
most apparent when one partner becomes depressed. His/her
depressive symptoms are covert and overt demands for atten-
tion and care. On an overt level the well partner accepts
responsibility for attending to, caring for and reassuring
the depressed spouse. His/her acceptance of the caretaking
role is a function of the guilt and discomfort depressive
symptoms elicit in others and of the vicarious gratification
and security to be derived from meeting the other's
dependency needs. On a covert, as well as overt, level the
caretaker expresses his/her anger and resentment at being
imposed upon. The depressed partner also harbors anger and
resentment at his/her dependent position. This anger finds
expression in depressive symptoms, as well as in overt
friction. Despite these ambivalences, the relationship is
basically shaped by both husband's and wife's mutual needs
to care and be cared for by each other. Although the rela-
tionship is over-close, it is not necessarily emotionally
rewarding for either partner. Their exchange of affection,
care, and support is limited by the superordinate constraint
of their bargain of mutual dependency. Neither partner's
needs for care and affection can ultimately be met for such
security and satisfaction would liberate the partners from
their symbiotic bond. As a rule, the depressed person and

spouse cope poorly with the disagreements and conflicts.

 

 

AH

.uu

s

a

37
They rarely confront their differences and disappointments
constructively. In cases of severe depression, it appears,
patient and spouse collude in denying their anger and dis-
appointment. In cases of less severe depression, the
marital partners expend their energy in bitter arguments
which probably focus on issues irrelevant to their real
conflict. The communication process in these marriages is
impaired. These couples do not express and explore their
wants, needs, and feelings; rather they expect each other to
know these without being told. These relationship patterns
are most pronounced during periods of one partner's depres-
sion, but are also discernible during symptom-free periods

as well.

Hypotheses

The hypotheses tested in this study are extrapolations
from a diverse, and not wholly consistent, body of case
study and research literature on the interpersonal, and
specifically marital, relationships of depressed persons.
The basic hypothesis, of this study, which can be tested
only indirectly, is that clinical depression serves a
homeostatic function in the .marital relationship of the
depressed psychotherapy client. What can be demonstrated
directly is that the interaction patterns of depressed
persons and their husbands and wives are congruent with,
that is, these promote and reinforce, depressive sympto-

lnatology. The following’ hypotheses predict reliable

38
differences between depressed client couples and psychi-
atrically normal couples and between depressed client
couples and couples in which one partner presents neurotic
or personality problems other than primary depression.

The central hypothesis is:

Hypothesis 1: The marital relationship of depressed clients
is marked by a higher degree of interdepen-
dence than that of either psychiatrically
normal adults or other psychotherapy clients.
a. Depressed clients and their spouses

relate to each other as autonomous adults
less than do normal husbands and wives
and other psychotherapy clients and their
spouses.

b. Depressed clients and their spouses
manifest more dominance, control, submis-
sion and deference than do normal
husbands and. wives, and other psycho-

therapy clients and their spouses.

The depressed client's relationship is not, however,
unambivalent, in that both partners, and especially the
"well" spouse, periodically' withdraw' in. anger from. this
over-close relationship. Consequently, the second

hypothesis is:

Hypothesis 2: Depressed clients and their spouses invoke

+>

.n-

 

" 1
(N
' 1

39
and assume hostile autonomy more often than
do psychiatrically normal husbands and wives
and other psychotherapy clients and their

spouses.

The third hypothesis pertains to affect exchange in

the marriage.

Hypothesis 3: The marital relationship of the depressed
client is less emotionally rewarding for
partners than is that of psychiatrically
normal adults and of other psychotherapy

clients.

The assumption here is that an emotionally rewarding rela-
tionship is characterized by a predominance of affection

over hostility. Thus:

a. Depressed clients and their spouses
express less affection and exchange fewer
verbal and non-verbal loving' behaviors
than do normal husbands and wives, and
other psychotherapy clients and their

spouses.

The relationship of the depressed client and his/her
partner is marked by a greater degree of hostility than are
the relationships of normal couples, and of other patients

and their partners. However, the relationship between

 

'l"

.-h

’5

 

RP. ‘1 4 .1‘

‘3‘

.c
PH.

40
depression and overt expression of hostility is problematic.
While Paykel and Weissman's (1974) study disclosed an
abnormal. amount. of friction. between. depressed. women and
their husbands, Forrest (1969) reports that severely
depressed patients and their partners collude in denying
their mutual hostility. Most of the women in Weissman and
Paykel's study were diagnosed as neurotically depressed.
This suggests that hostility expression varies with
intensity of the depression. It may be that the relation-
ship is an inverted U. Couples in which one partner is
mildly to moderately depressed experience more overt
hostility than do normal couples. Couples in which one
partner is severely depressed collude in suppressing any
expression of anger. As this study focuses on outpatients
whose depressions are in the mild to moderate range, the

following hypothesis is proposed:

b. Depressed clients and their spouses
express more overt hostility and friction
than do either normal husbands and wives
or other psychotherapy clients and their

spouses.

The fourth. hypothesis dovetails ‘with. the ;preceding

ones .

Hypothesis 4: The communication processes of depressed

client couples are more impaired than those

41
of normal couples and nondepressed client

couples.

Depressive symptoms are a form of indirect and
ambiguous communication, and as such are congruent with the
generally impaired communication between depressed men and
women and their spouses. Indeed, symptom complaints may be
the only channel left open in a communication system in
which neither partner can either acknowledge or accurately
interpret changing needs and stressors in their' marital
relationship.

These hypotheses have been tested only with respect to
the patient's marital relationship during a three-month
period which includes the early stage of the depressive
episode. Such limited data can neither specify which comes
first, the abnormal interaction patterns or the depressive
symptoms, nor demonstrate a causal relationship between
these two phenomena.

All that confirmation of these hypotheses can estab-
lish is the co-occurrence of depressive symptomatology with
certain abnormal features of marital interaction which are
proposed as) congruent with the symptoms themselves. Yet
this evidence can be construed as preliminary systematic
support for a family-systems conceptualization of depres-

sion.

CHAPTER 2

METHODS

Subjects

The 48 men and women who were selected for inclusion
in this study were married (or in one instance stably
cohabiting) residents of downstate Illinois. At the time of
their participation all were living with their spouses and
only one had been separated from his spouse for longer than
a week during the past three months. The participants were
all Caucasian, aged 20 to 62. Thirty-eight participants
were women; ten were men. Forty reported a religious
affiliation: 27 with a Protestant denomination, 11 with the
Roman Catholic Church, and one each with the Mormon and
Seventh Day Adventist Churches.

The 48 participants were comprised of three groups of
16. The target group of interest consisted of 16 depressed
outpatients. This group, to be referred to as the Depressed
Clients group, was compared with two control groups--the
Nondepressed Clients and the Psychiatrically Nermal Group.
The 32 volunteers in the two clinical groups were clients
either of one of eight community mental health or counseling
centers or of one of two registered psychologists in private

practice in Charleston, Illinois. The 16 normal controls

42

43
were recruited from the general adult population of Coles

and Edgar Counties, Illinois.

Client Participants

The 32 client participants were selected from a pool
of 50 clients who had given their therapists permission to
refer them to the principal investigator. Table 1 presents
the nine referral sources and the number of included par-
ticipants each referred to the study. With the exception of
Decatur Mental Health Center, these agencies serve rural and
small town communities. Decatur Mental Health Center serves
a more urban, industrialized county of 250,000. Eighteen
client volunteers were ultimately dropped from the study
because they failed to meet the inclusion criteria for
either the Depressed Clients or Nondepressed Clients groups.

At the .beginning' of data collection. the principal
investigator had stipulated that a client would be included
in the study only if his or her wife or husband participated
as well. This requirement soon proved to be a major
obstacle to conducting the study. Too often the spouse (and
usually this was the husband) was either unwilling or unable
to attend interview and questionnaire sessions. The
spouse's participation was then made optional. Fifteen
spouses participated in the study, almost all of whom either
were or had been in conjoint therapy or were in some way
actively cooperating with the identified patient's treat-

ment. The data collected from these spouses had not,

 

 

to
(D
D 9‘

44
Table 1

Referral Sources of Client Participants

 

 

Source Number

Decatur Mental Health Center, 12
Decatur, Illinois

Coles County Mental Health Center, 6
Mattoon, Illinois

Psychologists in Private Practice, 4
Charleston, Illinois

‘Vermillion.County Mental Health Center, 3
Danville, Illinois

Human Resources Center, 2
Paris, Illinois

‘V.A~ Medical Center, Mental Health Clinic 2
Danville, Illinois

Counseling Center, Lakeland College 1
Mattoon, Illinois

.Eastern Illinois university Counseling 1
Center, Charleston, Illinois

Franklin-Williamson County Family 1

Counseling and Mental Health Services,
Herrin, Illinois

 

a:
in

45

however, been included in the findings of this study because
a statistical comparison of the two groups of spouse par-
ticipants was not warranted.- The samples of the Depressed
Clients and Nondepressed Clients spouses were too small and
too dissimilar to be subjected to such analysis. Only five
spouses in the Depressed Clients group participated in the
study and they could not be matched to the ten other spouse
participants on the relevant social and economic background
variables.

Each client participant included in the study was
assessed as belonging in one of two diagnostic groups.
Sixteen outpatients in the Depressed Clients group had
received a diagnosis of primary unipolar depression. The
Nondepressed Clients group consisted of 16 outpatients who
had received a diagnosis other than primary depression or

alcoholism. The inclusion criteria for each group are

outlined below .

Inclusion Criteria for the Depressed

Client Group

A participant is to be included in the Depressed
Client group if and only if s/he meets criteria 1 through 3:
1. Receives a diagnosis of primary unipolar depres-
sion according to the following criteria (A and

B):
A. A diagnosis of primary unipolar depression

agreed on by the client's therapist and the

 

46

principal investigator. Diagnostic guidelines

follow 'Diagnostic Criteria for Use in Psychi-

atric Research' (Woodruff, Goodwin & Guze,

1974, pp. 199-209). For a diagnosis of

depression, 1 through 4 are required.

1. Dysphoric mood characterized by symptoms
such as the following: depressed, sad,
blue, despondent, hopeless, "down in the
dumps,” irritable, fearful, worried, or
discouraged.

2. At least five of the following are
required for "definite" depression; four
are required for ”probable” depression.
(1) Poor appetite or weight loss (positive
if two pounds a week or ten pounds or more
a year when not dieting.) (2) Sleep dif-
ficulty (including insomnia or hyper-
somnia). (3) Loss of energy, e.g.,
fatigability, tiredness. (4) Agitation or
retardation. (5) Loss of interest in
usual activities, or decrease in sexual
drive. (6) Feelings of self-reproach or
guilt (either may be delusional). (7)
Complaints of or actually diminished
ability to think or concentrate, such as

slow thinking or maxed-up thoughts. (8)

 

47

Recurrent thoughts of death or suicide,
including thoughts of wishing to be dead.

3. A psychiatric illness lasting at least one
month with no pre-existing psychiatric
conditions such as schizophrenia, anxiety
neurosis, phobic neurosis, obsessive
compulsive neurosis, hysteria, alcoholism,
drug dependency, antisocial personality,
homosexuality and other sexual deviations,
mental retardation, or organic brain
syndrome. (Patients with life-threatening
or incapacitating medical illness preced-
ing and paralleling the depression do not
receive the diagnosis of primary depres-
sion.)

4. No evidence of prior manic episodes.

B. Scores 18 or higher on the Beck Depression
Inventory (Beck, 1972). This score was chosen
as it was the mean for a group of inpatients
and outpatients who were diagnosed as udldly
depressed (Beck, 1972, p. 196).

2. Has not received electroshock therapy during the
past six months.

3. Is not actively psychotic.

Two amendments were :made in requirement. 3 of the

"Diagnostic Criteria for Use in Psychiatric Research."

48
First, depressive symptoms need be present for only three
weeks. Secondly, depressive symptoms need only predominate
over rather than antedate other psychiatric symptoms (except
for the case of schizophrenia). The rationale for this
second amendment is that it was often impossible to ascer-
tain whether and which other symptoms antedated a client's
depression. A client's own recollection of the development
of his/her emotional difficulties was often incomplete and
vague. Also a diagnosis of ”probable depression" would
suffice for a client's inclusion in the Depressed Clients

group.

Inclusion Criteria for the Nondepressed

 

Clients Group

 

A participant is to be included in the Nondepressed
Client group if and only if s/he meets criteria 1 through 6:
1. Receives one of the following diagnoses as agreed
upon by the client's therapist and the principal
investigator: anxiety disorder-panic; generalized
anxiety disorder, phobic disorder, obsessive-
compulsive disorder, dissociative disorder,
psychosexual disorder, personality disorder,
borderline personality organization, schizophrenia

in remission, adjustment disorder.
2. Does not receive one of the following diagnoses:

primary unipolar depression, bipolar depression,

49
alcoholism or alcohol abuse, organic brain syn-
drome, mental retardation.

3. Is not in treatment for a life-threatening ill-
ness.

4. Has not received electroshock therapy in the past
six months.

5. Is not actively psychotic.

6. Score$13 or below on the Beck Depression Inven-
tory. This cut-off score was chosen because it
would ensure that any client in this group would
report at least two fewer depressive symptoms than

any participant in the Depressed Clients group.

In practice, diagnostic decisions were made by the
principal investigator with the assistance of the referring
clinician. The principal investigator had originally
expected the referring therapist to provide a precise
diagnosis for each client. This expectation proved overly
ambitious. In many instances the referring clinician
provided useful, and on occasion detailed, information about
his client's problems, but bypassed a formal diagnosis
according to the criteria provided. There appear to have
been two reasons for this. First, the referring therapist
often forgot to refer to the specific diagnostic criteria
for the study, and relied instead on his/her own definitions
of depression, anxiety disorders, personality disorders,

etc. It is worth noting that clinical experience and

50

sophistication of training varied considerably among
referring clinicians. Secondly, several clients presented
symptom pictures sufficiently mixed as to make differential
diagnoses rather difficult. In all but three cases the
principal investigator's decision accorded with the
referring therapist's diagnostic impressions. In these
instances the referring clinician's diagnostic information
was so limited and imprecise as to allow the principal
investigator no choice other than to rely on her interview
data in formulating a diagnosis. When the principal
investigator had interviewed 40 client volunteers she
reviewed their case histories, interview data and Beck
Depression Inventory scores with her dissertation advisor,
an experienced clinical psychologist. Together they decided
which diagnostically dubious cases were to be excluded from
the data analysis. Following this review the principal
investigator interviewed additional client volunteers.

Tables 2 and 3 present brief descriptions of each
participant in the Depressed Clients and Nondepressed
Clients groups, respectively. As can be inferred from these
tables, the two groups are differentiable, but not wholly
dissimilar. The clinical pictures of the Depressed Clients,
although dominated by more numerous and more severe depres-
sive symptoms, also included a range of other symptoms.
One-third of these clients reported phobic, obsessive or

psychosomatic symptoms. Two women in this group appeared

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S6
sufficiently disturbed to warrant the additional diagnosis
of Borderline Personality organization (see Kernberg, 1975).

The Nondepressed Clients generally presented more
diffuse clinical pictures. Few of these clients obviously
fit other "textbook" descriptions of other psychiatric
disorders. Rather, 11 of these participants were assessed
as presenting the sort of mixed symptomatology associated
with the diagnoses of adjustment reaction or personality
disorder. These were the sort of clients many therapists
refer to as "garden variety neurotics." Nine of the Non-
depressed Clients reported current or prior difficulty with
depressive mood or symptoms. Yet, as can be seen from Table
4, the mean Beck Depression Inventory score of 6.50 of the
Nondepressed Clients is significantly lower than the mean
score of 28.06 of the Depressed Clients.

The treatment histories of the two clinical groups
were fairly similar. All but two participants from each
group had been in counseling for six months or less at the
time of their participation. The length of treatment of the
Depressed Clients ranged from 3 to 150 weeks, with a median
of 10 weeks and a mean of 21.37 weeks. The length of treat-
ment of the Nondepressed Clients ranged from 3 to 68 weeks,
with a median of 16 weeks and a mean of 19.68 weeks. The
difference between means is not statistically significant
(F = .026, p = .86, df = 31). Eleven of the Depressed
Clients and 12 of the Nondepressed Clients had received

professional help for emotional or psychiatric difficulties

Table 4

57

Comparison of Groups on the Beck Depression Inventory

 

Group

Mean BDI

Range SD

 

Depressed Clients

Nondepressed Clients

Normals

16
16

16

19-40 6.10
0-13 4.60

 

t-test Comparisons (separate variance estimate)

 

 

Comparison E value df .E probability
Depressed Clients 15.08 19 .000

vs. Normals
Depressed Clients

vs. Nondepressed 11.28 28 .000

Clients

 

58
prior to their current treatment. Three from the former
group and seven from. the latter had at some time Ibeen
hospitalized for psychiatric reasons. In only one instance,
however, (Nondepressed Client #10) had this hospitalization
been a part of a client's current treatment. Eleven of the
depressed and four of the nondepressed clients were cur-
rently taking antidepressants or minor tranquilizers. None
of the client participants reported having ever received

electro-convulsive therapy.

Psyphiatrically Normal Participants

Sixteen psychiatrically normal adults were selected
from a pool‘of 26 volunteers who had been recruited from the
general population of Coles and Edgar Counties, Illinois.
The 26 volunteers were recruited from a variety of sources
including educational institutions, civic organizations, a
newspaper advertisement and referrals from acquaintances of
the principal investigator. Table 5 presents the referral
sources of the included participants. Fourteen volunteers
had never met the principal investigator prior to their
participation and two volunteers could be described as
"passing acquaintances" of the principal investigator. Ten
volunteers were dropped from the study either because they
failed to meet the inclusion criteria or because no suitable

match could be found for them in the client groups.

Table 5

59

Referral Sources of Psychiatrically Normal Participants

 

 

 

 

 

 

Source Number

Newspaper Advertisement in the 4
Charleston Times Courier

Referrals from acquaintances of 4
the principal investigator

Eastern Illinois University, 3
Charleston, Illinois

Mattoon Area Adult Education Center, 2
Mattoon, Illinois

Lakeland College, Mattoon, Illinois 1

Physician's Office, Charleston, Illinois 1

Inclusion Criteria for Psychiatrically
Normal Participants
The inclusion criteria for the Psychiatrically Normal

group (to

be referred to as "Normals") are outlined below.

A volunteer is to be included in the Psychiatrically

Normal group if and only if he/she meets criteria 1 through

5

Is between 20 and 60 years of age.

Reports none of the following problems during the
past two years: severe prolonged anxiety symptoms,
depression of clinical intensity, alcoholism or
problem drinking, serious marital or sexual

problems, hospitalization for psychiatric reasons.

60
3. Has not been hospitalized for psychiatric reasons
since the age of 21.
4. Scores below 10 on the Beck Depression Inventory.
5. Has not been separated from his/her spouse for
frequent or extended periods during the past 3

months.

Although the principal investigator had specified that
she was seeking persons who had 922 experienced emotional
difficulties or psychiatric symptoms during the past two
years, several volunteers apparently overlooked or dis-
counted this. Six volunteers were excluded because they
either reported pronounced anxiety or depressive symptoms or
scored over 10 on the Beck Depression Inventory.

The 16 volunteers included in this normal control
group appear to have been psychologically healthy. None
reported either any history of psychiatric hospitalization
or any outpatient treatment during the past two years. One
volunteer (#15) said she had contemplated seeking marital
therapy but had decided this was not necessary. Another
woman (#2) reported occasional difficulties with tension and
anxiety headaches, but not so severe as to warrant profes-
sional help. None of the Normal participants reported
taking antidepressants or tranquilizers. These volunteers'
Beck Depression Inventory scores ranged from 0 to 8, with a

mean of 3.5 (see Table 4).

61

Matching Participant Groups

 

The three groups were matched on sex distribution,
age, length of marriage, and social class. Because each
participant reported on his/her spouses', as well as his/her
own, behavior and emotions, the groups were matched in terms
of the age and social status of the couple rather than of
the individual participant. A couple's age was defined as
the average age of the husband and wife. A couple's social
class was determined by the husband's occupation and educa-
tion, in accordance with the Two Factor Index of Social
Position (Hollingshead, 1965). The criteria for matching

couples are outlined below:

Criteria for Matching Couples

 

Two couples will be defined as matched if and only if:

1. The average ages of both couples fall within ten
years of each other (average age = husband's age +
wife's age /2).

2. The lengths of the two marriages fall within the
same range: a) under 2 years; b) 2-7 years; c) 8-
15 years; d) 16-25 years; and e) over 25 years.

3. The couples differ by no more than one class level
on the Hollingshead Two Factor Index of Social
Position. The Two Factor Index utilizes occupa-
tion and education to determine an individual and

his/her family's social standing in the community

62
(Hollingshead, 1965). This index demarcates five
social classes. Class I is composed of the
families of the business and professional elite,
that is, of the bank presidents, physicians,
lawyers, judges, and executives of large busi-
nesses in the community. Heads of Class I
households are college and professional school
graduates. Families in Class I are usually afflu-
ent and often enjoy the privileges associated with
inherited wealth. Class II is composed of house-
holds headed by lower ranking professionals and
business managers; that is, by personnel managers,
office managers, minor government officials,
librarians, teachers, pharmacists, and owners of
medium-sized businesses. Usually the heads of
Class II families have acquired some university
level education. These families typically are
prosperous and upwardly mobile. Class III
families are probably what many politicians have
in mind when referring to "average, middle-income
families.” The heads of Class III households
include administrative personnel, small business-
men and minor professionals such as insurance
agents, shop managers, credit and service man-
agers, owners of bakeries or groceries, roofing or
painting contractors, commercial artists and

travel agents. They have probably completed high

63

school and may have acquired some post-secondary
education as well. Class IV families are often
referred to as "blue collar," "working class.”
Heads of Class IV households are clerical workers,
and skilled and semi-skilled workers such as bank
tellers, bill collectors, electricians, welders,
machinists, roofers, taxi-drivers and foundry
workers. Typically they have received, at most, a
high school education. Families in Class V on the
Two Factor Index belong to what some social
scientists might call the ”working poor" or the
”socially marginal." These households are headed
by men and women whose jobs, if they are employed,
require little skill or education. They work as
janitors, domestics, construction laborers or
dishwashers. They are unlikely to have graduated
from high school (Hollingshead & Redlich, 1958,
pp. 84-135).

Because the Depressed Clients group was the one of
interest in this study, couples from the Nondepressed
Clients and Normals groups were matched to them. Table 6
presents the matched sets of couples and the sex of partici-
pant, age, length of marriage, and social class of each
couple. The actual matching of couples met the criteria
reasonably’ well. The 'within group sex distribution *was

equivalent across groups as well. Three participants in the

c 0 ~ 3 sub

64

 

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65

Depressed Clients and Normals groups each were men; four
participants in the Nondepressed Clients were men. This low
percentage of men in the Depressed sample is consistent with
the well established finding that women outnumber men by a
ratio of at least two to one in seeking treatment (Lehman,
1970; Weissman & Klerman, 1977; Woodruff, Goodwin & Guze,
1974).

A statistical comparison of the groups also demon-
strated that they were equivalent on the age, length of
marriage and social status variables. Table 7 presents the
mean, standard deviation and range, as well as the F ratios
and their probabilities for the comparison of groups on each
background variable. The couples were, on the average, 34
years old, married for 9 to 11 years, and in either Class

III or IV on the Two Factor Index.

Procedure

 

Briefing Clinicians and Establishing

Diagnostic Agreement

Prior to data collection, the principal investigator
met with the staff of the cooperating mental health centers
and with the two psychologists in private practice in order
to establish rapport and to familiarize these people with
the research project. The agenda for these meetings was
two-fold: to acquaint the clinicians with the design and

purpose of the study, and with its procedures and

66

 

 

 

 

 

 

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67
questionnaire materials and to instruct them in the applica-
tion of the diagnostic inclusion criteria for the two client
groups. Scheduling constraints limited these briefing
sessions to one to one and a half hours.

The principal investigator explained that the aim of
the study was to examine the marital relationships of out-
patients who fit a diagnosis of primary unipolar depression
and to compare these relationships to those of outpatients
who received some other diagnosis. Consequently, the
investigator was seeking only currently married clients as
volunteers. Copies of a handout entitled "Target Groups"
(see Appendix A), which specified the inclusion criteria for
the two client groups were given to each referring
clinician. The principal investigator asked clinicians to
periodically review their caseloads and invite any of their
clients who fit the inclusion criteria to participate in
this study. While the investigator asked that the thera-
pists refer as many clients as possible, as early in their
treatment as possible, she assured these therapists that
she, of course, left the decision on the suitability and
timing’ of any' client's participation to the therapist's
discretion.

This interview and questionnaire study, it was
explained, had been designed to be as nonthreatening and
even potentially useful and informative as possible to both
the participants and their therapists. Participation would

require about two hours of a client's time, for which s/he

68

would receive a $5.00 "Thank you" payment as well as feed-
back information. Another handout entitled "Guidelines for
Briefing Client Participants" (see Appendix B) detailed the
salient information about the principal investigator and the
study to be mentioned in recruiting any client's participa-
tion. The cooperating clinicians were urged to refer to
this handout when recruiting clients.

In order to minimize her demands on frequently over-
worked clinicians, the principal investigator asked only
that they brief their clients on the nature and requirements
of the study and then secure an interested client's permis-
sion to give his/her name and telephone number to the
principal investigator. She would assume full responsibil-
ity for scheduling appointments with the client. Moreover,
the principal investigator would take the initiative and
periodically telephone therapists to inquire about client
referrals.

Cooperating therapists were assured that the principal
investigator would in no way intervene in a client's treat-
ment program. She would be pleased, however, to provide
diagnostic impressions and questionnaire feedback which a
therapist might find helpful and/or interesting. An inter-
pretive summary of each client's questionnaire responses
could be provided to either the client and/or his therapist,
at the therapist's discretion. Upon meeting with a client
the principal investigator would ascertain his/her verbal,

though not written, consent to discuss interview and

69
questionnaire data with the referring clinician. The
principal investigator also jprovided. the clinicians ‘with
copies of the questionnaires their clients would be asked to
complete and commented briefly on the purpose and merits of
each.

The second task of these briefing sessions was to
establish inter-rater agreement in diagnosing primary uni-
polar depression. This proved to be difficult, as there was
seldom enough time to reconcile all differences between the
principal investigator's diagnostic criteria and a staff
member's often informal, and occasionally idiosyncratic,
definitions of depression, anxiety neuroses, personality
disorders, etc. The principal investigator was able, how-
ever, to discuss in detail the research criteria for a
differential diagnosis of primary depression and to point
out that this was a more stringent definition than might
commonly be used by clinicians. In addition, cooperating
clinicians were given c0pies of "Diagnosing Primary Unipolar
Depression" (see Appendix C), which details the criteria for
diagnosis according to guidelines provided by Woodruff,
Goodwin and Guze (1974). Where time permitted, staff
members were also asked to apply the criteria to several
case histories drawn from textbooks and the research
literature on depression (see Appendix D) and to discuss
their diagnostic decisions with the principal investigator.
These information discussions were intended to clarify mis-

understandings, as well as to point out difficulties in

70
applying the criteria, rather than to arrive at a precise

measure of inter-rater reliability.

Contacting, Interviewing and Testing

Client Participants

The principal investigator periodically telephoned
cooperating therapists in search. of referrals. In. most
instances the clinician provided diagnostic information in
making the referral. Upon securing an interested client's
name and telephone number, the principal investigator tele-
phoned him/her to introduce herself and to schedule
interview and questionnaire sessions. In order to insure
the client's informed consent, the investigator first
explained in detail what would be asked of each participant
and what would be offered him/her in return. She explained
that the aim of the interview she would conduct was strictly
to understand the nature of a participant's problems rather
than to intervene in the client's treatment. Participants
were also assured that all information they provided would
be held in strictest confidence. The interview and ques-
tionnaire session(s) would be scheduled at the participant's
(and in half the cases, the spouse's) convenience. Seven-
teen clients were interviewed at the referring agency, 13 at
the client's home, one at the client's business office, and
one at the principal investigator's home.

Interview appointments began with the principal

investigator's reading the following orientation protocol.

71

Orientation Protocol

 

Hello, I'm Paula McNitt, and as you know I am conduct-

ing a research study on marital relationships. Before we

begin, we need to review what the study involves, and what

your rights are as a participant.

1.

If Participant is a Client or Spouse

First I'll be asking you about yourself and the
problems you have been experiencing lately. My purpose
here is solely to get clear on why you have requested

help here at the Mental Health Center.

 

I'm not here to do therapy--that's your counselor's job.
This interview should last from one-half to one hour, at
most.
For all Participants

You'll (also) be asked to complete several question—
naires. One questionnaire asks for some simple back-
ground information about yourself, your job, your
schooling, etc. Another questionnaire asks about how
you are feeling right now. The others ask about your
relationship with your husband/wife during the last
three months. These questions are straightforward;
there's nothing sneaky about them. There are no right
or wrong answers, so please answer them as honestly as
you can. In all there are 300 questions of the
”multiple choice” type. These take about one hour to

complete.

72
Please understand that all your answers will be kept
strictly confidential. No one will be told about these
unless you give me permission, in writing, to inform a

particular person. If for any reason you wish to with-

 

draw from this project, you may do so--that is your
right.

When you (and your spouse) have completed the ques-
tionnaires, you will be paid $5.00 for your participa-
tion. This is my small way of saying "Thank you." In
addition, if you request, I will be glad to schedule a
"feedback session" with you in which we can summarize
and review your answers. This can be held in about four
weeks.

Eventually I can provide a summary of the findings
of the entire study.

Do you have any questions?

Before we proceed, I need your signature on this

consent form.

Following this, each participant was asked to sign the
"Departmental Research Consent Form" of Michigan State
University's Department of Psychology (see Appendix E). The
several participants referred from the Mental Health Clinic
of' the ‘Veterans .Administration. Medical. Center, Danville,
Illinois, were asked to sign an additional consent form

which met that agency's specifications (see Appendix F).

73

The assessment interview which followed was a semi-
structured one in which the investigator queried the client
about his/her current and recent emotional state, probed for
symptoms of depression and. anxiety disorders, and. asked
about. his/her treatment. history' and. reasons for seeking
professional help. The "Guidelines for Interviewing
Clients" presented in Appendix G indicate the directions in
which interviewer guided the client. After the client
finished his/her story, so to speak, the principal investi-
gator initiated a more structured series of questions by
which she checked for current or past symptoms and problems
not already mentioned by the client and ascertained the
details of his/her treatment history. This line of ques-
tioning, which she called the "Laundry List of Problems,"
followed the checklist of the Summary of Diagnostic Data,
samples from which are presented below. The complete format

is in Appendix H.

(Are any of these a problem for you now or have

they been in the past?)

I. Depressive Symptoms-~Current
A. Dysphoric Mood
depressed, sad, blue, hopeless, discouraged,
irritable, fearful, worried, cried a lot
II. C. Drug Dependency (include all street or prescrip-

tion drugs)

74
current Yes No
past Yes No

IV. C. Kinds of Treatment Received

individual therapy family
group therapy medical/somatic
marital

In many instances the principal investigator subse-
quently consulted with a client's therapist to clarify
vague or missing information and to exchange additional
diagnostic impressions. During the interview the principal
investigator took extensive notes and completed the Summary
of Diagnostic Data.

When a client's spouse participated as well, a con-
joint interviewr was conducted. In. these interviews the
partners typically alternated in reporting on his/her own
problems and the partner's problems, as well as on other
shared difficulties. The interviewer also queried each
partner individually on his/her symptoms and treatment
history, as specified by the Summary of Diagnostic Data.

At the conclusion. of the interview, if scheduling
permitted, the participant was given a packet of question-
naires to complete. In 23 of 32 cases both the interview
and questionnaires were completed in the course of one
meeting. An additional appointment had to be scheduled for
nine clients, usually within a week of the interview

session. The questionnaire packet contained an instruction

75

sheet and copies of the General Information Sheet (prepared
by the author, (see Appendix I)), the Beck Depression
Inventory (see Appendix J), the Marital Communication
Inventory (see Appendix K), the Love Scale (see Appendix L)
and Series A and B of the Structural Analysis of Social
Behavior (see Appendix M).

The principal investigator read through the following

instruction sheet with each client participant.

Instructions for Participants (A)

This packet contains several questionnaires. One
questionnaire asks for general information about your age,
education, occupation, marital history. Three question-
naires ask about your relationship with your husband/wife
during the past three months. There are a lot of questions,
so you certainly should spend no longer than a moment on
each one! The best answer is probably the one that comes to
mind first. It is most important that you answer the ques-
tions as honestly as you can. Please try to answer all of
the questions, but if you can provide no reasonable or
sensible answer for one, omit it. I am interested in what
m have to say about your marriage, not in what your
husband or wife, mother-in-law, daughter, or your best
friend thinks you should say. A few of the questions are
about things most of us consider to be private. Please
don't worry about this. Be assured that your answers will

be kept in strictest confidence. Neither I nor your

76
counselor will discuss your answers with anyone unless you

request, in writing, that we do so.

 

Thank you very much for your participation.

Paul C. McNitt, M.A.

She reviewed the format. of each. questionnaire and
explained how to use the separate answer form. for the
Structural Analysis of Social Behavior. Clients were
advised that they might complete the questionnaires in any
order they preferred. The principal investigator remained
with the participants while they worked on the question-
naires in order to answer questions and to discourage con-
sultations between husbands and wives who were completing
these questionnaires at the same time. Whenever a client
asked about the meaning or intent of an item, the author
suggested that s/he answer in accordance to his/his own
interpretation.

After the participant had completed the packet, the
principal investigator asked whether s/he had any concerns
or questions about the questionnaire items. She then
thanked the client for his/her participation and gave him/
her a handwritten thank-you note which contained the $5.00
payment. She also advised clients that individualized feed-
back would be available to him/her and/or his/her therapist
in about a month, and offered to mail the client a summary

of the findings when they became available.

77
Recruiting and Testing Psychiatrically

Normal Participants

The volunteers forming the psychiatrically normal
group were recruited from several sources. Several were
recruited from one of three educational institutions, from
the clientele of a large medical family practice in
Charleston, Illinois, and from civic organizations in Coles
County, Illinois. In these cases, recruiting involved
either publically posting or reading aloud an announcement
which stated that the principal investigator was seeking
married persons aged 20 to 60 who had not experienced
psychiatric or pronounced emotional difficulties during the
past two years who would be willing to complete question-
naires about their marriage in return for a $5.00 "Thank you
payment." Appendix L provides a sample recruitment
protocol. Interested. persons ‘were asked to leave their
names and telephone numbers on a sign-up sheet: the prin-
cipal investigator would contact them. Volunteers who had
been referred to the principal investigator by her
acquaintances had been given this same information somewhat
more informally.

During the course of data collection it became appar-
ent that the "normal" volunteers were noticeably older and
better educated and more affluent than the client partici-
pants. In order to attract younger persons who might find a

$5.00 payment an incentive to volunteer the principal placed

78
the following advertisement in the Charleston (IL) _T_i_r_n_<-2_s_
Courier, twice a week for two weeks:

Local psychologist seeks young married persons

to complete several questionnaires. Will pay

$5.00. For more information please call 345-

5039.

This advertisement proved quite effective in attracting
precisely the sort of young, lower income couples the
principal investigator was seeking.

During the first telephone contact with a potential
participant the principal investigator introduced herself
and explained that her study was investigating the marriages
of people who had been in "good mental health" during the
past two years. In order to allay any volunteer's doubt or
fears about the integrity of the principal investigator and
her project, she explained that the study was being con-
ducted in fulfillment of one of the requirements for the
Ph.D. degree in Psychology from Michigan State University.
Two faculty committees at that institution had approved the
study as reasonable and "safe for human beings" (investiga-
tor's words). The principal investigator reviewed what
would be asked of participants and what would be offered
them in return. Appointments were scheduled at the volun-
teer's convenience. These questionnaire sessions were held
at either the volunteer's home or a meeting room at Eastern

Illinois University, Lakeland College or the Mattoon Area

79

Adult Education Center. Five spouses of the 16 Normals
volunteers included in the study participated as well.

Questionnaire sessions began with the principal
investigator's reading the relevant section of the "Orienta-
tion Protocol” (see previous section) and securing the
participant's signature on the "Department Research Consent
Form." She next gave each participant a questionnaire
packet and asked that s/he read the following instruction

sheet along with her.

Instructions for Participants (B)

This packet contains six questionnaires. One asks for
some general information about you; a second asks about
specific problems you may have experienced during the past
two years; the third asks about how you are feeling right
now. The remaining three questionnaires ask you your rela-

tionship with your husband/wife during the past three

 

months. There are a lot of questions, so you certainly
should spend no longer than a moment on each one! The best
answer is probably the one that comes to mind first. It is
most important that you answer the questions as honestly as
you can. Please try to answer all of the questions, but if
you can provide no reasonable or sensible answer for one,
omit it. I am interested in what ygg have to say about your
marriage, not what your husband or wife, mother-in-law,
daughter, or best friend thinks you should say. A few of

the questions ask about things most of us consider to be

80
private. Please don't worry about this! Be assured that
all of your answers will be kept in strictest confidence.
Then, too, I am most interested in how the participants a§_a
gggnp answer these questions, so I will not be paying atten-
tion to how any one person answers any one question.

Thank you very much for your participation.
Paula C. McNitt, M.A.

The questionnaire packet given these participants
differed from that given the client participants only in
that the former included an additional sheet entitled
”Survey of Problems" (see .Appendix 0). This checklist,
prepared by the author, queried participants about current
or recent symptoms, emotional and relationship problems.

The principal investigator proctored these question-
naire sessions for the same reasons and in the same manner
as she did sessions with the client participants. Upon
completing the questionnaires each participant was asked
about any concerns or questions s/he had about the study,
thanked, given a handwritten "thank you" note containing the
$5.00 payment and offered both individualized feedback as

well as a summary of findings to be prepared later.

Feedback

In most instances the interpretive summary of a client
participant's questionnaire responses was forwarded to the

client's therapist, rather than to the client him/herself.

 

81

Such an arrangement. was usually the therapist's choice.
Three client participants attended feedback sessions with
the principal investigator and one received a written feed-
back summary as she requested. Those few of the normal
participants who requested individualized feedback, received
it in meetings with the principal investigator. A written
summary of the findings will be sent shortly to all cooper-
ating agencies and to those participants who requested such
information.

The following flow-chart summarizes the procedures the
principal investigator followed in the conduct of this
study:

Client Participants Normal Participants

 

I. Recruiting Volunteers

A. Contact referring A. Secure names and
therapists for names telephone numbers of
and telephone numbers interested persons
of interested clients. from:

- In some cases, 1. Sign-up sheets
referring clinician a. posted at
provides diagnostic local schools
information. & colleges

b. circulated at
meetings fol-
lowing reading
of recruitment

protocol

II.

82

Telephone volunteers to:

1. Introduce self and study.

2. Acquaintances of
the principal
investigator

3. Responses to
newspaper adver-

tisement

2. Brief volunteers on requirements, benefits,

rights etc. of participation.

3. Schedule appointment.

Data Collection

A.

Read Orientation protocol and secure the volun-

teer's informed, written consent.

Interview client B.
participant (and

Spouse, if avail-

able)

Proctor question- C.

naire session

Probe for client's
questions/concerns,
if any. Arrange

for feedback.

Proctor question-

naire session

Probe for partici-
pant's questions/
concerns if any.

Arrange for feedback

83
E. In some cases, contact
referring clinician re:

diagnostic questions

III. Provide Feedback

A. Individualized Feedback

1. Summary mailed--or 1. Provided orally
presented orally to some partici-
to clinician pants

2. Provided orally
to some client
participants
B. Overall Findings of Study--summary to be mailed to

participants and referring clinicians.

Instruments

All participants in this study completed the General
Information Sheet, prepared by the author, the Beck Depres-
sion Inventory (Beck, 1972), Series A and B of the
Structural Analysis of Social Behavior (Benjamin, 1979), a
modified version of the Love Scale (Swensen & Gilner, 1968),
and the Marital Communication Inventory (Bienvenu, 1978).
The husbands and wives in the Normals group also completed
the ”Survey of Problems" prepared by this author. This
brief self-report form asks about emotional and relationship
problems and psychiatric symptoms experienced during the

past two years.

84

The Beck Depression Inventogy (BDI) is a self-report

 

instrument which measures depth of depression. Its con-
struction presupposes that depth of depression varies
directly with the number and intensity of depressive symp-
toms. The BDI includes 21 clinically derived categories of
attitudes and physical symptoms specific to depression
(Beck, 1972, p. 189). Each category item consists of four
or five graded self-report statements. Numerical values for
these range from 0, for neutral, to 3, for maximal severity.
Individual scores, which range from 0 to 63, are determined
by the number and severity of symptoms reported. Beck
(1972, p. 196) reports mean scores associated with clinical
ratings of depression for a psychiatric population. These
range from 18.7 for mildly depressed patients to 30 for
severely depressed.

The body of data on the reliability and validity of
the BDI is impressive (Beck, 1972, pp. 184-202). The scale
is internally consistent; split half reliability is .93, and
item total correlations range from .31 to .68. Concurrent
validity of the inventory has been established by its high
correlations with other measures of depression. Beck (1972,
pp. 197-198) reports correlations of .65 and .75 between BDI
scores and clinicians' ratings of severity of depression.
BDI scores also correlate well with scores on Lubin's
Depression Adjective Check List (r = .66) and the MPI D-
Scale (r = .75) (Beck, 1972, p. 198). Unlike these latter

two, the BDI discriminates between depression and anxiety.

85

Moreover, changes in BDI scores can predict changes in
clinicians' ratings (Beck, 1972, p. 198). Construct
validity of the inventory has been supported by confirmation
of several hypotheses. These are: depressed patients are
more likely to report dreams with themes of deprivation,
failure, and frustration, to identify with the "loser" in
projective tests dealing with success and failure, to have a
history of childhood deprivation, and to respond to experi-
mentally induced failure with a disproportionate drop in
self-esteem. In short, the Beck Depression Inventory is as
good a measure of depression as one can reasonably expect of
a brief, easily administered self-report questionnaire, and
as such, was utilized in this study.

The Structural Analysis of Social Behavior (SASB)
(Benjamin, 1974, 1979a) is both a model of and methodology
for assessing interpersonal behavior. Benjamin has
developed this complex and sophisticated model over the past
17 years (Benjamin, 1980, personal communication) and has
presented extensive research data on its validity (Benjamin,
1974), as well as reported on its usefulness as a clinical
assessment tool (Benjamin, 1979b). The SASB, which elabor-
ates on earlier models of Leary and of Schaefer (Benjamin,
1974), presupposes certain explicit logical and mathematical
properties, which shall be discussed.

SASB's explicit theoretical model and the wealth of
research data supporting it, and the sophisticated computer-

ized techniques available for analysis of individual

86

protocols, make it a most attractive tool for clinical
research. The SASB questionnaires generate multiple
measures of affiliation, hostility, autonomy, dominance, and
submission, and thus a more complex, and consequently more
accurate picture of a respondent's perceived relationship
with a significant other. The several measures of autonomy
and of dominance-submission are of particular interest in a
study which hypothesizes mutual dependency as a defining
feature of the depressed client's marriage.

A Description of the Model: The model (summarized by
Figure 1) locates any social behavior on one of three
diamond-shaped surfaces. The top (first) surface describes
behaviors that are performed to or for another person. This
plane is referred to as the "Parent-like" and "Focus-on-
Other” surface. The middle (second) surface describes
behaviors that are done to or for the self (in response to
another's Surface 1 behavior). This plane is referred to as
the ”Child-like" and "Focus on Self" surface. These first
two planes implicitly define an active-passive dimension.
The bottom (third) surface is the introject plane. It
describes intrapersonal attitudes and behaviors. The
behaviors on this surface were deduced to be the conse-
quences of introjecting the parent-like behaviors of Surface
1. Because this study focuses on interpersonal behavior it
will assess only Surface 1 and 2 behaviors.

Each surface is defined by the horizontal, affilia-

tion, axis and the vertical, autonomy-interdependence, axis.

87

 

120 Enancipate
Go away now 128 118 You can do it
Exclude 127 117 Encourage divergence

 

Isolate 126 . "r---1'1‘ 116 Listen. equalitarian
115 Explore, let discover

Neglect. ignore 125
Bluff. illogical 124

 

 

Abandon. reject 123

114 Confirm, praise
113 Play, allow peer play

 

Deprive 122

112 Smile, greet war-1y

 

111 Kiss. heal. groan

 

Starve. poison 121

110 Embrace. tender.touch

 

Murderous attack 130

 

141 Support. cradle. nurse

 

 

Injure 131
Frighten 132

 

 

142 Indulge. T.L.C.

 

 

 

Iestrain. overprotect 133

143 Protect. keep conpany

 

 

 

Shout. criticize 134

 

 

 

 

 

 

 

 

 

 

 

 

 

144 Reasoned persuasion

Threaten 135 145 Stimulate. teach
Exploit 136 146 Overindulge
Authoritarian 137 L. .__J 147 Intrude
Shale, guilt control 138 148 Possessive
Doeinate 140
220 Be eoancipated
Flee, withdraw 228 218 Unassaultive assert

Coupete. try one-up 227...H ._ . 217 Individualistic

Io input. no response 226
Stinulate self 225

 

C:.. 216 Cooperative

215 Reveal, discover

 

Defy. suspect 224
Distrust. grieve 223 -

214 Display. court
Pl 213 Play, peer play

 

Touper tantrul 222

212 Approach, snile. understand

 

211 Accept. grooe. heal

 

Disgust. refuse. spit 221
Suffer. disaffiliate 230

210 Hug. affiliate

 

 

 

no not touch no 231

 

I
: 241 Accept. nurse. sleep

 

——i-—I—p-1

 

Rigid. hide, grinace 232

242 Flower child

 

Cling, annoy 233 I

l 243 Trust

 

 

Cringe. defend. whine 234

 

 

 

 

 

 

 

Present. ield. appease 235
entfu coeply 236

 

 

 

244 Comply willingly

245 Absorb. imitate
246 Incompetent

om routines 237 1...... 247 Overconforla, defer
flaky conply 238 248 Satellite

 

 

 

I. lounted. sub-it 240

 

320 Elancipate self

new In 328 318 Self-confident. reliant

Need
Exclude self, one-down 327 317 Self actualize
Isolate self 326 . N.....r.? 316 Fair, Just

 

 

Neglect. ignore self 325
Put self on 324

 

Reckless 323

315 Explore self

314 Confirm self
313 Entertain self

 

Self deprivation 322

312 Helcone self

 

311 Real. groom self

 

Starve. poison self 321

310 Self love

 

Self hate. suicide 330
anure self 331

 

341 Self support

 

—d——_

 

 

Frighten self 332

 

342 Self care

 

 

Apathy 333

343 Protect self

 

 

Criticize self 334

 

 

 

No products. nihilistic 335

 

 

 

 

Self sacrifice 336

 

 

 

344 Dignified, respect self

345 Self taught. accomplished
346 Overindulge self, addict

Person - cause 337 347 Self preoccupied
Accuse self, guilt 338 348 Self possessed

 

 

 

 

 

I an my own master 340

Figure 1. Map of SASB Model.

88
The poles of these axes are love (right) and hate (left) and
emancipate/be emancipated (top) and dominate/submit
(bottom), respectively. The axes define four' quadrants.
These are numbers I to IV in accordance with the Cartesian
tradition of assigning I to the upper right quadrant and
proceeding counterclockwise. They are labelled in the

following way (Benjamin, 1977):

 

 

Quadrant Focus on Other Focus on Self
I Encourage Friendly Enjoy Friendly
Autonomy Autonomy
II Invoke Hostile Take Hostile
Autonomy Autonomy
III Hostile Power Hostile Comply
IV Friendly Influence Friendly Accept

The behaviors in the bottom two quadrants are saturated with
control in the sense of either dominance or submission.
Each surface has also been divided into octants which are
similar to those in Leary's model (Benjamin, 1979). Figure
2 presents Surfaces 1 and 2 divided into octants. The names
presented here for each octant have been supplied by this
author.

Each of the 36 behavior points on a surface consists
of complementary proportions of affiliation and inter-
dependence. The poles (110, 120, 130, 140) represent
primitive behaviors: tender sexuality, emancipate,
annihilating attack, dominate. Points further away from the

poles represent less primitive behaviors. If one starts at

..-- ~-----H.

--'

Uncarinfly Ietgo128

 

89

120 Endorse freedom

11

I
8 Encourage separate identity

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

'm. “fiend not there 125 I ”5 Carefully. "MY cmsrder ——
8 Neflect interests. needs 125 I "5 F'Wfld‘v ““0" a.
"logical initiation 124 114 Show ernoath'oc understanding
_...H...H 113 Confirm as OKasis
Lt Sum cut our 322 112 Stroke. southe. cairn
dismiss, rem 121,1" Wiffl'ilv Mm
Annihilating m 130 —IL 110 Tender $080815”
W menaangly 131 141 Frtendly invite
W132 51W
Punish. take revenge 133 14 rorect. back 09
m. divert. misuse 134 1“ 50ml"- min"
b Accuse. blame 135 145 Constructive stimulate Li
- 145 Pamper. overindui
lntrude. block. restrict 137 — h. “‘7 Benevolent monitor. remind
Entoru conformity 138 L— ”—1 “3 5M" W1" b.“
Manage. control 140 S
220 Freely come aid go
Cowman" 223—1J1 2180mUentirv. standards
' —' —‘ 217 As n
' (o war-on. nondisclose 225 1 " u! cards on the u
Busy with own thing 225 1 215 Openly disclose. reveal ‘ o
Noncmtingent reaction 224 214 Clearly express
2 . .
Refuse assistance. care 222 212 Relax. now. enjoy
Flee. escape. withdraw 221 211 Joyful approach
Desperate protest 230 . 210 Ecstatic response
| S Wary. fearfu1231 L 241 Follow. maintain contact. ‘
i * k5
Appears. ram 233 243 Ask. trust. count on
Urtcornprenending agree 234 i * 244 Accept reason
Whine. defend. justify 235 1 L 245 Take in. learn from
(H 5011:. act out on 236 356 Cling, deggnd 1 9.
ti: comiianoe 237 L. { 247 Defer. overconiorrn
Follow ruies. proper 233 k 243 Submerge into m l 3
Yield, submit, give in 240
Figure 2. Map of SASB Octants.

90

any point and moves stepwise within its quadrant, the sub-
jective quality of these behaviors changes in the direction
of the pole being approached. A behavior point's absolute
value on each dimension ranges from 0 to 9, and the sum of
these absolute values is always equal to 9. The valences
(signs) on both dimensions vary according to the point's
quadrant. For example, "pamper, overindulge" (146), located
in quadrant IV, has +3 units of affiliation and -6 units of
autonomy; "openly disclose" (215), located in quadrant I has
+4 units of affiliation and +5 units of autonomy.

Every behavior point on Figure I is specified by a

three-digit code number. The first (1003) digit locates the

surface: 1 = Focus on Other, 2 = Focus on Self, and 3
Introject. The second digit (10s) locates the quadrant, 1
through 4. The third digit (ls) locates the track within

the quadrant. These tracks are: (Benjamin, 1979b)

Track 0--Primitive basics (poles)
Track l--Approach-avoidance

Track 2-—Need-fulfillment

Track 3--Attachment

Track 4--Logic, communication

Track 5--Attention to self-development
Track 6--Balance in relationship

Track 7--Intimacy-distance

Track 8--Identify

91
All points on the same track consist of the same proportions
of the two dimensions.

Opposite behaviors are located at 180 degrees from
each other, that is, on the same track in opposite quadrants
(I and III, II and IV). These behaviors differ only in
their valences on both dimensions. For example, "you can do
it fine” (117), with +2 units of affiliation and +7 units of
autonomy, is opposite to "intrude, block, resists" (137),
with -2 units of affiliations and -7 units of autonomy.

Complementary behaviors are those which tend to elicit
each other. These are located at the same point (quadrant
and track) on the first two surfaces. For example,
”blaming" (135) tends to elicit "defensiveness" (235); "open
self-disclosure" (215) tends to elicit "friendly listening"
(115). Behaviors from both the ”parent-like” and the
”child-like” surfaces can be elicitors. No one type of
behavior is the more responsible in a behavior exchange
(Benjamin, 1974). In complementary behavior exchanges each
person's behavior is equally responsible in determining the
sequence of events.

The antithesis of any behavior is the complement of
its opposite. For example, the antithesis of ”hostile wall
off, nondisclose" (226) is "pamper, overindulge" (146),
which elicits "cling, depend" (246). The principles of
complementary and antithetical behavior allow for behavioral
predictions and for prescriptions for desired behavior

change.

92

Benjamin (1974, 1979a) has developed a battery of
questionnaires whose items describe each behavior point on
Figure 1 with respect to a variety of relationships. This
study will utilize two of these: Series A and Series B.
Each series consists of 72 items, one for each point on the
"Focus on Other" and ”Focus on Self" surfaces. Series A
asks the subject to rate the interpersonal behavior of a
significant other vis a vis him/herself (the rater). Series
B asks the subject to rate his/her own behavior vis a vis
the significant other. The item structure is identical on

both series. For example:

Series A (20) accuses, blames me, tries to
get me to admit I'm wrong.
Series B (20) I accuse, blame him/her, try

to get him/her to admit he/she is wrong.

For the sake of clarity, the questionnaire items were modi-
fied so as to specify the person and relationship to be

rated. For example:

Series A (20) My wife blames me, accuses me, tries to
get me to admit I am wrong.
Series B (20) I blame, accuse my husband, try to get

him to admit he is wrong.

The questionnaire items appear in random order. Each item
is rated on a scale of 0-100. Anchor points are 0 = never,

not at all; 50 = sometimes, moderately; 100 = always,

93

perfectly. Subjects are advised to place their ratings at
the 10-point intervals. The directions for completing the
questionnaires follow Benjamin's (1979), with a few modifi-
cations (see Appendix M).

As Benjamin has emphasized (Benjamin, 1979a), SASB is
a "good faith” measure. Unlike the MMPI it does not attempt
to assess or to correct for the test taker's dishonesty or
defensiveness. Thus, subjects must be urged to be as honest
as possible in reporting their feelings and perceptions.
Moreover, the questionnaires tap only the rater's percep-
tions of his/her own and others' social behaviors. These
perceptions may or may not agree with the objective reality

of his/her relationships.

Validity Studies

 

Statistical analyses of extensive data drawn from
several different subject groups have confirmed the struc-
tures of the SASB model. Benjamin (1974) has argued that if
the SASB model mirrors the actual organization of social
behavior, then subjects should rate items adjacent on a
surface similarly, distant items dissimilarly and opposite
items, oppositely. Similarity of ratings is assessed in
terms of patterns of autocorrelations. The autocorrelation
at Lag 1 pairs scores for items immediately adjacent to each
other. The autocorrelation at Lag 2 pairs scores for all
items two steps apart, and so on for Lags 3 through 35.

Correlations for Lags 17 to 35 mirror those for Lags 1-17.

94

Theoretically the variation in autocorrelations across lags
should replicate an inverted normal (Z) curve. Correlations
are large and. positive at Lags 1, 2 and 3, decrease,
approaching zero at Lag 9, where item points are orthogonal,
and become increasingly negative as the curve approaches Lag
17, where opposite items are paired. The autocorrelation
curves generated from the questionnaire responses of normal
adults, in fact, approximate the inverted Z curve. The
average correlation between the obtained curves and inverted
normal curve were .92 and .97 for samples of 60 and 50
normal adults, respectively (Benjamin, 1974).

This correlation may be construed as an index or coef-
ficient of internal consistency insofar as it reflects the
degree to which a person gives similar ratings to items
hypothesized to be similar, opposite ratings to items hy-
pothesized to be Opposite and unrelated ratings to items
hypothesized to be orthogonal. Interview data from subjects
who completed the entire battery of SASB questionnaires
indicated that a high coefficient of internal consistency
was associated with behavioral stability over time
(Benjamin, 1974). A low coefficient of internal consis-
tency, Benjamin (1974, 1979a) suggests, is associated with
behavioral instability rather than with unreliability of the
questionnaires. To support this interpretation, Benjamin
(1974, 1979a) cites both interview data as well as her
finding that in every set of comparisons psychiatric

patients produced a much lower coefficient of internal

95
consistency than did normal adults. Behavioral instability
is a frequent, though not universal, concomitant of psychi-
atric disorder.

The dimensional structure of the model has been
supported by circumplex and factor analyses. The SASB model
assumes that each of its items taps both affiliation and
interdependence, and thus fits a circumplex model, which
also presupposes that a questionnaire's items simultaneously
tap each of two underlying dimensions to systematically
varied degrees. A circumplex is the model of interrelation-
ship between two factors such that the factor loadings for
every variable stand in the relationship defined by the

equation for an ellipse:
cza? + kab? = h2
i l

c, k, and h are arbitrary constants and ai and bi are the
factor loadings of variable i on the first and second
factors, respectively. The correlation coefficients rij =
a.a. + b.b. can be ordered in a circumplex pattern. This is

1 J l J
a correlation matrix wherein the correlations are highest
near the main diagonal, and decrease and increase again as
one moves away from the diagonal. The inter item correla-
tion matrix generated from the ratings of 221 mothers of
their 171 normal and 50 psychiatric clinic children fits
well with the circumplex pattern (Benjamin, 1974). A factor

analysis of the questionnaire responses of 110 adult sub-

jects yielded four factors which accounted for 64 percent of

96

the variance. These four factors: affiliation, disaffilia-
tion, emancipation, and domination, were replicated in
several additional data samples (Benjamin, 1974). A simple
transformation reduced these four factors to two: affilia-
tion and emancipation. A plot of each item's scores on the
two factors proved a reasonable facsimile of Figure 1
(Benjamin, 1974).

The principle of complementarity has been confirmed
for most pairs of complementary behavior items. Benjamin
(1974) reports that the correlations between mothers' (N =
171) ratings of their own Surface 1 behaviors and their rat-
ings of their children's Surface 2 behaviors were stat-
istically significant for 28 of the 36 pairings. For 19 of
the 36 Surface 1 items, the highest correlations with any of
the Surface 2 behavior items was with its complement or an
item within two steps of the complement. In general, normal
adults report a higher degree of complementarity in their
relationship than do psychiatric patients (Benjamin, 1979a).

Other systematic differences between the protocols of
normal adults and those of psychiatric patients have been
noted. Generally, the coefficient of internal consistency
is higher for normal respondents (r is .90 or higher).
Benjamin (1979a) reports a significant negative correlation
between Hamilton Checklist ratings of depression and con-
sistency of treatment received from a significant other in a
sample of aged women. Normal adults' ratings are usually

consistent with the dictates of social desirability. These

rate
aut<
and

(Be:

ways
A m.
res;
ab0\
deri
hiS/
rat:
Orie
deri

for

Slimm
eith
t10n

dime:

97
raters characterize their relationships as high on friendly
autonomy. Psychiatric patients report much more hostility
and dominance in their relationships with significant others

(Benjamin, 1974, 1979a).
Organization and Analysis of SASB Data

Questionnaire data can be organized in a variety of
ways. The basic unit of analysis is the individual's map.
A map can be generated which indicates all of a subject's
responses on a given surface, and highlights all of his
above median endorsements. For example, two maps can be
derived from a subject's responses on Series B: one of
his/her Surface 1 ratings and a second of his/her Surface 2
ratings. These maps provide a picture of the interpersonal
orientation of the person rated. Additional scores are
derived from these maps. The following have been selected
for inclusion in this study.

1. Weighted Affiliation and Autonomy Scores: These
summarize a rater's perception of the basic orientation of
either him/herself or a significant other in a given rela-
tionship. The formula for the weighted score on either

dimension is:
Weighted Score = z Endorsementi x Weighti

The weight, which is either positive or negative, is the
number of units of the dimension being scored. Weighted

affiliation and weighted autonomy scores are computed for

sig
ind
sco
pos
ind
the
per
the
mo
wei

COR

oct.
end

add

98

each surface assessed by a questionnaire. Weighted scores
may be either large or small, and positive or negative in
sign. On the affiliation dimension, large positive scores
indicate emotional warmth and intimacy; large negative
scores indicate discord. On the autonomy dimension, large
positive scores indicate autonomy and large negative scores
indicate dominance or submission in the relationship. Yet
these weighted scores are straightforward measurements of
perceived affiliation and autonomy in a relationship only if
the ratings from which they were derived were consistent
among themselves. That is, as Benjamin. warns (1979a),
weighted scores of a subject whose coefficient of internal
consistency is below .90 must be interpreted with caution.

2. Octant Scores: Each surface can be divided into
octants (see Figure 2). The octant score is the average
endorsement for items *within. the octant. The following

additional measures have been derived from these clusters:

Sum of Octants 1, 2, 9 and 10--Friend1y Autonomy
Sum of Octants 3, 4, 11 and 12--Affiliation

Sum of 5 and 6--Dominance

Sum of 13 and 14--Submission

Sum of 7 and 15--Hostility

Sum of 8 and 15--Hostile Autonomy

The Love Scale

The Love Scale assesses the manifestation of the

behaviors and feelings of love in a variety of close

99

interpersonal relationships. These include marital, par-
ental, friendship and sibling relationships. The scale, now
in its fourth version (Swensen & Gilner, 1968), was derived
from a pool of 383 statements about love relationships made
by a group of 300 college students (Swensen, 1961). Since
1961 the scale has been reduced to 120 items and admin-
istered to several large samples (Swensen, 1978). A factor
structure which includes verbal expression of affection,
self-disclosure, toleration of less pleasant aspects of the
loved person, nonmaterial evidence of love, feelings not
expressed. verbally, material evidence «of love, has been
replicated in several studies whose subjects ranged in age
from 18 to 50 years and older. These factors apparently tap
attitudes and behaviors not assessed by other measures of
personality and interpersonal behavior. Swanson (1978)
reports that the correlations between Love Scale scores and
scores on the Interpersonal Checklist, the Guilford-
Zimmerman Temperament Survey, the Maudsley Personality
Inventory, FIRO-B, and the MMPI scored by Leary's system for
the dimensions of love and dominance, are, with few excep-
tions, below .20.

The current form of the Love Scale (Swensen & Gilner,
1968) consists of 120 items divided into six subscales.

These are:

Subscale Items

Verbal expression of affection 1-20

100

Self disclosure 21-40
Toleration of less pleasant

aspects of the loved one 41-61
Nonmaterial evidence of love 62-85
Feelings not expressed verbally 86-104
Material evidence 105-120

Scale items are statements about either the rater's feelings
and behaviors toward a loved person or the loved person's
feelings and behaviors toward the rater. Items are marked
"never," "sometimes," and "always," and scored 1 to 3 (or in
some cases 3 to 1) accordingly. Raters are asked to assess
their relationship at the present time, with "present time"
referring to the past few weeks or months. Subscale scores
are the sums of the item scores. The overall Love Scale
Index is obtained by adding the scores for subscales 1, 2,
3, 4 and 6 and subtracting the score for subscale 5. The
score on subscale 5, "unexpressed feelings," is subtracted
because the scale has repeatedly been shown to correlate
negatively with the remaining five subscales (Swensen,
1978). Scores on the overall Index range from 44 to 284.
Swensen (1978) reports the means and standard deviations on
each of the subscales for various age groups and various
relationships assessed. The test-retest reliability for
each subscale has been assessed for subjects of various age
groups. Reliabilities for young (18-26) and "middle age"

(27-50) subjects range from .77 to .96.

101

Love Scale Scores and the Marital

 

Relationship

 

The Love Scale has been employed in numerous studies
of the marital relationship. Swensen (1978) cites at least
a dozen of these (many are unpublished studies conducted by
his graduate students at Purdue University). Overall, these
studies report no reliable differences between husbands and
wives in their assessment of their marriages. The amount of
love expressed is highest in the early years of a marriage
and declines slowly thereafter (Swensen, 1978). Marital
satisfaction, as measured by the Burgess-Wallin Marital
Satisfaction Scale, correlates significantly and positively
with all subscales but "unexpressed feelings." Scores on
this subscale correlate significantly negatively with
marital satisfaction scores (Swensen, 1978). Couples who
requested professional help for their marital problems
scored significantly lower on all but the "unexpressed
feelings” subscales than did a comparison group of couples
reporting no significant marital discord (Fiore & Swensen,

1977).

A Modified Version of the Love Scale

 

This study employed a shortened and modified version
of the Love Scale. Subscale 5, "unexpressed feelings," has
been dropped because the wording of its items is awkward,

and because a low score may indicate either the absence of

     

. , .. smiths r......a.fl...-.m«. East... I

f

102

affectionate feelings or reticence about such feelings.
Item #60: "You tell the loved one you want to marry him"
has been eliminated because it makes no sense whatsoever for
persons who are already married. Several items have been
expanded to make them more relevant and comprehensible for a
sample of married subjects. Items have also been reworded
so as to specify the "loved one" as either "your husband" or
"your wife.” Two forms, one for wives and one for husbands,
were used. A total Love Scale score was computed for each
participant.

The Love Scale was included as an additional measure
of affection/affiliation not only because of the impressive
array of validity studies, but also because of the spec-
ificity and concreteness of its items. This questionnaire
asks the respondent to assess his/her marriage in terms of a
variety of attitudes, emotions, and overt behaviors, and, as
such generates a more detailed picture of his/her marital

relationship.

The Marital Communication Inventory

The Marital Communication Inventory (Bienvenu, 1970,
1978) was designed to assess the patterns and style of
communications between marital partners. The 46 items of
this inventory question the extent to which partners express
their wants and feelings, listen to and understand each
other, and discuss their mutual difficulties. All items

relate solely to communications between husband and wife,

but
to

the
poi
eff

ran

exp
riel
mid-c

disc

rape;

aged

103
but are answered by partners individually. Two forms, one
to be completed by the husband, and one to be completed by
the wife, are available. Each item is scored on a four-
point, 0 to 3, scale. Favorable responses, those indicating
effective communication are scored highest. Total scores
range from 0 to 138.

The 46 items of the inventory were derived from an
experimental 48 item scale given to 344 subjects (172 mar-
ried couples). These were predominately white, Protestant,
middle-class couples in their late 208. Of the 48 items, 45
discriminated between the upper and lower quartiles of the
sample at the .01 level, and one item discriminated at the
.05 level. The mean score for this sampLe of 172 couples
was 105.78. This score was cross-validated on a second
sample of 60 subjects whose mean score was 105.68. The
split half reliability (Spearman-Brown) coefficient for this
sample of 60 was .93 (Bienvenu, 1970). Bienvenu (1978)
reports similar mean scores for a 1973 sample of 155 couples
aged 21-25 and 50 couples aged 26-34.

The Marital Communication Inventory has been used in a
few studies of marital adjustment and psychOpathology.
Bienvenu (1970) reports a study of 23 couples receiving
marital counseling which found that they scored signifi-
cantly lower on the MCI than did a comparison group of well-
adjusted. couples. Murphy’ and..Mendelson (1973) report. a
correlation of .846 (p = .05) between scores on the Locke-

Wallace Marital Adjustment Scale and MCI scores for a group

of l
beti
repc
5am;
(Has
repc
stoc
migl

stud

deri
SCOI
Tabl
auto
qual
Subj

104
of 30 young couples. Wasli's (1977) study of communication
between 16 hospitalized depressed women and their husbands
reports a mean MCI score of 79.56. The range for this
sample 'was 41-125 and the standard deviation. was 19.89
(Wasli, 1977, p. 46). This score is well below the norm
reported by Bienvenu (1978). This brief, and easily under-
stood instrument was utilized so that findings in this study
might be compared with those of one of the few available
studies of' marital communication and depression (Wasli,

1977).

Dependent Measures

The dependent measures of this study were 18 scores
derived from the SASB questionnaires, the Love Scale total
score, and the score on the Marital Communication Inventory.
Table 8 presents the Operationalization of the variables of
autonomy-interdependence, affiliation, hostility, and
quality of communication. Each measure was calculated for

subjects individually.

Predictions

 

The hypotheses stated in the previous chapter have
been translated into specific predictions in terms of the

operationalized dependent measures presented in Table 8.

Hypothesis 1: The marital relationship of depressed client

couples is marked by a higher degree of

Table 8

105

Operationalization of Dependent Measures

 

Autonomy-Interdependency SASB

A.

Overall Interdependency

1. Sum of weighted autonomy scores- 11
Surfaces l and 2 Self (Series B)

2. Sum of weighted autonomy scores— 12
Surfaces 1 and 2 Other (Series A)

Friendly Autonomy

3. Sum of Octants scores 1, 2, 9, A1
and 10 Self

4. Sum of Octants scores 1, 2, 9, A2
and 10 Other

Hostile Autonomy

5. Sum of Octants scores 8 and 16 HA1
Self

6. Sum of Octants scores 8 and 16 HA2
Other

Dominance

7. Sum of Octants scores 5 and 6 D1
Self

8. Sum of Octants scores 5 and 6 D2
Other

Submission

9. Sum of Octants scores 13 and 14 81
Self

10. Sum of Octants scores 13 and 14 82
Other

(table continues)

 

106

Table 8 (cont'd.)

II.

III.

Affiliation

A.

Weighted Affiliation SASB

11. Sum of scores for Surfaces 1 and
2 Self

12. Sum of scores for Surfaces 1 and
2 Other

Octant Scores SASB

13. Sum of Octants scores 3 and 4
and 11 and 12 Self

14. Sum of Octants scores 3 and 4
and 11 and 12 Other

Affiliation Love Scale

15. Total Score on Love Scale
Hostility SASB

16. Sum of Octants 7 and 15 Self

17. Sum of Octants 7 and 15 Other

Quality of Communication

18. MCI total score

 

107
interdependence than that of either psychi-
atrically normal adults or other psycho-
therapy clients.

Predictions:

 

1. Depressed Clients will be lower in I1 and
I2 than either NOndepressed Clients or
Normals.

Hypothesis 1a: Depressed clients relate to each other as

 

autonomous adults less than do normal hus-
bands and. wives, and other psychotherapy
clients and their spouses.

Predictions:

 

1. Depressed Clients will be lower in A1
and A2 than either Nondepressed Clients
or Normals.

Hypothesis 1b: Depressed clients and their spouses manifest
more dominance, control, submission and
deference than do normal husbands and wives,
and other psychotherapy clients and their
spouses.

Predictions:

 

1. Depressed Clients will be higher on 02
than either Nondepressed Clients or
Normals.

2. Depressed Clients will be lower on D1
than either Nondepressed Clients or

Normals.

Hypothesis 2:

 

Hypothesis 3:

 

Hypothesis 3a:

108

3. Depressed Clients will be higher on S
than either Nondepressed Clients or
Normals.

4. Depressed Clients will be lower on S
than either Nondepressed Clients or
Normals.

Depressed clients and their spouses invoke

and assume hostile autonomy more often than

do normal husbands and wives and other
psychotherapy clients and their spouses.

Predictions:

 

1. Depressed Clients will be higher on HA1
and HA2 than either Normals or Non-
depressed Clients.

The marital relationship of depressed

clients is less emotionally rewarding for

both partners than is that of psychi-
atrically normal adults and other psycho-
therapy clients.

Predictions:

 

1. Depressed Clients will be lower on Af1
and Af2 than Normals or Nondepressed
Clients.

Depressed clients and their spouses express

less affection and exchange fewer verbal and

nonverbal loving behaviors than do normal

Hypothesis 3b:

Hypothesis 4:

 

109
husbands and wives, and other psychotherapy
clients and their Spouses.

Predictions:

 

1. Depressed Clients will be lower on Af3,

Af and AfS than Normals or Non-

4:
depressed Clients.

Depressed clients and their spouses express

more overt hostility and friction than do

normal husbands and wives, or other psycho-

therapy clients and their spouses.

Predictions:

 

1. Depressed Clients will be higher on H1
and H2 than Normals or Nondepressed
Clients.

The communication processes between

depressed clients and their spouses are more

impaired than those between normal husbands
and wives and other psychotherapy clients
and their spouses.

Predictions:

 

1. Depressed Clients will be lower on C1

than Normals or Nondepressed Clients.

CHAPTER 3

RESULTS

In order to determine whether the participant groups
differed with respect to autonomy, affiliation, hostility
and quality of communication within their marriages, a one-
way analysis of variance was computed for each of the 18
dependent measures. The specifically hypothesized differ-
ences between the Depressed Clients and each of the two
control groups were tested by simple two tailed 2 tests. It
was expected, however, that these comparisons would entail
some redundancy not only because these involved multiple
measures of autonomy, affiliation, hostility and quality of
communication, but also because these latter variables might
well be correlated among themselves. Consequently, a step-
wise discriminant function analysis was conducted to
determine which subject of dependent measures best discrim-
inated. between. groups. The functions derived from ‘this
analysis could then be evaluated in terms of how well they
classified all of the cases.

The first group of hypotheses tested in this study
predicted that the Depressed Clients would report less
autonomy and more dominance and submission in their
marriages than. would the two control groups. Tables 9

through 13 present the between groups comparisons on these

110

111

 

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nucowao commouooocoz

 

 

 

 

 

 

 

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naoeuoz odoEuoz
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noun w on m unnuucoo noNN w No m unnuucoo
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mv.vN~.v mv Houuu ob.nN~.n mv uoNNm
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bouo M M me no oousom noun M M as no oousom
cocoauo> no nemaaont aozuco
NN.NN NHnaNoz NN.NN .NHnaNoz
m~.m~ oucowau ounuouooocoz om.om macaquo ooonouooocoz.
NN.NH nucoHHo oonnuNNoo NN.HN- nocoHHo nonnouooo
coo: macho coo: macho

 

museum 1 >80:0u:< ooucoNoz i «H

uuom i h50:0u:¢ voucmuoz 1

HH

 

 

cocoocumuououcn co nmwouo mo coowuooeoo

a manna

ON oHetE

112

 

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undefined oocowuo> ooaooo a

 

oucoaao ooououooocoz

nucoaao commouooocoz

 

 

 

 

 

 

 

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oouo m up M umouucoo oouo M no N umouucoo
macawuooeoo name i w
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noun M M we . mo oouoom noun M M we no oousom
oocoqun> mo nwomnocd anzoco
om.mn~ odoEuoz mN.~m~ mHnENoz
m~.omH oucowao commouooocoz oo.-~ oucoNHo oummouooocoz
NN.NNN nucoHHo oonnmnaoo NN.NNH nucoHHo omnnoNNmo
coo: ozone coo: ozone

 

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o

 

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an wands

113

 

macaqunu uocoNuo> announce an

ouoaNuoo oocoauo> ouaooo a

 

nucowao ooooouooocoz

nucowao oomoouooocoz

 

 

 

 

 

 

 

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oouo M M as no oou30m noun M M me no oouoom
oocoquo> mo oNomaoct Nosoco
NN.NN maneuoz Nc.un maneuoz
vv.mm nucowau oomnouooocoz oo.mv oucuwau oommouooocoz
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coo: ozone coo: osouo

 

oosoow i oococweoo t No

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meow i oococweoo i o

 

 

oococwaoo co nooouo No canwuomeou

Hm manna

114

 

ouoluuou oosowuo> ououoooo as

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nucoaau venouuooocoz

avocado oonoouooocoz

 

 

 

 

 

 

 

mmv. mva coN. o> avocado ooooouooo Hoo. m~\H «amm.m n> nucoaao commouooo
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nono w No m unnuucoo ooNN w No w unnoucoo
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noun M M oi no oousom nouo M M we no oousom
oocowuo> mo owoaaoc< >o3ono
om.mv euoeuoz Nn.Hm nameNoz
n~.oo avocado ooonuuooocoz oo.Nm mucowau oowoouooocoz
NN.NN nucoHHo connouooo NN.NNH nocoHHo nonnouooo
coo: ozone coo: macho

 

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nnocu>wnoaanam :0 omsouu mo :omwuooeou

NH OHQMB

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115

 

ouelaueo oocoauo> ououuooo as

ouoawuoo oocowuo> ooHOOQ a

 

avocado ouoeeuooocoz

nucowau commoumoocoz

 

 

 

 

 

 

 

NNN. NN\H NN.H N> nucoHHo oonnouoon NHN. NN\H .NN.N n> NunoHHo connonooo
odoauoz madEuoz
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oouo M M as no coupon noun M M me no oousom
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HN.NN NHneuoz NN.NN NHneNoz
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aeocousc unauooz co omoouu no cONNuomEou

nu wanna

116
variables, which were operationalized as measures derived
from ratings on Series A and B of the Structural Analysis of
Social Behavior.

Hypothesis 1 states that the marital relationships of
depressed clients are characterized by a higher degree of
interdependence than those of either psychiatrically normal
adults or other psychotherapy clients. Table 9 compares the
groups on measures Il-Weighted Autonomy-Self and Iz-Weighted
Autonomy-Spouse. These are measures of perceived overall
interdependence within the marriage; that is, these measures
take into account both autonomous and liberating and
controlling and submissive behaviors. The predictions that
the Depressed Clients would rate both themselves (11) and
their spouses (12) lower on autonomy than would the other
participants were for the most part confirmed. As can be
seen from Table 9, the Depressed Clients' mean of -31.56 on
I1,_a negative assessment of their own autonomy in the
marriage, was significantly lower than the means of the
Normals (74.44) and. of the Nondepressed. Clients (50.50)
(both ps < .001). The Depressed Clients rated their spouses
(I2) as less autonomous in the marriage than did the Normals
(t = -2.44, p < .05), but no differently than did the Non-
depressed Clients (E.= -.72, p > .45).

Hypothesis 1a. states that depressed clients and their
spouses relate to each. other as self-determining, self-
asserting adults to a lesser degree than do either psy-

chiatrically normal adults or other psychotherapy clients

117

and their husbands and wives. The predictions testing this
hypothesis were that the Depressed Clients would score lower
on dependent measures Al-Friendly Autonomy-Self, and A2-
Friendly Autonomy-Spouse, than either comparison group. As
can be seen from Table 10, these predictions were for the
most part confirmed. The Depressed Clients rated themselves
lower on asserting and promoting their own and their
spouse's friendly autonomy (A1) than did both groups of
control subjects (t = -4.3, p < .001; E = -2.4, p < .05 for
Normals and. Depressed. Clients, respectively). In. rating
their spouses, the Depressed Clients reported them to be
lower on friendly autonomy (A2) than did the Normals (_i._:_ =
-2.11, p < .05) but no differently on this measure than did
the Nondepressed Clients (3 =-521, p > .80).

Hypothesis 1b. states that depressed patients and
their spouses manifest greater dominance and submission in
their marriages than do either psychiatrically normal adults
or other psychotherapy clients and their husbands and wives.
The specific predictions testing this hypothesis were that
Depressed Clients would report less dominance and greater
submission (D1 and $1) on their own part and greater domin-
ance and less submission (D2 and $2) on their spouses' part
than would either of the other participant groups. As can
be seen from Table 11, the between groups differences on the
Dominance measures were not those predicted. The Depressed
Clients reported higher, rather than lower, dominance levels

on their own part than did the Normals (E = 3.85, p < .001)

118
and levels on this measure equivalent to those reported by
the Nondepressed Clients (£_= 1.67, p > .10). As predicted,
the Depressed. Clients rated their spouses as higher on
Dominance (Dz) than did the Normals (E = 5.83, p < .001).
Contrary to prediction, however, the difference on this
measure between the two clients groups was not statistically
significant (3 = 1.78, p > .05). Table 12 presents the com-
and S .

1 2
As expected, the Depressed Clients reported higher levels of

parison of groups on measures of submissiveness, S

submissiveness on their own part (81) than did either the
Normals or the Nondepressed Clients (E = 4.11, p < .001; p =
3.93, p < .01, respectively). Contrary to prediction, the
Depressed Clients rated their spouses as more, rather than
less, submissive than did the Normals (E = 2.02, p < .05).
The two client groups did not, however, differ on the $2
measure (3 = .70, p > .45).

Hypothesis 2 states that depressed patients and their
spouses invoke and assume hostile autonomy more often than
do normal husbands and wives or other psychotherapy clients
and their spouses. Specifically, this study predicted that
the Depressed Clients would score higher on the HA1 and HA2,
the SASB measures of hostile autonomy, than would either
control group. Three of the four predictions entailed were
confirmed. The Depressed Clients rated themselves higher
on Hostile Autonomy (HA1) than did either the Normals or the
Nondepressed Clients (3 = 4.6, p < .001; E}= 2.57, p < .05,

respectively). In assessing their spouses the Depressed

119
Clients reported higher levels of Hostile Autonomy (HA2)
than did the Normal participants (5 = 3.39, p < .01), but
not higher levels than did the Nondepressed Clients (_t_ =
1.83, p > .05).

The second group of hypotheses tested in this study
pertain to the expression of affection and hostility. These
variables were operationalized in terms of six measures
derived from SASB ratings and of the score on the Love
Scale. Hypothesis 3 states that the marital relationships
of depressed patients are less emotionally rewarding for
both. partners than are those of psychiatrically normal
adults or of other psychotherapy clients. Tables 14 through
17 present the between groups comparisons of these seven
measures. This hypothesis was operationalized in terms of
Af

-Weighted Affiliation-Self and Af -Weighted Affiliation-

1 2
Spouse. These are measures of overall affiliation which
take into account both affectionate, affiliative and
hostile, rejecting behaviors. The study predicted that the
Depressed Clients would score lower on both Af1 and Af2 than
would either control group. As Table 14 indicates, the pre-
dicted between group differences were statistically reliable
only for the Depressed Clients vs. Normals comparisons. The
former group rated themselves (Afl) and their spouses (Af2)
as lower on overall affiliation than did the latter (3; =
-4.63, p < .001; E = -3.08, p < .01, respectively).

Hypothesis 3a. pertains to affectionate behavior in

the marriage, without regard to any counterbalancing

120

 

ouoawuoo oocouuo> ououoooo an ouoeNuoo uocoNNo> ou~ooo 4

 

 

 

 

 

 

 

 

 

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mansuoz onENoz
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noun w up w unnuocoo noNN w up w unnuucoo
mnemwuooeoo ones i m
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noun M M as no ouusom coho M M me up mouaom
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121

 

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mu manoh

122

 

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123

 

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ha manna

124

hostility. It states that depressed patients and their
spouses express less affection and exchange fewer verbal and
nonverbal loving behavior than do psychiatrically normal
husbands and wives or other psychotherapy clients and their
spouses. This hypothesis was tested in terms of SASB
measures Af3 and Af4, Affiliation-Self and Affiliation-
Spouse and Afs, the Love Scale Score. It was predicted that
the Depressed Clients would score lower on all three
measures than would either comparison group. These pre-
dictions were not confirmed on measures Af3 and Af‘1 (see
Table 15), the Depressed Clients differed from neither the
Normals nor the Depressed Clients. The Depressed Clients
rated their marital relationships no less favorably on the
Love Scale than did either control group. As Table 16
indicates, neither between group comparison was statis-
tically reliable.

Hypothesis 3b. states that depressed clients and their
spouses express more overt hostility and friction than do
either normal husbands and wives or other psychotherapy
clients and their spouses. This hypothesis was translated
into the predictions that the Depressed Clients would score

higher on SASB measures H -Hostility-Self and Hz-Hostility-

1
Spouse than would either comparison group. Two of the four
predictions were confirmed. As Table 17 indicates, the
Depressed Clients rated themselves as higher on hostility

(H1) than did the Normals (E = 5.12, p < .05) but no dif-

ferently than did the Nondepressed Clients (_t; = 1.57, p >

125

.10). The results were similar for measure H The

2.
Depressed Clients rated their spouses as more hostile than
did the Normals (E = 2.91, p < .01) but no more or less
hostile than did the Nondepressed Clients (E = 1.06, p >
.25).

The fourth, and final, hypothesis of this study states
that communication between depressed clients and their
spouses is more impaired than that between either other
therapy clients and their spouses or normal husbands and
wives. To test this hypothesis the three groups were
compared on the Marital Conununication Inventory. As Table
18 indicates the prediction that the Depressed Clients would
score lower on this instrument was confirmed in part. The
Depressed Clients' mean of 72.25 was significantly lower
than the Normals' mean of 101.63 (E = -4.92, p < .001) but
no different from the Nondepressed Clients' mean score of
82.25 (E = -1.67, p > .10).

To provide more information about the relationship
between severity of depression (rather than diagnostic
category) and autonomy, dominance-submission, affiliation,
hostility, and quality of communication, simple bivariate
correlations (Pearson product moment) were computed between
Beck Depression Inventory scores and scores on each of the
18 dependent measures. Table 19 presents these correla-
tions. Fourteen of the 18 correlations were statistically
reliable at the .05 level or higher. Only the measures of

affiliative, loving behaviors, Af3, Af4, and AfS' and one

126

 

ounflquoo uocowuo> eunucnoo «a

ouoawuno oocofiuo> ooaoon a

 

 

 

 

 

 

 

 

HNH. NNNH .NN.H- nucoHHo nonnonooocoz n> nucoHHo oonnououo
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nconwuoneou name I m
mom mv uOuuu
NNN. NN.NH NNN.N N Noaouo coosuom
noun M. M as no oousom
oocowuo> no nunaaosd nosoco
no.HoH mnofiuoz
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m~.~N avocado ooooounoo
coo: noouo

 

 

No I oouoom not i soduoONGsaaoo so unwouo no :onauoneoo

«a manna

127

 

 

 

 

 

 

 

 

 

goo. v Q «as
HN. v N ..
No. v N .
...HN.- Ham
Ho
COHUUUHCQEOU No mmhgmfimz
..NN. ...Nv. No.1 NH.u NH.- .NN.- ...No.u Hon
N: H: Nun 4N: NN< Nun HNa
:oNuoNHNuu4 no nauseous
«one. eaaNm. eon. aeavo. aaewm. eeHv. n~.i eaahv.l 4400.1 aaamm.i Ham
No: He: NN Hm No Ho No He NH HH

 

cocooconoouuucu i haosouat no nauseou:

 

 

cONuoofisaeEou one .coNuoanduucluamocound one :oNnoounon no auwuo>om i unoNuoaouuou

on manna

128
measure of autonomy, Az-Friendly Autonomy-Spouse, were un-
related to severity of depressive symptoms. In most
instances, the correlations between. BDI scores and SASB
ratings of one's own behavior were higher than those between
BDI scores and SASB ratings of the spouse's behavior.

As expected, the 18 dependent measures were also
inter-correlated. Table 20 presents the correlation matrix
for these measures. In several instances these correlations
are quite high (.70). This suggests that the various E-test
comparisons discussed above were providing redundant
information. To reduce this redundancy a step-wise discrim-
inant function analysis was conducted. This technique
determined which subset of measures best discriminated
between groups. The discriminant analysis reduced the space
within which the participants could be plotted from the 18
dimensions defined by the dependent measures to a more
wieldly and interpretable two dimensions. The number of
dimensions is equivalent to number of groups-1. In this
case the number of groups equahSthree, and thus the maximum
number of discriminant functions that can be derived is two.
Each dimension, or function, is a linear combination of some
optimal subset of discriminating measures. Rao's V was
chosen as the selection criterion for the step-wise analysis
because this criterion maximizes overall separation between
groups (Klecka, 1980, pp. 54-55). The computer' program

employed was that of the Statistical Package for the Social

 

Sciences (2nd Edition) (Nie, Hull, Jenkins, Steinbrenner &

 

Hooscaucoo canon.

 

 

 

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ON manna.

 

 

om.l om.i ow. mo. no. no. mo. no.1 «v.1 o~.t mv.i no.1 no.1 oo. mm. mm. Nv.

no. an. ov.i o~.1 no.1 «v.1 oo. nv. on. av. mo. mm. No.1 vn.1 0N.I «v.1

mn.l on.1 on.1 vo.i oo.| no.1 vo. on. on.

No. oo. «v.1 nv.i om.i mm.1

130

oo. mm. mm. av. om.l nm.i oN. oo. mu.l o~.I Nv. mm. on.1 oH.i u<

oo. on. em. vo.i mm.1 on. ma.1 om.l wH.I me. me. mu.l mu. u<

cm. no. ov.| Ho.i Ha. no. on.1 on.1 am. No. no. ao. Nd

am. No.1 no.1 mo.l on.l

ou.i ev.i no. mm. ma. mm. w<

 

v n N a

N
:1:

H4 u¢ u< u‘ u< <3 4:

 

..@.u:OU. ON munch

131
Bent, 1975). This analysis used the SPSS default values for
the selection criteria: tolerance, F-to-enter, and F-to-
remove. [These criteria define the minimum conditions to be
met for a variable's inclusion in a step-wise analysis.)
Table 21 presents a summary of this analysis, which
required only four steps. The four variables selected were
Il-Weighted Autonomy-Self, AZ-Friendly Autonomy-Spouse, Af -

1

Weighted Affiliation-Self, and C -MCI Score. After these

1
variables were selected, none of the remaining variables
contributed sufficient unique discriminating power to
warrant inclusion on the functions. Two discriminant func-
tions were derived, and of these, the first proved to be by
far the more powerful disciminator. A comparison of the
eigenvalues with Functions 1 and 2 reveals that Function 1
carried approximately 92% of the discriminating power in
this system. As Klecka (1980, p. 36) emphasizes, however,
the most powerful function derived in a discriminant
analysis is not necessarily either (substantively) useful or
(statistically) reliable in differentiating among groups.
(After' all, a (discriminant analysis cannot. create group
differences if the variables included in the functions are
themselves weak in differentiating among groups.) Addi-
tional measures must be employed to assess the usefulness
and statistical significance of a discriminant function.

A measure of a function's utility is its canonical

correlation coefficient. This coefficient indicates the

degree of relatedness between group membership and

132

 

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oooov.i ovoom.
Noomn. mova.Hl
N :oNuucsn a cannonsn

 

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aoH. n Voo.m gun. a mm. oo.ooH NNH. «N

coo. a o~m.~v mom. 0 no. em.um omn.~ ea

UHm no Dflmdaom ¢DQZ<A ZOHBUZDM .Aflmmou Bun NDA<> ZOHBUZDE
1H=U mxAHz KNBhd ZOZ¢U :DU IZQOHN

 

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ooo.H a usucm 0» N eoeHcN:
Noo. u No>oq oocouoaoe seeded:

> N.onz n ocean:

 

 

ownawosc noduocon unusaaduoodo onasunuum mo auoessm

an wanna

133

discriminant. function scores. One interpretation. of the
canonical correlation which can be enlightening to those who
are accustomed, as many psychologists are, to thinking in
terms of the analysis of variance, is that the correlation
is equivalent to eta. The canonical correlation squared is
equivalent to eta-squared, that is, to the proportion of
variation in discriminant function scores attributable to
group membership (Klecka, 1980, p. 37). Judged by this
criterion, only Function 1 is a good or useful discrimina-
tor. Its canonical correlation of .76 is quite high; 57% of
the variance in scores on this function can be explained by
group membership. Function 2 proves to be far less useful
in differentiating among participant groups. Its canonical
correlation is an unimpressive .33. Only 11% of the
variance in scores on this second function can be explained
in terms of group membership.

Because this. analysis includes sample, rather ‘than
population, data, it is necessary to ask whether the group
differences derived are "real" or merely the product of
sampling error. That is, one must ask whether the dis-
criminant functions are statistically significant. The most
commonly used test of significance is Wilks' Lambda (Klecka,
1980, p. 38), which can be converted to a chi-square value.
This derived chi-square value is, in turn, associated with a
specific probability level. Wilks' Lambda is an indirect
measure of significance in that it measures the residual

discrimination in the system prior to deriving a function,

134

rather than the significance of the function itself. This
is an inverse measure whose values range from zero to 1.0.
A very small lambda indicates that a great deal of discrim-
inating' power remains in the system (of ‘variables). A
lambda which approaches the maximum value of 1.0 indicates
that the remaining functions carry very little power to
differentiate among groups.

In this analysis .the Wilks' Lambda value prior to
deriving the first function is .37. This indicates that the
variables possess a fairly high degree of discriminating
power. As Table 21 indicates, this lambda was converted to
a chi-square value of 42.9, which in turn, is associated
with a .000 probability level. This means that the between
group differences are significant prior to extracting
Function 1. .After’ deriving this first. function, Wilks'
Lambda increased to .89. This indicates that little dis-
criminating power remains in the system. The chi-square
value of 5.00 derived from this Lambda is not statistically
significant (p > .10). This means that the between group
differences on Function 2 are not statistically significant.
Consequently, in this discriminant analysis, the first
function (extracted) emerged not only as the more powerful
one, but as the only one which is both statistically sig-
nificant and substantively useful.

The second stage in assessing the results of a dis-
criminant function analysis is the interpretation of the

derived functions. Only Function 1 will be interpreted

135

because it alone proved substantively and statistically
significant. In interpreting a function it is advisable to
examine both the standardized (canonical) discriminant
coefficients and the structure coefficients (Klecka, 1980,
p. 34). The standardized discriminant coefficient indicates
a variable's unique contribution to a discriminant function
score. Thus this coefficient is affected by the simultane-
ous contributions of all the other variables loading on that
function. If two or more variables are intercorrelated,
their standardized discriminant coefficients will be
adjusted to correct for this redundancy. This correction
can take the form of either decreasing the absolute value of
both coefficients, or of assigning a negative sign to one of
two equal-valued coefficients. The structure coefficient is
a simple bivariate correlation between scores on a given
variable and scores on the discriminant function. Unlike
the standardized discriminant coefficient, it is unaffected
by the simultaneous contributions of all the other vari-
ables. As such, the structure coefficient is a simpler,
more straightforward index of the relationship between a
variable and a discriminant function. For these reasons,
Klecka (1980, p. 34) recommends that the structure coeffi-
cients be given greater weight in interpreting a discrimin-
ant function.

Table 22 presents both the standardized discriminant
coefficients and the structure coefficients and recapitu-

lates the correlation matrix for the four variables selected

 

Hmoscwucoo manna.

 

 

 

NNNN. NNNN. Na
NNNN.- HNNN. HH
N onNozoN H onNozoN
mucoaoammoou ououoouum
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% HNNHN. HNNNN. Hon
1 N
NHNNN. NHNNN.- a
emomm.i vomoo. HH

 

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mucoaoammoou :oNuo:NENuomNo ooNNouoosoum mo somwuoneoo

NN GHQMB

137

 

 

 

 

 

 

 

NNN.H NNNN. HNNN. NNNN. o
NN.H NNNN. HNNN. HNa
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NN.H Ho
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vvmo. mono. HO
NNNN. NNHN. HNN

N onNozoN H onNozoN

mucowowmmooo ousuoouum

H.o.ocooo NN oHone

138

by the step-wise analysis. The standardized discriminant
coefficients are not easily interpreted when considered by
themselves. Variables 11, A2, and C2 appear to be the most
important in determining scores on Function 1. Yet I1-
Weighted Autonomy-Self and Az-Friendly Autonomy-Spouse make
opposite valenced contributions, and this is not easy to
interpret. An examination of the structure coefficients
suggests, however, that Function 1 is most closely related
to 11' Afl, and C1. Their structure coefficients are .83,
.72, and .73, respectively. That C1 correlates highly with
Af1 and A2 (r = .78, .70, respectively) probably accounts
for .Afl's lowered and .Az's larger, but negative, stan-
dardized discriminant coefficients.

Function 1 might then be best interpreted as a con-
joint measure of overall autonomy, affiliation and communi-
cation. One name which suggests itself for this function is
"Affectionate Cooperation"; that is, the interpersonal
orientation of one who is intimately involved with another
without sacrificing his/her own identity or autonomy and who
is able to adequately communicate his/her wants, needs and
feelings to his/her partner.

The third stage in assessing the results of a discrim-
inant function analysis is classification. At this stage
each case is classified according to its proximity to each
of the group centroids. [A group centroid is that coordin-

ate in n-dimensional space defined by the mean for that

group on each of n discriminant functions.] A comparison of

139

the predicted classifications with actual group membership
constitutes another test of the adequacy of the derived
discriminant functions. In this analysis, a random assign-
ment of cases to groups would, theoretically, result in a
correct classification rate of 33%. The classification
results should be evaluated in terms of this prior proba-
bility.

Tables 23 and 24 present the classification of cases
according to discriminant scores. As Table 23 indicates,
75% of all the cases were correctly classified. Only two of
the Depressed Clients were misclassified. Of the 16 Non-
depressed Clients, three were assigned to the Depressed
Clients group and two to the Normals. Five participants in
the Normals group were assigned to the Nondepressed Clients
group. These classification results are substantially
better than chance, and attest to the adequacy and utility
of the discriminant functions in differentiating among the
three participant groups.

Table 24 presents the classification of each of 48
cases. An a posteriori analysis of clinical and other back-
ground information on the misclassified cases revealed no
patterns. or’ characteristics which :might. account. for the
misclassification. The two misclassified Depressed Clients
presented no clinical or life history data which cast doubt
on their original diagnosis or obviously differentiated them
from the other Depressed Clients. Indeed, other Depressed

Clients presented. more complex: and. difficult issues for

140

 

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mN manna

n‘ei

 

141

 

Hmoscaucoo oHnou.

 

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om OHQMB

142

 

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142

 

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143

 

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144
their original diagnosis. The misclassified Nondepressed
Clients, presented too varied clinical data and life-
histories to suggest any reason for their misclassification.
Two of the five misclassified Normal participants had
reported mild psychological distress during the past two
years, but the other three misclassified participants
provided no evidence of emotional or marital difficulties.
The most reasonable, or conservative, conclusion then is
that the four variables selected in the step-wise analysis
are good, but imperfect differentiators of the participant

groups.

CHAPTER 4

DISCUSSION

The guiding premise of this study is that clinical
depression is a homeostatic mechanism in the marriages of
depressed patients. One partner's symptoms, however dis-
couraging, puzzling and vexing, may be nonetheless vital in
maintaining the marital status quo. First, a depression
maintains the status quo in that it, like other psychiatric
syndromes, can preserve a marriage when it might otherwise
disintegrate under the strain of environmental or matura-
tional stressors. The depressed partner's demands for help,
care, and sympathy deflect attention from the couple's basic
or long-standing problems and conflicts. Secondly, clinical
depression preserves the marital status quo in that its
symptoms are congruent with, or even outgrowths of, the
couple's relationship roles and rules. That one partner's
depression prevents marital breakdown cannot be observed
directly. Functional explanations are necessarily a matter
of inference. Relationship roles and rules can, however, be
reported on directly or inferred from the partners' habitual
patterns of interaction. This study asked depressed out-
patient therapy clients to report on numerous aspects of

their relationships with their husbands and wives during the

145

146

three months prior to meeting with the principal investi-
gator. This study hypothesized depression specific patterns
of marital interaction. The clinical and research litera-
ture to date suggest that the depressed patient and spouse
form a depressogenic dyad which disallows autonomy and
self-assertion, limits mature expression of affection,
transforms disagreement or dissatisfaction into overt
hostility, and prohibits open, straightforward communication
between parties. This is a symbiotic bond in which the
depressed partner's need to be cared for complements his/her
spouse's need to be the caretaker. This is not an unam-
bivalent relationship, however, for the excessive demands
placed on the caretaker and the powerlessness and dependency
felt by the identified patient give rise to mutual resent-
ment and alienation as well.

Moreover, these features of the marital relationship
were proposed as specific to the depressed client, rather
than as common to psychotherapy clients in general. Pre-
sumably, the clinicians who have written about their
depressed patients' family lives (e.g., Forrest, 1969;
Hogan & Hogan, 1974; McLean et al., 1973; Rubinstein &
Timmons, 1978) have (implicitly) compared these with the
family relationships of their other clients. Yet such
comparisons have not been discussed in their writings. Only
a very few studies (notably Hautzinger et al., 1982) have
systematically compared couples in which the identified

patient was diagnosed as depressed with couples in which the

147

identified patient received some other psychiatric diag-
nosis. Those systematic studies which have examined the
family relationships of depressed patients (notably
Hinchliffe, Hooper & Roberts, 1978; Weissman & Paykel, 1974)
have relied on psychiatrically normal adults for control
subjects. This study compared depressed outpatients, not
only with symptom free adults, but also with other
outpatient therapy clients, who might best be labelled as
"garden variety neurotics." Because this latter group
presented diverse clinical pictures and histories, no
complex or symptom specific patterns of differences between
the two clinical groups ‘were hypothesized. Rather, the
principal investigator predicted simply that the differences
between depressed outpatients and "normals" applied as well
to comparisons with other therapy clients.

The findings of this study provide considerable, but
hardly unequivocal support for its hypotheses. First, the
Depressed Clients differed from the control groups in rating
their marriages on autonomy, dominance-submission, hostile
autonomy, overall affiliation, hostility, and communication,
but not on verbal and nonverbal expression of love and
affection. In this regard the Depressed Clients evaluated
themselves and their spouses no less positively than did any
of the other participants. Secondly, on some measures
significant differences were found only for the comparison
between the Depressed Clients and the Normals but not on

those between this target group and the Nondepressed

148

Clients. This latter limitation questions whether the
hypothesized patterns of marital interaction characteristic
of depressed outpatients and their spouses are in fact
depression specific. Thirdly, the between groups difference
on some variables were limited to the participants' self-
ratings; these differences did not emerge on their ratings
of their spouses.

The results of this study suggest that it is in regard
to autonomy and interdependence that the marriages of
depressed persons differ most markedly from those of other
psychotherapy clients or of symptom-free adults. On two
SASB measures, Il-Weighted Autonomy-Self, and 141-Friendly
Autonomy-Self, the Depressed Clients rated themselves as
lower on asserting their own and promoting their spouses'
autonomous identity and decision making than did both
control groups. In rating their spouses on overall Autonomy
and Friendly Autonomy (12 and A2) however, the Depressed
Clients differed in the predicted direction from the
Normals, but not from the Nondepressed Clients.

This pattern of group differences is puzzling, for it
suggests that the impairment in asserting and promoting
autonomy in the marriage is depression specific for the
identified patient, but not for his/her spouse. This is not
to suggest that depressive symptomatology emerges and/or
persists wholly independently of the "well" spouse's
behavior. That the husbands and wives of the depressed out-

patients were rated lower on autonomy than were the husbands

149

and wives of the psychiatrically normal participants sug-
gests otherwise. One possible interpretation of these
findings is that it is the depressed patient's failure to
meet (or avoidance of) the demands of adult autonomy which
is the more significant in the emergence of depressive
symptoms. This retreat from autonomy, as some clinicians
have suggested (notably Hogan & Hogan, 1975) may well have
its source in prior significant family relationships. While
the identified patient may play the dominant role in a
relationship system that engenders depression; the ”well”
spouse plays a significant collusive role as well.

The comparisons of the participant groups on dominance
and submissiveness yielded unexpected results. The study
predicted that the Depressed Clients would rate themselves
lower on dominance and higher on submission and their
spouses higher on dominance and lower on submission than
would any of the other participants in the study. On the
SASB measures of dominance (D1 and D2), the Depressed
Clients rated themselves and their spouses as exerting, or
attempting to exert, greater interpersonal control in the
relationship than did the Normals. On these measures the
target group did not differ from the Nondepressed Clients
control group. The Depressed Clients also described them-
selves as more submissive (SASB measures 81) than did either
control group. Surprisingly, the target group also des-

cribed their spouses as more submissive than did the Normal

150
participants, though no differently than did the Non-
depressed Clients.

These results challenge the notion that the depressed
patient reverts exclusively to the passive, dependent,
child's role in his/her significant interpersonal relation-
ships, while his/her partner assumes the role of all-power-
ful parent. Instead, the evidence at hand suggests that the
depressed client and spouse are in conflict over who shall
direct the course of their life together. Apparently, the
depressed patient's attempts at control extend beyond the
passive manipulation of the depression itself. It must be
noted though, that this increased dominance on the part of
both client and spouse does not appear to be depression
specific. The increased submissiveness of the Depressed
Clients does though appear to be depression specific.

There are two different, although not necessarily
mutually exclusive, interpretations of the depressed
client's increased submissiveness. The first, and perhaps
more parsimonious account, is that the submissiveness is an
aspect of the increased helplessness which is a symptom of
depression. An alternative explanation is that the
depressed partner's submissiveness is a pervasive feature of
his/her marital relationship and that the overt helplessness
of acute depression is an extension or outgrowth of this.
These alternative explanations raise the difficult question
of the direction of the casual link between submissiveness

and clinical depression: Is submissiveness merely a symptom

151
or by-product of depression or is it a precondition for the
emergence of clinical depression in the :marital system?
Unfortunately, the evidence collected in this study cannot
answer this question. An answer to this question requires
information gathered both prior to and following, as well as
during a client's depressive episode.

One of the more surprising results of this study is
that the Depressed Clients described their spouses as more
submissive than did the Normal Controls. This challenges
the notion that the "well" spouse is, or at least is per-
ceived to be, the all-potent parent figure in the relation-
ship. This increased submissiveness may be simply an
attempt at appeasing or pacifying the unhappy spouse, whose
symptoms may be taken as the reproach they in fact may be.
A second possibility is that the "well" partner yields to
and accommodates the identified patient because s/he too
would wish, though unconsciously, to retreat from adult
responsibility and the role of the caretaker. As several
clinicians (Forrest, 1969; Rubinstein & Timmons, 1975) have
noted, the marriageSof some depressed patients are shaped by
an underlying conflict over who shall be the dependent,
cared for one.

The finding that the spouses of the Depressed Clients
were rated as more submissive than the spouses of the Normal
control subjects raises the intriguing question of whether
and how this submissiveness might contribute to the

identified. patient's} depression. One ;possible answer is

152

that the spouse's submissiveness reinforces an underlying
marital agreement that this is a relationship based on the
model of parent and child, that is, of mutual dependency.
While the partners may battle over or exchange roles, the
relationship's structure remains unchallenged. Autonomous
action and decision making, which are essential features of
adult-to-adult relationships, are avoided, if not actually
prohibited in such a relationship. The "well" partner's
submissiveness may serve to remind the depressed partner
that any fundamental change in the relationship rules is
impossible.

The relationship roles and rules of depressed out-
patients and their spouses may limit or even prohibit each
partner's autonomy, but they do not ensure a harmonious,
uninterrupted symbiosis. On the contrary, the Depressed
Client's ratings indicate that their marriages are punctu-
ated by considerable, mutual alienation. These participants
rated themselves as more likely to withdraw from or dismiss
their spouses in times of anger and hurt than did either the
Nondepressed Clients or Normal participants. The Depressed
Clients also rated their spouses higher on hostile autonomy
than did the Normals, but no differently than the Non-
depressed Clients. Thus, in the depressed patient's
marriage autonomy apparently assumes the negative, even
degenerate, form of alienation.

There are (at least) two interpretations of the

association between hostile autonomy and clinical

 

 

 

 

153
depression. First, mutual alienation may be a response to
the depression itself. The depressed spouse withdraws in
anger from a partner who cannot or will not meet his/her
exaggerated, and often inarticulate, demands for help, care
and reassurance. Similarly, the "well" partner becomes
frustrated and angered by his/her spouse's demands and walls
him/herself off. An alternative interpretation is that
hostile autonomy is a precursor and reinforcer, as well as a
concomitant, of depressive symptomatology. A relationship
system which disallows mature, straightforward expression of
needs and wants and which constrains husbands and wife to
(assume) either the child's or the parent's role can grow
unbearable for both partners. Such a system allows for
little self-correction. Rather, the only relief from its
constraints, the only means of protest the system allows is
flight and isolation. The "well” partner retreats from the
identified patient's dependency and/or dominance and thereby
precipitates, or at least reinforces, the partner's feelings
of despair and helplessness. Conversely, the "sick" partner
may retreat in protest from his/her spouse's domination and/
or failure to meet his/her dependency needs. Angry with-
drawal not only precludes more effective communication,
which might resolve basic marital conflicts and misunder-
standings, but also intensifies the depressed partner's
feelings of helplessness, sadness, and futility. The
evidence collected in this study cannot by itself confirm

either of these interpretations. More extensive data,

154
gathered both prior to and following depressive episodes is
needed to determine the temporal, and ostensibly causal,
connections between hostile autonomy and depression.

It is with respect to the expression of affection and
of hostility that the marriages of the depressed outpatients
differed least from those of the control subjects. The
results of this study provide little support for its
hypotheses concerning these variables. The findings fail to
confirm the key hypothesis that the depressed patient
inhabits an affectionless and emotionally unrewarding family
environment. On the three measures of affiliation and
verbal and nonverbal loving behaviors, Af3, Af4, and Afs,
the Depressed Clients' ratings of themselves and of their
spouses were no lower than those of either the Normals or
the Nondepressed Clients. The Depressed Clients reported
that they and their spouses exchanged as many verbal and
nonverbal tokens of affection, offered each other as much
help and support, and welcomed physical/sexual contact as
muchx as did. the participants who reported no emotional
distress or psychiatric symptoms.

That the Depressed Clients scored no lower on the Love
Scale (Afs) than the Normals control group is particularly
noteworthy, because this scale appears to be a good index of
generalized marital dysfunction and unhappiness. Research
on the Love Scale has shown that scores on it are signifi-
cantly correlated with other measures of marital satisfac-

tion (Swensen, 1978) and are significantly lower among

 

155
couples seeking' professional. marital. counseling (Fiore &
Swensen, 1977). Thus, the target group's "normal" scores on
this measure suggest that the depressed patient's assessment
of his/her marriage involves more than the commonplace com-
plaints of discord and unhappiness.

This is not to suggest that the depressed patient's
marriage is entirely happy, adaptive or growth promoting.
The Depressed Clients' high scores on hostile autonomy and
hostility indicate otherwise. Rather, this finding of
"normal" levels of affiliation and affectionate exchange in
the marriages of the Depressed Clients suggests that what-
ever is amiss in their marriages lies beyond such overt
issues as whether these couples are physically affectionate,
whether they assist each other with household chores or job-
related tasks, or whether they remember each other's birth-
days.

Several clinicians have observed that the marriages of
their depressed. patients may appear to be quite happy.
Rubinstein and Timmons (1978) have suggested that the bond
between the depressed patient and spouse as overclose and
overwarm. The Bristol research group (Hinchliffe, Hooper &
Roberts, 1978) has observed that the marriages of (many of)
their depressed patients are superficially adequate and
supportive. On the surface there are few signs of conflict,
but on a deeper level the interaction is quite negatively

toned.

 

156

The mutual affection and concern reported by the
Depressed Clients did not, however, preclude reports of high
levels of hostility in their marriages. This target group
rated themselves (H1) and their spouses (H2) as higher on
hostility than did the Normals control subjects. This find-
ing accords with previous findings of higher than ”normal"
levels of overt friction between depressed women and their
husbands (Weissman & Paykel, 1974), of increased levels of
marital conflict during and after depressive episodes
(Rounsaville et al., 1979, 1980), and of depression related
increases in overall hostility level (Fava et al., 1982).

The temporal and causal connections between hostility
and clinical depression, however, remain undetermined. The
hostility the Depressed Clients reported may be simply a
reaction to the depression itself. The ”sick" partner's
anger may be little more than an expression of frustration
and disappointment with a spouse who can neither alleviate
his/her depressed mood nor restore his/her self-esteem and
self-confidence. Similarly the "well" spouse's anger may
simply reflect his/her frustration and resentment in the
face of the depressed partner's constant and strident
demands for help and reassurance.

An alternative account of the depressed couple's
hostility is that, as the Yale researchers have suggested
(Rounsaville et al., 1979, 1980; Weissman & Paykel, 1974),
it is a pervasive and enduring feature of the marriage.

While the hostility may intensity during symptomatic

 

157
episodes, conflict and resentment both antedate and persist
after the acute depressive periods. Both partners are
angered by a relationship system which perpetuates mutual
dependency, but. which fails to satisfy their dependency
needs.

Moreover, increased hostility and marital conflict
have not been shown to be depression specific. The studies
previously cited (e.g., Fava et al., 1982; Rounsaville et
al., 1979, 1980; Weissman & Paykel, 1974) did not compare
depressed patients with other diagnostic groups. In this
study, the Depressed Clients reported no higher levels of
hostility than did the Nondepressed Clients.

Considered conjointly, the findings pertaining to
affectionate behavior and. to hostility suggest that the
marriages of depressed outpatients are not so much loveless
as ambivalent. These results can also explain. why the
Depressed Clients scored lower on the two measures of
overall affiliation (Afl-Weighted Affiliation-Self and Afz-
Weighted Affiliation-Spouse). These two SASB scores take
into account a subject's ratings on all 72 items on a sur-
face. These include ratings of both affiliative and hostile
behaviors. The between group differences on these measures
may thus be explained as a function of the Depressed Clients
group's high scores on hostility (H1 and H2) and hostile
autonomy (HA1 and HA2), rather than of their ratings on

affiliation and affection.

158

The results of this study support the hypothesis that
communication between the depressed patient and his/her
spouse is impaired. The Depressed Clients scored signifi-
cantly lower on the Marital Conununication Inventory (MCI)
than did the Normal control group. The mean MCI score of
this target group was 72.25, which is 1.75 standard devia-
tions below the mean score of 105 for the normative samples
on which this instrument was developed and validated
(Bienvenu, 1970, 1978). The mean score of the Depressed
Clients is also comparable to the mean score of 79.56 for
the group of 16 depressed female inpatients studied by Wasli
(1977).

This impairment in communication cannot, however, be
said to be depression specific because the difference in MCI
scores of the two client groups was not statistically sig-
nificant. The failure to find. a significant difference
between the Depressed and Nondepressed client groups may be
a function of the questionnaire used. The Marital Communi-
cation Inventory can hardly be described as a complex
instrument which probes for qualifications, nuances, and
inconsistencies between message and Emma-message levels of
communication. Rather, its straightforward questions ask
whether husband and wife confide in each other or refrain
from discussing problems and feelings, whether they argue
over money matters or can disagree without losing control of
their tempers. It does not ask precisely how, or with which

words, husband and wife make requests or demands of each

 

159
other, or register complaints, whether and how long partners
will discuss a problem until they reach a solution, whether
and when humor or anger enters a conversation or precisely
how each partner responds to criticism. The Marital
Communication Inventory, thus, provides only a first-line
indictation of impaired communication.

Yet, on further reflection it may be that the critical
question is not whether impaired communication is depression
specific, but rather, which aspects of impaired communica-
tion are depression specific. If as family-systems
theorists contend (e.g., Jackson, 1968) psychiatric symptoms
preserve relationship roles and rules, and such roles and
rules are embodied in patterns of communication, then, one
might expect to find faulty communication patterns in the
marital or family units of any (diagnostic) group of psycho-
therapy clients. Recent studies by the Bristol group
(Hinchliffe et al., 1978) and by Hautzinger and colleagues
(Hautzinger, Linden & Hoffman, 1982) have attempted more
complex and sophisticated analyses of the communication
processes between depressed patients and their spouses.
Only the latter study compared depressed client couples with
a psychiatric control group, and it did reveal depression
specific impairments in marital communication.

The findings of the present study indicate that some-
thing is indeed. amiss in the patterns of communication
between depressed clients and their husbands and wives. The

Depressed Clients group reported greater reticence, tension

 

160

and friction on the part of both spouses than did the
symptomrfree participants. What is needed. now is addi-
tional, detailed information about which topics of conversa-
tion are broached and which are avoided, and how and when
tension and friction are expressed and how these are
resolved or dissipated, etc. Such information may illumin-
ate whether and how impaired communication contributes to
the identified patient's depression.

This study compared its three participant groups on
multiple measures of autonomy, dominance-submission,
affiliation-affection, hostility and quality of communica-
tion, as if these variables were independent of each other.
While these are theoretically distinct, they in fact appear
to be related to each other. The correlations among the 18
dependent measures indicate, for example, that quality of
marital communication correlates quite highly with friendly
autonomy (.65, .70) and overall affiliation (.78, .82) and
negatively with hostile autonomy (-.62, -.73) (see Table
20). A posteriori, these correlations are hardly puzzling.
It seems most plausible that partners who communicate well
are those who are warm and close with each other and who are
self-assertive, independent, and noncontrolling. Yet the
strength of these associations could not necessarily have
been predicted a priori. Moreover, these correlations
indicate that the between groups comparisons on all 18

dependent measures entailed a fair amount of redundancy.

 

 

161

The step-wise discriminant function analysis revealed
that a linear combination of three SASB measures, Weighted
Autonomy-Self, Friendly Autonomy-Spouse, and Weighted
Affiliation-Self plus the Marital Communication Inventory
Score, performed best in differentiating among the three
groups. The name of this combination which suggests itself
to the principal investigator is ”Affectionate Cooperation"
because cooperation would seem to be the interpersonal
stance of one who maintains his identity and autonomy in a
loving, intimate relationship and who communicates effec-
tively with his partner. While it is tempting to suggest
that it is precisely a deficiency of "Affectionate Coopera-
tion" which distinguished the Depressed Clients from the two
control groups in the study, some caution is in order. The
inclusion criterion used in the step-wise analysis, Rao's V,
is one which maximizes overall group separation, rather than
separation between one group and all the others. Moreover,
the one statistically significant discriminant function
derived in this analysis performed well, but imperfectly, in
differentiating among groups.

The between groups overlap on discriminant function
scores was large enough to misclassify 12 of the 48 cases.
There are two competing explanations to account for these
misclassifications. The first, and more problematic pos-
sibility, is that these 12 participant cases were initially
miscategorized. The alternative account is that the initial

categorization of cases was essentially correct, but that

 

 

162
the dependent measures, and consequently the discriminate
function derived from these, are at best imperfect in
differentiating among groups.

Five of the apparently symptom-free psychologically
normal participants were classified with the Nondepressed
Clients. This may not be so surprising or puzzling on
further consideration. One possible reason for these mis-
classifications is that seemingly' healthy ‘volunteers *who
agree to participate in a psychologist's study of marriage
are more likely to be concerned about or dissatisfied with
their marriages. They may be concerned about aspects of
their marriages which may well prove to be the source of
future conflicts and/or symptoms. A second possibility is
that any sample of the "normal" adult married population,
will include a subset whose marital interaction pattern
resembles those of a clinical population. Such similarity,
though, entails) no conclusions about risk; of subsequent
emotional or psychiatric disturbance. The former explana-
tion suggests that, in. effect, five "normal" volunteers
miscategorized themselves. The latter explanation implies
that certain patterns of marital interaction, although more
prevalent in a clinical population, are hardly unique to
that group. The evidence gathered in this study cannot
eliminate either alternative. [The relatively high per-
centage of misclassified cases (five of 16) suggest to this

author that the first explanation is the more probable.]

 

163

The misclassification of the client participants
raises more difficult issues. These participants had been
interviewed and assessed by two clinicians, yet their
classifications by discriminant function scores placed two
Depressed Clients in the Nondepressed Clients groups and
three Nondepressed Clients in the Depressed Clients group
and two in the Normals group. These misclassifications may
be attributed to initial miscategorizations. Such diagnos-
tic errors might be due either to limitations in the
principal investigator's skill and/or her access to
pertinent diagnostic information or to inadequacies of the
diagnostic guidelines employed.

The possibility of diagnostic error is mitigated by
several considerations. First, an a posteriori review of
all the participant cases revealed no systematic differences
between those participants who were correctly and those who
were incorrectly classified. Secondly, several of the
correctly classified clinical cases had initially posed
diagnostic difficulties for the principal investigator and
the referring clinician. Thus it is dubious that the mis-
classified cases were precisely those that had been miscate-
gorized to begin with, although the available evidence
cannot disprove this possibility.

An alternative, and more plausible, explanation for
the misclassification of cases is that the original assign-
ment of cases to groups was essentially correct, but that

the 18 discriminating variables are imperfect group

 

164

differentiators. A classification of cases based on dis-
criminant function scores derived from these measures would
then be expected to include some errors. The Depressed
Clients differed from the Normals on all but three of the 18
dependent measures, but on only four measures (II-Weighted
Autonomy-Self, Al-Friendly Autonomy-Self, Sl-Submissiveness-
Self and KAI-Hostile Autonomy-Self) did this target group
differ from the Nondepressed Clients as well. The misclas-
sification of at least a few client cases is thus not
surprising in light of this pattern of group differences.
The findings that the Depressed Clients differed from the
Nondepressed Clients on only four dependent measures and
that seven of the 32 client participants were classified in
the wrong client group challenge this study's basic
hypothesis that the marital interaction patterns character-
istic of depressed psychotherapy clients and their spouses
are depression specific.

The author hypothesized that the marriages of de-
pressed outpatients are uniquely characterized by decreased
autonomy, increased hostile autonomy, decreased affection,
increased hostility, and impaired communication. Not only
were the Depressed Clients' ratings of affectionate, loving
behaviors no lower than those of either control group, but
their ratings of dominance, hostility and impaired communi-
cation differed only from those of the Normals group. Yet,
these latter dependent. measures correlated significantly

with scores on the Beck Depression Inventory. All but four

 

165

dependent measures, three of affiliation (Af3, Af4, Afs) and
one of the spouse's Friendly Autonomy (A2) correlated
significantly with this measure of severity of depression
(see Table 19), although for only four measures (11, Afl, S1
and. HA1) were the between. group) differences depression-
specific. These seemingly inconsistent findings can, how-
ever, be reconciled.

The mere presence of depressive symptoms does not by
itself specify a diagnosis of primary unipolar depression.
On the contrary, depressive symptoms accompany a variety of
psychiatric and medical disorders (Beck, 1972, p. 73).
Consequently, a statistically significant, but. moderate,
correlation between symptom severity and some other variable
does not. entail a significant relationship» between that
variable and the diagnosis of primary, unipolar depression.
Many of the Nondepressed Client participants, it will be
recalled, reported low mood and other symptoms of depres-
sion. These participants also reported above normal levels
of hostility and of dominance as well as impaired communica-
tion in their marriages. Thus just as depressive symptoms
appear to be common to a wide range of therapy clients, so
too increased dominance and hostility and impaired communi-
cation appear to be common to their marriages as well,
regardless of primary diagnosis. These characteristics of
marital interaction appear to be associated with the
presence of depressive symptoms, but not with a diagnosis of

primary depression.

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166

On the other hand, four dependent measures, Weighted
Autonomy-Self, Friendly Autonomy-Self, Hostile Autonomy-
Self, and Submissiveness-Self} did. differentiate the
Depressed from the Nondepressed Clients participating in
this study. These measures were also those which correlated
highest with the Beck Depression Inventory (see Table 19).
This suggests that it is precisely these variables which
differentiate psychotherapy clients who report some symptoms
of depression from those whose current clinical picture is
dominated by more pronounced and pervasive depressive
symptomatology.

The finding that it is the dependency relationship,
marked by lowered autonomy and increased submissiveness and
alienation which uniquely characterizes the marriages of
depressed psychotherapy clients concurs with the research
findings and clinical observations of several other authors.
Overall (1971), for example, working from data gathered from
a very large sample of psychiatric patients, has concluded
that depression is particularly related to dependency rela-
tionships in less than adequate social settings. Several
clinical writers, notably the Hogans (Hogan & Hogan, 1975)
and Rubinstein and Timmons (1978) have observed that the two
person dependency relationship is the core feature of the
depressed patient's family system.

The third limitation on the extent to which the
evidence gathered in this study confirms its hypotheses is

that the depression specific between group differences

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167

emerged only for the participants' self-ratings. On none of
the dependent measures were the comparisons between the two
client groups' ratings of their spouses statistically sig-
nificant. The Depressed Clients rated their spouses less
favorably on Weighted Autonomy (I2), Friendly Autonomy (A2),
Dominance (DZ), Submissiveness ($2), Hostile Autonomy (HA2),
weighted Affiliation (Afz), and Hostility (H2) than did the
Normals, but no differently than did the Nondepressed
Clients. This suggests that the husbands and. wives of
depressed outpatients, do not behave, or are not perceived
to behave, as "normally" or desirably as the husbands and
wives of psychiatrically normal, symptom-free adults. On
the other hand, this target group of spouses appears not to
differ from the spouses of other psychotherapy clients.

Two different, but not necessarily mutually contra-
dictory, interpretations. can. account. for' the udiscrepancy
between the Depressed Clients' self-ratings and their
ratings of their spouses. One interpretation is that the
depressed partner plays the dominant role in defining this
abnormal marital relationship while the "well" spouse plays
a secondary but necessary role as well. That the depressed
partner assumes the dependent, submissive role in no way
diminishes his/her power in defining the marital system.
The identified patient's critical role in defining this bond
is thus reflected in his/her extreme self-ratings. An
alternative explanation is that the depressed patient's

extreme, negative self-ratings on autonomy (11, A HA1) and

1’

 

 

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168
on submissiveness (SI), are but expressions of the negativ-
ism, self-blame, and sense of powerlessness which are
aspects of the depressive experience itself.

The former interpretation suggests that the well
spouse's role in the emergence and maintenance of his/her
partner's depression is less important than this study has
assumed. This study has presupposed, although it has not
explicitly hypothesized, that the two members of the
depressive dyad contribute equally to a unique pattern of
depressogenic interactions. The evidence gathered in this
study does not support this view. The latter account of the
Depressed. Clients' extreme self-ratings, if' it .alone is
correct, more seriously undermines a family systems inter-
pretation of clinical depression. Such an account denies
that depression is a homeostatic mechanism, is both the
product and perpetuator of a couple's basic relationship
rules. Again, the data gathered. here is inadequate to
decide between these two interpretations.

Two very important caveats must be included in the
discussion of this study's findings. The first is that
these findings are of limited generalizability. The second
caveat is that, the author's obvious theoretical predelic-
tions notwithstanding, the study's findings do not
constitute proof of a causal relationship between marital
interaction patterns and the emergence and maintenance of

primary depression.

 

 

 

169

The findings of this study are of limited generaliza-
bility because the principal investigator was able to
interview and query the identified patient partner only once
during the course of his/her treatment. Moreover, the
questionnaires employed asked a participant to assess his/
her own and his/her spouse's behavior for only the three
months period prior to meeting with the principal investiga-
tor. The limitations of such a data base are obvious.

First, the inferences drawn from this data. apply,
strictly speaking, to the participants' perception of their
marital interaction, rather than to the behavior itself.
This is particularly true of inferences about the partici-
pants' spouses. These inferences are based on second—hand
reports. Had these spouses all rated themselves and their
partners, a different, although not necessarily more honest,
accurate or objective, picture of their marriages might have
emerged as well. Thus, strictly speaking, one cannot
generalize from the participants' perceptions of their own
and their spouses' behavior to the behavior itself. Yet
information about perceptions of interpersonal interaction
is certainly not without value, for such perceptions no
doubt influence overt behavior and emotion.

A second limitation on the generalizability of these
findings is that they pertain only to the three month period
prior to participation in the study. Whether the patterns
of interaction characteristic of the weeks including the

onset of symptoms is characteristic of the depressed

 

170
patient's marriage in general cannot be answered by this
study. It can be argued that these marital interaction
patterns are specific to the depressive period. Two com-
ments are in order. First, it is assumed that the patterns
of increased. dominance and submission, hostile autonomy,
hostility, and of impaired communication are more pronounced
during clinical episodes. Secondly, other research evidence
indicates that these features of the marital relationship
are not unique to the symptomatic period. Weissman and
Paykel's (1974) study revealed persistent overall impairment
in the depressed women's performance in the marital role up
to one full year after symptomatic recovery. These
researchers also noted that at least half of the marriages
of the 27 depressed women who were living with their
husbands to be chronically difficult and unstable prior to
symptom onset. Additional reports from the Yale depression
research group (Rounsaville et al., 1979, 1980) indicate
that conflicts between depressed women and their husbands
persisted for months, and in some cases, even years after
symptomatic recovery. The Bristol research group
(Hinchliffe et al., 1978) has also reported that the highly
negatively toned quality of the communication between
acutely depressed women and their spouses was evident at
symptomatic recovery as well. The reports on the marital
and family treatment of depression (see Feldman, 1976;
Forrest, 1969; McLean et al., 1973; Rubinstein & Timmons,

1978) also imply that the excessive interdependency and its

 

171
concomitant impairment in communication and affect exchange
is an enduring characteristic of the depressed patient's
intimate relationships.

The third limitation on the generalizability of these
findings is that they apply only to outpatients in psycho-
therapy. The patterns of marital interaction documented in
this study may not apply to all people experiencing clinical
depression. First, the patterns of interdependency,
hostility and communication may differ for couples in which
one partner's depression is so severe as to warrant hospi-
talization. For example, as Forrest (1969) has observed,
the marital interaction of these inpatients may be virtually
devoid of overt friction and hostility. Secondly, not all
people who become clinically depressed seek psychotherapy.
It may be that their marriages differ from those of
depressed psychotherapy clients. Indeed, the possibility
that anyone seeking such therapy is more likely to describe
his/her marital and family relationships in highly negative
terms (in order to justify his need of help) cannot be as
yet ruled out.

The second critical caveat in interpreting the
evidence collected and presented here is that it provides no
proof of a causal connection between marital interaction and
clinical depression. This data pertains only to the client
participants' marriages during a three month period which in
many cases included symptom onset. Such limited data cannot

specify which came first, the abnormal marital interaction

 

 

 

172
patterns or the symptoms of depression, and thus cannot
demonstrate causal connections. Unfortunately the practical
realities of research with a clinical population makes it
exceedingly difficult to establish conclusively the
temporal, and thus presumably, causal, connections between
marital and family processes and symptom onset.

Ideally, a research project would interview and query
clients both prior to symptom onset and following sympto-
matic recovery, as well as during the acute symptomatic
phase. Yet researchers cannot easily identify and query
clients before they first become symptomatic. While it is
preferable to interview clients as early in the treatment
process as possible, even data gathered then must be inter-
preted with caution. Retrospective accounts of marital and
family processes gathered at intake interviews may be
affected by the client's having been symptomatic for weeks
before requesting help. Data gathered after symptomatic
recovery must also be interpreted judiciously. Marital
interaction patterns following recovery are not necessarily
identical to those of the premorbid period. One cannot
assume that. a marriage remains unaltered by the couple's
experience with the identified patient's depression. This
experience may have permanently altered each partner's per-
ception of him/herself, his/her spouse and/or the marriage.
Long-standing conflicts and resentments may have been per-
manently exacerbated by the identified patient's sickness.

Thus, even extensive data gathering, while necessary and

 

 

173
desirable, may not be able to demonstrate conclusively the
temporal connection between interpersonal processes and the
onset and maintenance of clinical depression.

This limitation which seems to be unavoidable in many
clinical research projects, poses a critical problem for the
researchers who adhere to a linear model of causality. If,
on the other hand, one assumes, as a family systems-frame-
work does, that causal connections within family processes
are circular, rather than linear (von Bertalanffy, 1974),
the question of which phenomenon precedes which, the inter-
personal interaction process or the emergence of symptoms,
diminishes in importance. This is not to suggest that a
family systems conceptualization needs only limited data for
confirmation. On the contrary, a family systems researcher
needs as extensive information about family and .marital
roles and rules preceding, during and following a clinical
depression as does any other researcher.

Yet a family-systems framework, which employs such
concepts as deviation amplifying feedback mechanisms
(Wender, 1968), can more easily accommodate data in which
the temporal sequences of interpersonal process and symptom
onset remain imprecise, for such a theoretical framework
assumes that these variables are mutually causative. If one
assumes that interpersonal processes can give rise to
psychiatric symptoms, which in turn influence those
processes; then some degree of uncertainty as to which

occurred first is far less intellectually troubling than if

174
one assumes that causal connections are linear and intransi-
tive.

Admittedly, all that this study has demonstrated is
the co-occurrence of depressive symptomatology with certain
abnormal features of marital interaction which has been
proposed as congruent with the symptoms themselves. Yet
this evidence can be construed as preliminary additional
systematic support for a family—systems conceptualization of

depression.

 

 

Appendices

175

APPENDIX A

Target Groups

Clients
1. Age - 20-60 years

2. Currently married (or cohabitating) and not separated
extensively during past three months.

 

 

 

Depressed Clients Nondepressed Clients

A client will be included A client will be included

in this group if he/she: in this group if he/she:

a. Receives a diagnosis of a. Presents symptoms/com—
of primary, unipolar de- plaints associated with
pression agreed on by two one of the following
clinicians. diagnoses: anxiety neu-

rosis, phobic neurosis,

b. Scores 18 or higher on obsessive-compulsive
the Beck Depression neurosis, hysteria, sex-
Inventory. ual disorder, character

disorder, schizophrenia

c. Has not received shock in remission, borderline
therapy in past six personality organization
months.

b. Does not receive
d. Is not psychotic. the diagnosis: primary
unipolar or bipolar de-
pression, alcoholism/
alcOhol abuse, organic
brain syndrome, mental
retardation.

c. Does not score above 13
on the Beck Depression
Inventory.

 

d. Has not received shock
therapy in past six
months. ‘

e. Is not psychotic.

1.

S.

176
APPENDIX B

Guidelines for Briefing Client Participants

Inform about the research project:

Subject/purpose: To learn more about the marriage
relationship of men and women who have been exper-
iencing problems similar to the client's.
Principal Investigator: Paula C. McNitt of
Charleston, Illinois (if client seems concerned
about credentials, mention that McNitt, an exper-
ienced psychologist, is a doctoral candidate at
Michigan State University, who has worked at men-

tal health facilities in East Central Illinois).

Invite/urge client to participate:

Explain that client's participation will provide the

mental health center with useful information which

may help in the client's treatment.

Clients will be paid $5.00 as a “Thank-you" for their

participation.

Outline what participation will involve:

a.

b.

Client will be interviewed by Ms. McNitt. Inter
view will last up to one hour.

Husband/wife may (if willing and able) be inter
viewed by Ms. McNitt. Interview will last about
one hour.

Client (and spouse optional) will complete several
questionnaires. This should take about one hour.

Reassure clients that all information they provide

will be kept in strictest confidence.

Offer feedback session in which questionnaire answers

will be reviewed and interpreted.

 

177

APPENDIX C

Diagnosing Primary Unipolar Depression

 

This is less iaposing than it sounds. basically. this diagnosis applies
to clients the are depressed and for whoa depression is the prison 'fs'échiatric
gates; rather the an adjunct to seen other pro-existing psyc atr c t
sue as schisophrenia or alooholisa.

The following diagnostic criteria will be used (Note parallel structure in .. ,_
M of Diagnonic lnforntion) . 1

A. Dyaphoric Ibod I Sad, blue, discouraged. hopeless, irritable. fearful. wor-
ri

I. At least four of the following:

l. Poor appetite or weight loss (or gain)‘

2. Sleep difficulty - insomia, hyperso-Iia. or early nrning wehoning

3. boss of energy, fatigability or tiredness

d. Agitation: or retardation

5. loss of interest in usual activities or decreased libido

6. Feelings of self-blaao, self-reproach or guilt

1. Oleaints of or actually diainished ability to think or concentrate

I. Recurrent thoughts of death or suicide. including thoughts of wishing to
be dead

c. Depressive syntoas lasting at least 2 to 3 weeks with no pro-existing
psychiatric condition such as:

1. Anxiety Msisu‘l'his refers to chronic free-floating anxiety with
recto-rent anxiety attacks. Ibst dipressed clients report anxiety. ad
soaetiaos experience anxiety prior to the onset of a depression, as if
to fight off the letter. If, however. the anxiety symptoms are long
standing and doainste the clinical picture, assess as anxiety nemesis
rather than priaary depression. lf anxiety merely aceoqenies or fore.
shadows the depression. assess as priaary depression.

2. Phobic Mair-This refers to clear—cut phobias of the type described
in textbooks.

3. steria (This is a sore difficult diamosis.)--‘l'his refers to comer-
s on syaptoas and fugue states. as well as chronic. vague aultiple mox-
plained aedical coaplaints. (Use clinical judgnent here). Note: A
priaary depression say be seen in clients shose personality style night
be called "hysterical", i.e. i-aturity. labile aoods. psmdohypersexu-
ality. etc. .

d. Obsessive-C lsive Neurosis-J'his refers to obsessive thoughts and
fantasies an: I(go—spills!“ behaviors. rituals. and 12; to the obsessive-
coapulsive neurotic personality style.

 

178

S. Alcoholism/Alcohol Abuseu‘lhis refers to the condition as -described in
nst textEEEs. He—evy drinking nay accoqaany depression, especially in

.aen. lf increased drinking is specific to the depressed period and does
not overshadow the latter, assess as priaery depression. if it is too
difficult to decide whether the drinking or the depression is the pri-
aary condition, diagnose the depression as figgog.

6. Waffle refers to dependency on street drugs or abuse of
prescript on rugs Idlich antedates the depressive syaptoas.

7. Antisocial Personalit «Disgrace only if strong evidence of chronic
delmcy, antisocial behavior. vagrancy. myocational and/or

nrital asladjustaent.

d. Schismreniao-Assess by either presenting smtoas, or history. by
so -report or clinical record o_r_ by aedicstion history. Present or
past use of any of the aajor tranquilizers, such rs Navane, Hellaril, or
Thorotine. should be taken as prise facie evidence of schizophrenia.

 

9. Sense! Deviations-Jhis refers to deviations such as transennlity, or
seams ty rs r than to semi dysfmction.

10. m1: Drain SM

11 . 'hental Retardation

12. Life Threat-ling lllness

D. No evidence of Mic Episodes--Assess in terns of history or of lithiu-
treatasnt.

 

I.

A i’ll-yt'nt-ultl tn.tlc sought p~ytltinttic as-
sisnmcc dming tltc wintct quarter of his
tltitd ycatt itt .1 highly cmnpctititc cnllcgc. Hc

was of supctinr intelligence and tinting thc .

pt etc-ding two years had «asked hard
enough to bring his cumulative grade point
average f t otn C-minus to a solid 3 average.
However. he had not found much satis-
faction in his work and was currently ex.
pt “sing uncertainty regarding his voca~
tional goals. He was quite inltutct'tcd. had
nor participated itt many athletic or social
actititics. and tended to become deeply in-
voltcd in relationships with a few other
students of both sexes and to lit-come disap-
points-d when they failed to reciprocate or
liyc up to his expectations. .

The deptt-ssion that led to his seeking
psychmhcrapy had been pt ccipitntcd by the
loss of his current girl friend. but he did on
report this immediately. His presenting
complaints were as follows. "l’vc been de-
pressed -just different things bothered me.
My relation to my parents I can't be free of
them. and my ideas are very different front
theirs. And I have a strong fear of social
gatherings. and inability to make friends.
And my home life was very unhappy. My
parents have net been happy. it's been more
like a battleground than a home. The depres-
sion comes and goes. Sometimes I feel I
don't want to do anything. Sometimes I go
for months thinking that the world doesn't
make sense. lf my feelings didn't change 1
would't want to go on living. In high school I
remember feeling miserable because my
parents naggt-d me. In the seventh grade I
wished I could put aside the next ten years
and live my own life.“

179

APPENDIX D

Sample Case His tories

A thirty-six-ycet-old tcscutch chemist was referred '
[or analytic treatment because of complaints of
severe chronic fatigue. excruciating. neatly con-
stant headaches. weekncss. sexual malmlinstment.
and various minor somatic complaints. 83: chance.
he was on the toll and thin side. with a typical
osthem’c [nonothlcu’c] build and impdllcct posture.

l-lt's fatigability was such that the slightest exen
tion was completely exhausting. He had gradually
reduced his working time to a total of only four
hours per day. When lfirst saw him. he was on the
point 0! giving it up entirely. During thc remainder
of his time. which was spent Strictly at home. he

_ carefully alternated each fiftccn to thirty minutes

of activity with one half-hour of reclining.

Thcsc measures were torelly incficcrtvc in reduc-
ing his fatigue. Hc had experienced progressive
difficulty in concentration. Together with his sc-
verc headaches. thcsc symptoms had resulted in an
increasingly restricted social lit'c. a situation futct'gn
to his prcvious nature. Life had bccomc so tntulctu-
blc that he had bccn on the point of sutcidc He
chose psychiatric treatment in what amounted to a
lost desperate resort. bat-ing visitcd half a dozen
physicians in various fields in his search for an
organic basis and cure of his terrible symptoms.

.. "air patient. however. proved -
an apt candidate [or intensive treatment and even-
tuolly. during the course of more than {our years of
treatment—on a tbtce-tt'mcs. and later two-times a
week b..st's—hc stepped having his headaches en-
tirely. His fatigue also complctcly subsided. For
more than two years he has worked full-rim: and
has been able to resume his t'urmct level of social
acriwty. (p. 486)

 

 

180

3’ ‘ Case 7 —-L. C—. a married woman. art 33, was admitted to hospitai on llctc‘ml-ct
at. tozl. There was nothing noteworthy tn the family history save that her grand-
father had been insane She had done well at school: was sulweqoently a telephone
girl. until her marriage at the age of 26 She had been engaged for two years
before. She had never become pregnant. Coitns occurred twice a week. With
no contrateptise measures; there was dyspareunia soon after marriage and no
gratification until recently. lier periods had always been nit-polar and she had
been depressed just before the onset. Ten years hefOte (totS) she had a' ‘nen ous
brealtdow’n .during which she was depressed and thought she was going mad.
Since then she had been well and fond of amusement. though shy and somewhat
reserved.

. Her present illness had begun three months before w itb pains at the buds of her
head and increasing Iistlessness. She gase up her usual aetis ities and did not eat
properly. She felt sen frightened of rats. and thought she was not looleiug after
the cat properly. She tried to take poison. She believed she was wicked and to
blame for worrying others; she w as' ‘plotting against her husband s life and would
be hanged for it ” She thought that her husband would die of consumption.
She attempted to diown herself on the day of admission. .

On admission she was restless and agitated. insisting that it was all her l. unit
and that she must " go somewhere" She scratched her gums until they hled.
saying. "1 thinlt 1 must do it" She asked where she had to no to. She said
she was worried because of the dis-grace on the family through her. She said she
was utterly tttiseralile and that sh: was. the cause of the trouble With the other
patients. llcr skin was salluw and greasy. then-Owns an attnifotrtt rash on her
face and back, her thyroid gland was slightly enlarged. There was fine. rapid
tremor of both hands. her tongue was tremolons and she had alveolar pyorrluea.
She continued very restless. she made slight attempts to commit suicide and kept
asking what she should do, saying it was " all her fault 9'. By April. tom. she was
less agitated. though she always looked bewildered and kept asking, " What shall
we do for thg but 3 " She would wander about wringing her hands ; she said she
ought not to take her food. Her physical and mental condition improved. and
by the time she left hospital. August 29. 1929. she seemed quite well. Sol-se-
quently she had very brief spells lasting perhaps a day. of mild depression and. now
and then. she would get a ltttle too excited over some happening she w as looking
forward to. For the most part. however. she has been ll\ ely and cheerful. In
193! she adopted the orphaned baby of a relative and has hrought it up quite
well. She has somewhat altered her way of life since the illness. e. g. .. she always
rests completely now for half an hour after lunch. During the six years since her
illness she has not had any depression of the kind she remembers in her illness.

 

 

181

Va The patient was a 23-year-old engineer, who gave the following spontaneous
description of his problem: “I am feeling very depressed. I feel as though I'm drag-
ging myself down as well as my family. I have caused my parents no end of
aggravation. The best thing would be if I dug a hole and buried myself in it. If I
would get rid of myself, everybody would be upset for a time but then they would
get over it. They would be better 06' without me.”

The immediate life situation related to his depression was a job he had talten
three months before. After graduating from college, he had had a succession of jobs
and had started a small business that failed. He was not doing well in his current
position and was certain that he would be fired within a few days. He experienced a
gradual loss of self-confidence as his work did not seem to measure up to the ex-
peetations of his employer. Two days before his psychiatric consultation he received
notice that he would be fired. He became very discouraged and experienced a com—
pleu loss of appetite and considerable difliculty in sleeping. He thought of various
ways of hillinghimself, such as taking an overdose of pills or throwing himself from
a high building. .

A day before his consultation with me, he called his older brother to inform
him that he was leaving town. His intention as that time was to commit suicide in a
distant city. His brother suspected that something was wrong. so he came over to
visit and to talk to him. After discussing the problem with his brother, the patient
began to feel better. His brother told him he would lend him money to tide him over
until he could get another position and he also made arrangements for the patient to
start psychotherapy. The patient went to a football game that afternoon and began
to feel better since his favorite team won.

When I saw him the following day, he looked dejected and moderately de-
pressed. He did not show any retardation or agitation. I administered the Depression
Inventory (see Chapter 12). His cumulative score of 20 indicated a moderate de-
pression. He acknowledged having the following symptoms: continual unremitting
sadness; discouragement; feelings of being a failure; lack of satisfaction; guilt feel-
ings for ”having let everybody down”; self-dislike; self-reproach; suicidal wishes;
some loss of interest in other people; indecisiveness; insomnia; anorexia; and easy
fatigability.

 

5.

182

Cas: )7 —E. \V. D—, a tramway EmlFfl- a-t 51, “'3‘ first admitted to hospital

_ in May. 1927. His father had been a drunkard and was a patient in a hospital

for criminal lunatics. where he died. A paternal uncle who died in a mental
hospital and an aunt were also drunkards The patient worked as electrician
until the war and snlN-qucntly as cable tori-man. He had married and his wife
had one child when he was 3:. He had always been a serious man. somewhat
grumpy; he was ia'msicmally intempcrate as to alcohol. but not often. After the
strike in row he was reduced in rank and also in wages. In September. man. he
was operated on for hernia. "
His present illness had begun just before his operation for hernia- and had
become gradually more evident. He had not been able to sleep and had felt low-
spirited. He said that his inside was not \\ orking properly. (hi admission he was
depressed. rather discontented. though without precise grounds. and complained
that his bowels were not working because of the operation lor hernia. He
said that some of his clothes were being worn by some of the other patients.

' He complained sometimes of trivial slights which he thought had been put upon
, him. and said that he had been put in the worst bed in the ward. J-le improved
' steadily, became cheerful and amiable. and was discharged in july. 1017. He

was admitted to the hospital again on June 3. r920. He had returned to his work
as aganger; and continued at it until May. 1929. At the end of March. however, he
had felt depressed and tired. and worried about a recurrence of his hernia. He had
been promised an operation at St. Thomas's Hospital. where he was to enter as
an in-patient on May 3o. As this time approached he became more depressed.
and found that he could not put his mind to anything: he could not account for
this and did not regard it as his own fault. He became prumm' and disagreeable
at times and wandered of! to Southend one night and came home next morning.
He had been getting on fairly well with his wife. who was. however. twenty years
older than himself. There had been no coitus since his operation in '936- He
had lost all sexual desire for the last three years. and had previously been afraid
to attempt coitus for fear of causing a recurrence of his hernia.

On admission he looked depressed, with wrinkled forehead and serious face:
he looked also slightly discontented. His answers were terse and to the point.
He said that the others disturbed him. that he felt low-spirited. and he had been
worrying a great deal about his job. He did not think that he was ill except in
0" at)?“ “Mt: he was run down. and had congestion at the bottom of his
atom .

He became a little more cheerful. but was disinclined to net up because of
rheumatism. which he said he had. He struck another patient and ra'casirrnally
swore without provocation. He worried because he thought that his temperature
wu. raised. At times he was restless and agitated. but at other times quiet and
diner-fol. He improved further and admitted that he had been unduly irritable.

.—--—— -—- ._' .m

On LAugust as .henwas. translgred to another hospital for operation on his

. . C . .

He reappeared at the out-patient department on January 7. 193o. He had
resumed work. but had continued depressed and irritable after the operation and
had thrown up his job a week earlier. He was unwilling to return to hospital. and
as he had been swearing at his wife. and threatening her. with intervals of showing
excessive aflection. he was taken to the local observation ward. He had been
talking constantly about his having lost his job; he became argumentative over
tritles and blamed the world in general for his failure. He had ceased to worry
about his hernia. He was admitted to a mental hospital in May. 1930. saying
that his bones were drying up and were hollow. He said that everything round
him was lousy and dirty. He said he would be better dead. out of the way: he
muttered to himself and was occasionally blasphemous. He had threatened to
drown himself and had attacked his wife and his daughter. On admission to the
mental hospital there was no intellectual impairment. He said that he was now
fit for nothing. He continued to believe that his bowels were stopped up and his
bones hollow. But by May he said he thought his hollow bones were filling out.
and two months later said he thought these ideas had been imaginary.

He improved further and did clerical work in the hospital. In jannary. r931.
his depression and hypochondriacal ideas returned in a milder form. He muttered
to himself. ground his teeth and was disinclined to do work of any kind. The
following year he worked in the stores and was free from gross delusions. though
he worried about his physical health. deplorin'g his loss of energy. He had
nothing to do with the other patients, and never wrote to his wife or daughter.
He is now (April. 1936) doing work quite well in the stores. is on good terms
with the other patients. laying billiards and chess with them. and seems content
to stay in hospital. He as pulmonary emphysema and some arterio~sclcrosis.

‘

 

183

LC“" 3-“5- M. B—. l student. 81. 22. female, was admitted to hospital on
December 17. 1928. because she had been sent down from Oxford. had been sleeping
badly and felt rather miserable. . - ° .

Her father was a reserved. secltrsive, sensitive man. drank heavily 3‘ intervals;
her mother " was jumpy ". excitable and irritable. Her youngest sister was rather

excitable and had rare spells of depression. Her parents qu‘arrelled; she sidul '

with her father. and did not get on well with her mother.

She had frequent attacks of rheumatism up to the age of to. night terrors

and tantrums. She had bitten her nails. and for the last three years had

stammered. She did very well at school. went to Oxford with a scholarship and :
in the previous term sat for her final examination. She had not done well in this. -.

Her periods had been regular ; latterly she had had a good deal of pain during her
period, and felt irritable and depressed. Her sexual life had been devoid of
incident; she said she had never felt sexual desire. nor fallen in love. She had
been devoted to two girl friends. most unhappy when parted from them. She
has always been reserved. umderately cheerful. quiet and smuewhat st'tlrrsive,
though she got on well with a small circle at Oxford. She experienced tlu- kit-nest
pleasure. almost ecstasy. when listening to oratnrirrs. She had indulged in fantasies
of having children or teaching many girls. \‘ery sell-conscious, she dreaded enter-
ing crowded tram-cars and felt as if she could burst out crying. She had always

been " serious never went to dances or theatres. but sat at home and read modern ‘

poetry or blue-books and works on constitutional history.

Her present illness had begun in the middle of my. after she had la-erfwnrking .

hard. although she had been clreerfnl for a considerable period before this. She
had begun to feel " fed-up " and Very miserable. She found she Could not get on
with her work. She became gradually more miserable. was disinclined to associate
with people and did pumly in her examination.

On admission she was very quiet and showed scarcely any ernntinn save that
she gnawed her knuckles and picked at her fingers. She jumped at any slight
noise. She became “my pale when s'mm' lilurid was taken lrrurr her \eirr She
tallied clearly and to the point. She said she was irulilrr-rent and saw ru- prrrpuse
in life; she saw things now as they really were and not as illusions. She had
lost all feelings for her friends. She thought she should have made an effort and
denied that she was ill. She was rather obese and pale.

She had two anxiety attacks soon after admission. on seeing another patient
become upset. She continued to be miserable. and unable to see how maple could
find any pleasure inliving. She said at times that for a brief interval she was feeling
happy and energetic. Mostly she did not feel inclined to eat anything. During

the rest of her stay in hospital she remained in the same condition. though occa- '

sionally she seemed more hopeful. She left hospital on June 29. 1929. still resigned
and miserable.

In September. 1929. she took a job in a private school. at which she has done
well. She has remained reserved and quiet. but has become ruore cheerful. except
when she is at home. In the judgment of her family she has been quite well since
taking up work again. She is reticent. intolerant of noise. and " snappy " at the
time of her menstrual periods. All her friends are women.

In 1933 she returned to the University for a year and took her teaching diploma
easily. She professes to be contented and well.

a.” ----.- - . .u- I u o -

 

 

184

AJHFEFHJIXIIE

MICHIGAN STATE UNIVERSITY
Depart-ent of Psychology

DEPARTMENTAL RESEARCH CONSENT PORN
I have freely consented to take part in a scientific study being conducted
by: Paula McNitt
under the supervision of: Dozier Thornton
Acadelic Title: Professor of Psycholo‘yfi_

The study has been explained to Ie and I understand the explanation that
has been given and what Iy participation will involve.

I understand that I an free to discontinue ay participation in the study 1
any tile without penalty.

I understand that the results of the study will be treated in strict con-
fidence and that I will relain anonylous. Nithin these restrictions.
results of the study will be aade available to re at ay request.

I understand that ay participation in the study does not guarantee any
beneficial results to ae.

I understand that, at my request, I can receive additional explanation of
the study after my participation is coapleted.

Signed:

 

 

Date:

 

 

 

185

APPENDIX F

mm: m: A STUDY Immoinnc m ”It“. WTIQBBIPS
W PM mum MISS!“ in am

WM: isto findoutnorsebouthowyouseeyourself
endyourspouseinyournarriage. This studygeddtoourunderstanding of
whether ad how the narriage relationship relates to a person's notional diffi-
culties. ‘l'his my ultinstely assist in coinseling persons who are depressed and!
or anxious. before we begin we need to review what the study involves. and what
your rights are as a participant.

First, you will be asked to attend an interviu with us. I'll be asking you
about the probl- that led you to request help here at the VA lhntal health Clinic
I'n not here to do therapy; that's your counselor's job. this interview will last
fron one-half to one hour. at nest. You'll also be asked to coqlete several
queatiomaires. we questionnaire asks for sons sinle background intonation
about yourself. your job. your schooling. etc. the others ask about your relation-
ship with your hsbandlwife during the past three nonths. and about how you are
feeling at prunt. mess questions are straightforward: there's nothing ”sneaky”
aboutthn. nerearenorigbtorwrongenswers. Inallthereareabout300
questions of thenltiple choice type. You'll need about o’ne and a half to two
hours to anslssr thu.

r... and your spouse will be paid I total of $5.00 for your participation.
Thisisnys.llwayofseying"!hank-you.” Inaddition. ifyourequest, Iwill
begladtoschsaleafeeoacksessionwithyouinwhichwecanst-ariaeanddis-
cuss your answers. this 21 help you and your counselor to better understand your
probl-e. Ihiscsnbeheldinabouttwoweeks. Severalnonths fronnowlcan
provide a am of the findings of the entire study.

There will be no poalty if you do not wish to participate in this study. You
nay withdraw at ny tine without penalty. Your veteran's benefits will not be
affected by your decision about participation.

Please understand that all your answers will be kept strictly confidential.

No one will be told about these unless you give as pernission, in writing, to infer:
a particular person. also the study is reported you will not be identified by nans

If you have any questions about the study or your participation, please ask,

and I will answer th- for you.

Signature:

 

SUBJETANDMTB

 

smmfi

 

 

186

APPENDIX G
Guidelines for Interviewing the Clients
1. How are you today?
Note: mood, other somatic complaints.

2. How long have you been in conseling with ?

 

How frequently have you met with him/her?
3. Why did you come to the Center? What
problems brought you here?
Note: Depressive symptoms
Anxiety Symptoms
Family Problems
Ask about depressive symptoms not mentioned:e4p,
sleep difficulties, appetite or weight change.
Ask about alcohol intake (especially if client is
male).
Assess: Which problem seems most serious/important?
4. How long have you had these problems?
Note onset of depressive symptoms.
Note onset of other symptoms or family problems.
5. Have you experienced problems before? If so, when?
Note number and dates of previous depressive
episodes.
Note number and dates of other problem/symptom

periods.

 

187

APPENDIX H

9.17 of Diagnostic Data

To the Clinician:

Please fill out this su-ary within two working days of your assess-ent
interview. SyQtoI itens should be checked off (underline) only if these are
observed or reported during the interview. Peel free to question the client about

any synpton or problen he or she does not spontaneously report--if you suspect he

 

has experienced it since his problen period began. For itens referring to history
or nedication--by all mans check the client's (available) clinical records-4f

this will help .

 

188

Client Clinician
N"°= Name:
Age: Place of Employment:
Diagnosis (DSH II): . - Date:

I. Depressive Synptons--Current

A.

Dysphoric Mood

depressed, sad, blue, hopeless, discouraged, irritable, fearful, worried.
tries a lot

Physical Symptoms

poor appetite, unintentional weight loss or gain (2 lbs. week)
insomnia, hypersomnia, early morning wakening

energy loss. fatigability

agitation, retardation (speech, body movements)

Other Psychological Symptoms

loss of interest in usual activities, decreased sexual desire
guilt, self reproach

diminished ability to think or concentrate
suicidal thoughts, wish to be dead, suicide attempt

Evidence of Prior Manic Episodes

client reports, case history evidence, Lithium treatment

II. Other Past or Present Psychiatric or Medical Disorders

A.

Neurotic-Anxiety Disorders

1. Anxiety Neurosis--free floating anxiety with recurrent anxiety

attacks
present Yes No
antedate depressive symptoms Yes No
predominate over depressive symptoms Yes No
2. Phobic Neurosis--obvious phobias
present Yes No
antedate depressive symptoms Yes No
predominate over depressive symptoms Yes No

3. Hysteria (conversion symptoms, fugue states. chronic, multiple, vague
unexplained medical problems)~
present . Yes No
antedate depressive symptoms Yes No
predominate over depressive symptoms Yes No

 

III.

IV.

189

4. Obsessive-Compulsive Neurosis-~obsessional thoughts. impulses, com-
pulsive behaviors

present Yes NO
antedate depressive symptoms Yes No
predominate over depressive symptoms Yes No

D. Alcoholism-Alcohol Abuse (does not include heavy drinking consequent to
depressive symptoms)

present Yes No
antedate depressive symptoms Yes No
predominate over depressive symptoms Yes N°
C. Drug Dependency (include gl1_street or prescription drugs)
current Yes No
past Yes No

D. Antisocial Personality (Check only if strong evidence of chronic delin-
quency, antisocial behavior, vagrancy, m vocational and/or marital

mdladjustment). Yes No
E. Schizophrenia
current (evidence of overt psychotic symptoms) Yes No
in remission (evidence--history or medication) Yes NO
P . Sexual "Deviations"
homosexuality pederasty
trans—sexuality voyeurism

6. Organic Drain Syndrome
H. Mental Retardation

I. Serious or Life-Threatening Illness
cancer kidney
heart disease other (specify)

History of Depressive Symptoms

A. Length of Present Episode
less than 3 weeks 6 weeks to 6 months
3-6 weeks 6 months or longer

3. Previous Episodes?
0, l, 2, 3, 4, S, 6, or more than 6

C. Most Recent Previous Episode?
within past 6 months within 5 years
within year more than five years ago

Treatment History
A. Hospitalization

hospitalized for present condition How long?
past psychiatric hospitalizations O, l, 2, 3. 4, S, 6, more than 6

 

 

190

B. Outpatient treatment
Psychotherapy or psychiatric consulthtion (at least 2 consults)

1. This or other mental health center
0, l, 2. 3, 4. 5, 6, more than 6

2. Private mental health pfactitioner
O, l, 2, 3, 4, S, 6, more than 6

3. Family physician (e.g., for valium prescription)
0.1, 2, 3, 4. 5, 6, more than 6

C. Kinds of Treatment Received

 

individual therapy family
BTWP therapy medical/somatic
marital

D. Medicationucurrently prescribed (by trade name)
1. Anti-depressant medication
Tofranil, Norpramin. Elavil, Aventyl, Nardil,
Harplan, Parnate, Lithium carbonate, other
2. Minor tranquilizers
Valim, Librim, Miltown, Tranxene
3. Anti-psychotic medication
Thorazine, Stelazine, Haldol. Mellaril, Nevane, Prolixin

 

Su-ary

Is this client depressed? Yes No
Mildly Moderately Severely

Is depression the cl ient's primary problem? Yes No

If no, depression appears secondary to

 

Is this the client's first depressive episode? Yes No
first psychiatric disorder of any kind? Yes No

191

APPENDIX I
General Information Sheet

ID 0:

Age:

Education (highest level completed):

Occupation: Working now?

Rel ig ion: Protestant Cathol ic Jewish Other None

Race: Caucasian Negro Oriental

About your marriage:
How long have you and your spouse been married?

During the past three months have you and your wife/husband been separated
for more than a week's time?

If “yes", how many times?
This marriage is your: first second third fourth fifth?
How many children do you have?

How many' children are living in your home?

 

__;I

 

192

APPENDIX J

Beck's Depression Inventory

 

 

 

 

I.D. I N.H.C.
Age: Sex:
IBCK'S 0.!

Instructions: Please read each set of statements completely, then circle the
one which most represents how you—feel right m. For example, read all the
statsnsnts ill category "A". reflect for a minute, then choose one of also and
circle it. Then continue to the next set until you have chosen one statement
for every letter through "0".

A. I do not feel sad.
I feel blue or sad.

I am blue or sad all the time-and I can't snap out of it.
I am so sad or unhappy that it is quite painful.
I am so sad orunhappy that I can't stand it.
I. I am not particularly pessimistic or discouraged about the future.
I feel discouraged about the future.
I feel I have nothing to look forward to.
I feel that I won't ever get over my troubles.
I feel that the future is hopeless and tlmt things canmt improve.
C. I do not feel like a failure.
I feel I have failed are than the average person.
I feel I have accomplished very little that is worthwhile or that means
anything. ‘
As I look back on my life all I can see is a lot of failures.
I feel I am a complete failure as a person (parent, husband, wife)-
D. I am not particularly dissatisfied.
I feel bored most of the time.
I don't enjoy things the way I used to.‘
I don't get satisfaction out of anything any more.
I am dissatisfied with everything.
a. I don't feel particularly guilty.
I feel badorulnlorthyagoodpart ofthe time.
I feel quite guilty.
I feel bad or unnrthy practically all the time now.
I feel as dough I am very bad or worthless.
P. I don't feel I am being punished.
I have a feeling that something bad may happen to me.
I feel I am being mished or will be punished.
I feel I deserve to be punished.
I want to be punished.
6. don't feel disappointed in myself.

I
I am disappointed in myself.
I don't like myself. ‘

I am disgusted with myself.
I hate myself.

 

 

 

 

193

I ubn't feel I as any worse than anybody else.

I am critical of myself for my weaknesses or mistakes.
I blame myself for my faults.

I blame myself for everything bad that happens.

I don't have any thoughts of harming myself.

I have thoughts of harming myself. but I would not carry them out.
I feel I would be better off dead. '

I feel my fully would be better off if I were dead.

have definite plans about co-itting suicide.

d kill myself if I could.

t cryan'y more than usuml.

33”
5
g
E
E
3

can't stop it.
able to cry but now I can't cry at all even though I want

a
f
i"
.5

I
I
I
I
I
I

:ai
8
8'

no more irritated now than I ever am. .
annoyed or irritated are easily than I used to.
irritated all the time.
't get irritated at all at the things that used to irritate me.

:33

not lost interest in other people.

ass interested in other people now than I used to be.

lost most of my interest in other people and have little feeling -
tho.

pas

V

ail?

s-e Hess-s
ll.

lost all my interest in other people and don't care about them at

have
al
I make decisions about as well as ever.
I try to put off nking decisions.
I have great difficulty in nking decisions.
I can't aka any decisions at all any are.

I don't feel I look any worse than I used to.

I am worried that I am looking old or unattractive.

I feel that there are pernnent changes in my appearance and thOY ”119 '9
look unattractive.

I feel that I u ugly or repulsive looking.

Icanworkaboutaswell asbefora.

It takes extra effort to get started at doing something.
I don't work as well as I used to.

I laws to push myself very hard to do anything.

I can't lb any work at all.

I can sleep as wall as usual.
I wake up more tired in the morning than I used to.
I wake up l-Z houurs earlier than usual and find it hard to get back to

sleep.

I wake up early every day and can't‘ get more than 5 hours sleep.

 

 

U.

194

I don't get any are tired than usuml.

I get tired more easily than I used to.

I get tired from doing anything. .
I get too tired to do anything. “

My appetite is no worse than usual .

My appetite is not as good as it used to be.
My appetite is much worse now.

I have no appetite at all any more.

haven't lost much weight, if any, lately.
have lost Dre than 5 pounds.
have lost more than 10 pounds.
have lost are tlmn 15 pounds.

NHH.-O

am no are concerned about my health than usual.

am concerned about aches and pains or upset Sumch or constipation.
am so concerned with how I feel or what I feel tlult it's hard to think
of Itch else.

I am coqletely absorbed in what I feel.

HHH

have not noticed any recent change in my interest in sex.
am less interested in sex than I used to be.

am much less interested in sex now.

have lost interest in sex completely.

HHHH

 

 

195

APPENDIX K

FORM F

A MARITAL COMMUNICATION
INVENTORY

DEVELOPED BY

MILLARD .l. BlliNVl-INl'. SR. 1979 Revision

 

This inventory offers you an opportunity to make an ohjcctiyc study ol‘thc Liquor
and patterns of communication in your marital relationship. It it ill cntuhlc y on and
your husband to better understand each other. We hclicuc you uill liuutl it both
interesting and helpful to make this study.

DIRECTIONS

I. Please answer each question as quickly as you can according to the way you lccl
a! the moment (not the way you usually feel or felt lust neck.)

2. Do not consult your husband while completing this inycntory. You may
discuss it with him after both of you hate completed it. Remember that the
counseling value of this form will be lost if you change um- utusucr during or
after this discussion.

3. Honest answers are l'l'l'l' necessary if this form is to be of \aluc. Please be as
frank as possible. Your answers are confidential. Your name is not rcquircd.

4. Use the following examples for practice. Put a check ( ) in Ullt' of the four
blanks on the right to show how the question applies to your lulurriuugc.

Ml“?-
Isl \ll\ I|\lt.\ HI'HNHI \Iflill

Does your husband talk about his real feelings?

 

Does he let you know when his feelings are hurt‘.’

 

5. Read each question carefully. If you cannot give the exact answer to a qucsl iouu.
answer the best you can but be sure to answer each one. There are no right or
wrong answers. Answer according to the way you fch m (In: prt-swu (film.

I upyrlght I"! “land 1. Ilrmenu. M. W rights resent-d.
Printed in the l nilrd Slates of uni-tics.
Published by l “Ill \ II” Pt II It \mns. l\t
Rm 421. haluda. \.t . 28773

 

 

 

196

. Do you and your husband discuss the manner in

which the family income should be spent?

. Does he discuss his work and interests with

you?
Do you have a tendency to keep your feelings to
yourself?
Is your husband‘s tone of voice irritating?
Does he have a tendency to say things which
would be better left unsaid?
Are your mealtime conversations easy and
pleasant?
Do you find yourself keeping after him about him
faults?
Does he seem to understand your feelings?
Does your husband nag you?
Does he listen to what you have to say?

. Does it upset you to a great extent when your

husband is angry with you?
Does he pay you compliments and say nice things
to you?

. Is it hard to understand your husband's feelings

and attitudes?
Is he affectionate toward you?

. Does he let you finish talking before responding

to what you are saying?

Do you and your husband remain silent for
long periods when you are angry with one
another?

. Does he allow you to pursue your own interests

and activities even if they are different from
his?

. Does he try to lift your spirits when you are
‘depressed or discouraged?
. Do you avoid expressing disagreement with him

because you are afraid he will get angry?

. Does your husband complain that you don‘t under-

stand him?

. Do you let your husband know when you are

displeased with him?

. Do you feel he says one thing but really means

another?

. Do you help him understand you by saying how

you think. feel. and believe?

. Are you and your husband able to disagree with

one another without losing your tempers?

.80“!-
lhl \l.l.\ TIMES

SHIN!“

8}} l."

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

197

SOME.
l'SlTAIJJ TIMES SELDOM VIEWER

25. Do the two of you argue a lot over money?
26. When a problem arises between you and your
husband are you able to discuss it without losing
control of your emotions?
27. Do you find it difficult to express your true
feelings to him? 7
28. Does he offer you cooperation. encouragement a
and emotional support in your role (duties)
as a wife?
29. Does your husband insult you when angry with
you?
30. Do you and your husband engage in outside in-
terests and activities together?
3|. Does your husband accuse you of not listening to
what he says? _
32. Does he let you know that you are important
to him?
33. Is it easier to confide in a friend rather than
your husband?
34. Does he confide in others rather than in
you?
35. Do you feel that in most matters your husband
knows what you are trying to say?
36. Does he monopolize the conversation very
much? __
37. Do you and your husband talk about things which
are of interest to both of you? _
38. Does your husband sulk or pout very much? _ __ __ __
39. Do you discuss sexual matters with him? __ __ ____... __
40. Do you and your husband discuss your personal
problems with each other?
4|. Can your husband tell what kind of day you have
had without asking? __ __ __ __
42. Do you admit that you are wrong when you know
that you are wrong about something? ._ __ __ _
43. Do you and your husband talk over pleasant things
that happen during the day? __ __ _ .—
44. Do you hesitate to discuss certain things with
your husband because you are afraid he might hurt
' your feelings? __ __ __ __
45. Do you pretend you are listening to him when
actually you are not really listening? _ _ __ __
46. Do the two of you ever sit down just to talk
things over? .__.. __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

198

ABOUT YOU

Read the following sentences and complete them with the first thing that comes to
your mind. It is important for you and your spouse to agree that you will not hold
anything against each other for expressing your views. Your goal is to better
understand each other. so please be frank in order to benefit as much as you can
Irom this activity.

I. LATELY. OUR RELATIONSHIP

 

 

Es)

THE MAIN PROBLEM I SEE FACING US AT THIS TIME IS—

 

3. ABOUT MY SPOUSE. l APPRECIATE:
a.
b.

4. TWO THINGS I WANT FROM MY SPOUSE THAT I'M NOT
GETTING:

 

 

a.
b.
5. IT WOULD HELP OUR RELATIONSHIP IF I

 

 

 

 

6. I'M WILLING TO

 

General Informatlion:
Your Age;— Husband's Age____ Length of Present Marriage _
Your Religious Preference.___ Your Husband‘s Preference

Have You Ever Been Married. Divorced. or Widowed Before? YES NO
If YES. Please Explain

 

Your Education Occupation

 

H usband's Education H is Occupation

 

 

Your C hildren's Ages: Ages of Boys Ages of Girls

 

 

 

 

199

APPENDIX L

S-10-68 (copyrighted)

 

Scale of Feelings and Behavior of Love
Clifford H. Swensen and Frank Gilnsr
Purdue University, St. Louis University
(Modified by Paula C. McNitt. 1980)

iThis scale contains itens describing the nany ways in which people feel .
they express love. Some of these iteas describe things said between people who
love each other, some describe feelings people have fer people who- they love,
and some describe things people do fbr people they love.

‘ When you answer the itens for your relationship with your wife be sure to
mark an answer fer every iten. Each iten has three choices. Mark the choice
that cones closest to describing the way you behave, talk or feel toward your

wife as your relationship exists a: thg_present tine. This leans during the

 

past three months and gg£_just today.
There is no time linit, but you should nark your answer to the items as

rapidly as you can.

 

 

200

Ybur wife tells you that she feels you get along well together.

a) She never tells you this.
b) She occasionally tells you this.
c) She freggently tells you this.

Your wife tells you that she wants to live up to your expectations fer
her.

a) She never tells you this.
b) She occasionally.tells you this.
e) She fregggntly tells you this.

Year wife tells you that she feels a good "spirit? in the things she does
with you.

a) She never tells you this.
b) She occasionally tells you this.

c) She fregggntly tells you this.
Ybur wife tells you that she feels free to talk about anything with you.

a) She never tells you this.
b) She occasionally tells you this.
e) She freguently tells you this.

Your wife tells you that she trusts you completely.

a) She never tells you this.

b) She oecasionall tells you this.
e) She freggently tells you this.

You tell your wife that you feel safe when you are with her.

a) Ybu never tell her this.
b) YOu occasionally tell her this.
c) Ybu fEESEEntly tell her this.

You tell your wife that you feel that your relationship has improved with
tine.

a) You never tell her this.
b) Ybu occasionally tell her this.
c) Ybu frequently tell her this.

Ybur wife tells you that the thought of you dying disturbs her.
a)- She never tells you this.

b) She OEEigionally tells you this.
c) She freggently tells you this.

 

 

 

 

10.

11.

12.

13.

14.

15.

16.

201

Your wife tells you that she feels your relationship has leproved with
tile.

a) She never tells you this.
b) She occasionally tells you this.
e) She frequently tells you this.

Yeu tell your wife that you feel that you understand each other.
a) Yea never tell her this.

b) You occasionally tell her this.

e) You frequently tell her this.

You tell your wife that you don't have to put up a 'false front" around
her.

a) You never tell her this.
b) You occasionally tell her this.
c) You fregggntly tell her this.

Yeu tell your wife that you have a warn, happy feelirg when you are with
her.

a) You never tell her this.

b) Ybu occasionall tell her this.

c) You fregggntly tell her this.

You tell your wife that you have faith in her.

a) You never tell her this.

b) Ybu occasionally tell her this.

c) You freguently tell her this.

Ybu tell your wife that you want to live up to her expectations fer you.
a) You never tell her this.

b) You occasionall tell her this.

c) You fregggntly tell her this.

You tell your wife that you feel lore cheerful, optimistic and confident
when you are with her.

a) Ybu never tell her this.

b) Ybu occasionall tell her this.

c) Ybu fn ggently tell her this.

You tell your wife that you feel a "good spirit" in the things you do with
her.

a) You never tell her this.

b) Yeu occasionally tell her this.
c) Ybu fregggntly tell her this.

 

 

 

17.

19.

20.

21.

22.

23.

24.

202

You tell your wife that you trust her coupletely.

a) You never tell her this.

b) You occasionally tell her this.

c) You fregggntly tell her this.

Yeu tell your wife that you feel she is important and worthwhile.
a) You never tell her this.

b) Ybu occasionall tell her this.

c) You fregggntly tell her this. .

Yeu tell your wife that you feel free to talk about anything with her.
a) You never tell her this.

b) You occasionall° tell her this.

c) Ybu freguentiy toll her this.

You tell your wife that you feel her expectations of you are not too
great--they are reasonable.

 

a) Ybu never tell her this.
b) Ybu oceasionallv tell her this.
c) You fTEQuentlv tell her this.

Yeur wife tells you whether or not she does anything special to aaintain or
ilprove her appearance, such as, diet, exercise, etc.

a) She never tells you this.
b) She occasionall tells you this.
c) She fregggntly tells you this.

Ybur wife tells you the kind of behavior in others which annOys her, or
lakes her furious.

 

a) She never tells you this.
b) She occasionally tells you this.
c) She freguentli’tells you this.

Ybur wife tells you her thoughts and feelings about religious groups other
than her own.

a) She never tells you this.
b) She occasionally tells you this.
c) She freggently tells you this.

Ybur wife tells you whether or not she plans sole major decision in the
near future--such as, returning to school, getting a new job, having a
baby, buying soaething big.

a) She never tells you this.
b) She occasionall tells you this.
c) She f¥Egggntly_tells you this.

 

 

 

26.

27.

28.

29.

30.

31.

32.

203

Ybur wife tells you her favorite jokes-~the kind of jokes she likes to
hear.

a) She never tells you this.

b) She occasionall tells you this.

c) She ffigggntly tells you this.

You tell your wife what particularly anmys you at st about your closest
friend. -
a) You have never told her this.

b) You have occasionall told her this.

c) You have ffzgggntly told her this.

You tell your wife things about your own personality that worry or anno
you. ' ' .

 

a) You have never told her this.

b) You have occasionall told her this.

c) Ybu have ffzgggntly told her this.

Ybur wife tells you what her chief health concern, worry, or problel is at
the present tine.

a) She never tells you this.

b) She occasionall tells you this.

c) She fEEQEgntIy tells you this.

Ybur wife tells you about her sparetile hobbies or interests.

a) She never tells you this.

b) She occasionall tells you this.

c) She fregggntly tells you this. .

Your wife tells you what particularly annoys her nest about her closest
friend. ' .

 

a) She never tells you this.

b) She occasionall tells you this.

c) She f5eguently tells you this.

You tell your wife what the chief pressures and strains in your daily work
are.

a) Ybu never tell her this.
b) You occasionally tell her this.
c) You fregggntly tell her this.

 

Ybu tell your wife things about the future that worry you at present.

a) Ybu never tell her this.
b) Ybu occasionall tell her this.
c) You Wad tell her this.

 

 

33.

35.

36.

37.

39.

40.

204

You tell your wife what you are most sensitive about.

a) You never tell her this.
b) You occasionally tell her this.
c) You fregggntlz tell her this.

You tell your wife the kind of behavior in others that most anncys you. or
lakes you furious.

a) You never tell her this.
b) You occasionally tell her this.
c) You fregggntlz tell.her this.

You tell your wife what you regard as your chiif handicap to Joins a
better job in your work or school.

a) You never tell her this.
b) You occasionally tell her this.
c) You freggentlz tell her this.

You tell your wife what your strongest albitiot.iu at the present time.
a) Ybu never tell her this. .

b) You occasionally tell her this.

c) You freggentli tell her this.

You tell your wife whether or not you plan some eajor decision in the near
future--getting a new job, starting a new busine ss, moving to a new home,
buying something big.

a) You never tell her this.

b) You occasionally tell her this.

c) You fregggntliitell her this.

Yeur wife tells you the chief pressures and strains in ner daily work.

a) She never tells you this.

b) She occasionally tells you this.

c) She freguentli tells you this.

Your wife tells you what she is most sensitive abcut.

a) She never tells you this.

b) She occasionall tells you this.

c) She f?eguentIz_tells you this.

Your wife tells you her views about what is acceptable sex morality for
people to fellow.

a) She never tells you this.
b) She occasionall tells you this.
c) She freguentlz tells you this.

 

 

 

41.

42.

45.

You
is 1

46. ‘

47,

48.

41.

42.

43.

45.

46.

47.

48.

205

Your wife tells you the things about her appearance that she likes IOSt ‘r
is proudest of.

a) She never tells you this.
b) She occasionally tells you this.
c) She fregggntly tells you this.

 

You provide support for your wife's food, clothing and housing.

a) Yeu never do this.
b) You occasionall do this.
c) You freguently Eb this.

You sacrifice your own needs. such as clothes, in crder to provide for
your wife.

a) You never do this.
b) YOu occasionally do this.
c) You fregggntli—do this.

Your wife gives you an accurate knowledge of her sex life up to the pre-
sento-the names of sex partners in the past, if any; her ways of getting
sennal gratification.

a) She never tells you this.

b) She occasionall tells you this.

c) She In magently tells you this.

Yeur wife tells you what she feels the guiltiest about, or most ashamed of
in her past.

a) She never tells you this.

b) She occasionally has mentioned such things.

c) She alwa tells—you when she has done something she feels very guilty
or asfiim i about.

Your wife tells you the characteristics of her mother that she does not
like or did not like.

a) She never tells you this.
b) She occasionally tells you this.
c) She freggently tells you this.

You tell your wife whether or not you have sex problems and the nature of
these problems.

a) You never tell her this.
b) You occasionally tell her this.
c) You fggguently tell her this.

You feel that you don't have to put up a "false front" around your wife.
a) You neLer feel this way.

b) You occasionally feel this way.
c) You have fgggggntly felt this way.

 

 

49.

SO.

51.

$2.

53.

SS.

56.

206

You give your wife an accurate knowledge of your sex life up to the pre-
sent--the names of your sex partners in the past if any; your WPYS 0f
getting sexual gratification.

a) You neLer tell her this.
b) You occasionally tell her this.
c) You Ezeguentliitell her this.

You tell your wife what you feel the guiltiest about, or ncst ashamed of in
the past.

a) You never told her this.
b) You occasionally have aentioned such things.

c) You fre ntl tell her when you have done something you feel guilty
or :EEIEEE‘:E§bz.

Your wife shows love by’a willingness to change or give up her ideals in
order to please you.

a) She never does this.
b) She occasionall" does this.

c) She frguently foes this.

 

You provide money or support for her education, a new business venture. or
other interest.

a) You never do this.

b) You occasionall do this.

c) You fregugntly 55 this.

Ybur wife is like another person that you have loved, such as a relative.
a) You nLver feel this way.

b) You occasional F—TL¥ feel this way.

c) You ent eel this way.

You do things or go places with your wife even though these activities
don't particularly appeal to you.

a) You never do this.

b) You occasionall do this.

c) Yen fregggntly 50 this.

You show love for your wife by a willingness to change or give up ideals
for her.

a) Yen never do this.

b) YOu.occasionally do this.

c) You frequently do this.

You teach your wife values and ideals in life.

a) Ybu never do this.

b) You SEEEEionally do this.
c) You greguently do this.

 

 

 

57.

$8.

59.

60e

61.

62.

63.

65.

 

207

You discipline your wife.

a) You never do this.
b) You occasionally do this.
c) You freguently do this.

The differences that come up between you do ggt_lizrupt the relationship.
a) Our differences fre entl disrupt the relationship.

b) Our differences occas anally disrupt the relaticnship.

c) Our differences never disrupt the relationsh p. 3 “H
You pray for your wife.

a) You never do this.
b) You occasionally do this.
c) You freguently do this.

 

Your wife tells you that she wants you to agree with her when she is in an
argument with a third person.

a) She never tells you this.
b) She occasionally tells you this.
c) She freguently tells you this.

Your wife can trust you because you are honest and truthful with her.
a) Your wife can never trust you.

b) Your wife can occasionally trust you.
c) Your wife can freguently trust you.

 

Your wife teaches you values and ideals in life.

a) She never teaches you values and ideals.

b) She occasionally teaches you values and ideals.

c) She freggently teaches you values and ideals.

You listen with interest when your wife talks.

a) Yen never do this.

b) Yen occasionall do this.

c) You freguentlz do this.

Your wife teaches you skills, such as how to drive a car or how to sew,
cook, fix things at home.

a) She never teaches you skills.
b) She occasionally teaches you skills.
c) She fregggntly teaches you skills.

 

Your wife can be trusted because she has been honest and truthful with
you.

a) You can never trust her.

b) You can occasionall trust her.
c) You can fregggntly trust her.

 

 

67.

68.

69.

70.

71.

72.

73.

74.

20E!

Your wife approves of you.

a) She never does.

b) She occasionallé does.

c) She fregugntly s.

You write or telephone your wife when you are separated.
a) You never do.

b) You occasionall do

c) You fregggntly go.

You approve of your wife.

a) You never do.
b) You occasionally do.

c) You fregggntly‘do.

You are 225 over demanding of your wife, but are causiderate of her time,
energy, etc . '

a) You are mgge rtly over demanding.
b) You are occasionally over demanding.
c) You are never ever demanding.

You encourage your wife when she is discouraged.
a) You never do this.

b) You occasionally do this.

c) You freguently’do this.

Your wife shows an interest in you and your work.

a) She never does.
b) She occasionally does.

c) She fzggiently does.

 

Your wife is ngg_over demanding of you, but is considerate of your oon
time, energy, etc.‘

a) She fre entl is ever demanding.
b) She occasionally is over demanding.
c) She never is over demanding.

 

Your wife gives you encouragement when you are discouraged.

a) She never does.

b) She occasionall does.

c) She freguently goes.

Your wife allows you to make the final decisions in the things that are of
prieary iaportance to you.

a) She never does.
b) She occasionally does.
c) She freguently does.

 

 

 

75.

76.

77.

78.

79.

80.

81.

82.

83.

209

Your wifo is respectful and considerate of your opinions.

a) She never is.
b) She occasionally is.‘
c) She grgggentli is.

Your with is even-tempered and kind in dealings with you.
a) She never is.

b) She occasionall is.

c) She fraggently Es.

You try to live up to your wife's ideals and expectations for you.
a) You never try to.

b) You occasionall try to.

c) You freggently try to.

You are respectful and considerate of your wifo's opinions.

a) You never are.

b) You occasionall are.

c) You frT—Tz' 2m zare.

You are courteous to your wife.

a) You never are.

b) You occasionall are.

c) You freggently are.

You are even-tempered and'kind in your dealings with your wife.
a) You never are.

b) You occasionall are.

c) You frgggentiy are.

Your wife tries to get you in a good mood when you are angry.

a) She never tries.
b) She occasionally tries.

c) She fregggntly tries.
Your wife gives you good or useful advice.

 

a) She never does.

b) She occasionally does.
c) She freguently does.
Your wife disciplines you.

a) She never does.

b) She occasionall .does.
c) She frggggntiy 55.3.

 

85.

86.

87.

89.

90.

91.

92.

210

You obey your wife.

a) You never do.
b) You occasionally do.

c) You freggentlz do.
Your wife prays for you.

a) She never does.
b) She occasionally does.
c) She freggently does.

You try to get your wife in a good need when she i: angr'.
a) You never do this.

b) You occasionall do this.

c) You H guenty this. _

Your wife runs errands for you--to the store, etc.

a) She never does this.
b) She occasionally dues this.
c) She fregggntly does this..

Your wife loans objects of value to you--such as a :1?-

a) She never does this.

b) She occasionall does this.

c) She freguently goes this.

Your wife provides constructive criticism when you neei it.
a) She never does this.

b) She occasionally does this.

c) She frgguentlz does this.

Your wife directly protects you froe harm or bocfly in;trY-
a) She never does this.

b) She occasionally does this.
c) She freguently does this.

 

If you support your wife, she tries to be economical in her expenditures.

a) She never tries to be, or this item does not apply.
b) She occasionally tries to be.
c) She fregggntly tries to be.

Your wife secures favors for you, such as getting a job, :pecial appoint-

ments, discounts on things you want to buy.

a) She never does this, or this item does not apply.
b) She occasionally does this.
c) She fregggntly does this.

 

93.

95.

97.

99.

100.

211

You run errands for your wife--to the store, etc.
a) You never do this.

b) You occasionally do this.

c) You freguently do this.

You secure favors for your wife, such as obtaining a job. special appoint-
seats, or a discount on something she wants to hnv.

a) You ngggg_do this, or this item does not aptl'.
b) You occasionall do this.
c) You freguently do this.

Your wifo provides support for food, clothing ans housing for YOU-

 

a) She never does. .
b) She occasionall does.

c) She reguent y oes.

Your wife performs chores for you-~washing or ironiig clothes, typing.
driving you around, etc.

a) She never does.
b) She occasionally does.

c) She fregugntly does.

Your wifo helps you with tasks such as homework, household tasks. garden
work, etc.

a) She never does.
b) She occasionally does.
c) She fregggntly‘does.

Your wifo serVes on things you are involved in, such as spcnsor for a club
to which you belong.

a) She never does.
b) She occasionally does.
c) She freggentlifidoes.

Your wife provides direct support when you are in difficulties, such as
intervening when you are in conflict with school authorities, your bcss,
or the police, etc.

a) She never does.

b) She occasionall does.

c) She ffeggently goes.

Your wife provides Ioney or support for your education, a new business
venture, or some other interest.

a) She never does this.

b) She occasionally does this.
c) She frigugntlz‘does this.

 

 

212

APPENDIX M

SASB Questionnaires

DIRECTIGIS
for
IN'I'REX QESTIGINAIRES

This questionnaire asks you to rate ways you feel about you'self and sole sir
nificant others. You are asked to rate each question on a scale of 0 (never,
not at all) to me (always, perfectly).

The analysis of the questionnaire organises your answers in ways which can help
you thd why you feel the way you do. People who go ahead and answer
honestly, avoiding any teeptatim to “whitewash" or "paint a rosy picture" usu-
ally ara very pleased with the results. If you agree, the results can be made
available to you to help you with your understanding of you-self.

Please answer the questions for how you really think or feel. Your initial
reaction to each question will most often be your best answer. If a question
offends you, score it were or leave it blank. There are no ”right" or "wrong”
answers. It ‘s you- view fluid: is important-«not what is necessarily "tune”,
"false" or what someone else eight think you should say.

Put your answers on the proper answer sheets making sure you match the letter
of the questionnaire with the letter of the answer sheet. lien you've fin-
ished, give the questionnaire and the answer sheet back to the person who gave
you these materials. The results will be returned as quickly as possible.

 

 

213

INTREX FORM C’

Please use the answer sheet marked "C" and indicate how well each question
describes your wife.

Use the scale which appears at the top of the answer sheet.

Constructively, sensibly, persuasively analyzes situations involving me.
Has her own separate identity, internal standards.

Insists I follow har norms and rules so that I do things 'pmpcrlyfl'

. Puts me down, tells me I do things all wrong, tells me her ways are super-
ior.

Learns from as, takes advice from as.

Just does things my way without much fooling of her own. is apathetic.

ODIN"

GUI

 

7. Angrily leaves me out, absolutely refuses to have anything to do with as.

3- "TIJY. comfortably accepts help, caregiving when I offer it.

9. Does her own thing'by doing the exact opposite of what I want.

10. Is straightforward. Clearly expresses her positions so I can give them due
consideration.

ll. Enthusiastically shows, shares herself or "thing" with me.

12. Tortures, aurders, annihilates me no aatter what I do because "I'a as."

 

13. Does strange, irrelevant, unrelated things with what I say or do; goes on
her "own trip."

14. Ecstatically, joyfully, exuberantly, lovingly responds to me sexually.

ls. Harlly, cheerfully invites me to be in touch with her as often as I want.

16. Warmly, happily keeps in contact with me.

17. Freely comes and goes as she pleases.

18. Out of great love for me, she tenderly, lovingly touches ae sexually if I
seen receptive.

 

l9. Stimulates and teaches me, shows me how to understand, do.

20. Accuses and blames as; tries to get me to admit I am wrong.

21. Enthusiastically, very lovingly shows me how glad she is to see as just as
I am.

22. Looks to me, depends on no to take care of everything for her.

23. Harshly punishes me, takes revenge, makes me suffer greatly.

24. Understands as well, shows empathy and warmth even if I don't see things as
she does.

 

1980, INTREX Interpersonal Institute, Inc.

 

 

214

 

 

 

 

25. Is trusting. Asks for what she wants and counts on me to be kind and con-
siderate.

26. willingly accepts, yields to my reasonable suggestions, ideas.

27. Screams, agonizes, protests desperately that I am destroying. killinl hfir-

28. Gently strokes me verbally and/or physically; she lovingly gives me
pleasure with "no strings attached."

29. Intrudes, blocks, restricts me.

30. Even though very suspicious and distrustful of me, she goes along with I?
arguments, ideas.

31. Obeys my preforred rules, standards, routines.

32. Rips me off, gouges me, grabs all she can from me.

33. Pleasing me is so important that she checks with me on every little thing.

34. Is obviously terrified, very fearful of me; is extremely wary.

3S. Misleads, deceivas, deludes and diverts me.

36. In a very grouchy, surly manner, she goes along with my needs and wants.

37. Provides for, nurtures, takes care of’me.

38. Lets me speak freely and can be trusted to negotiate fairly even if we dis-
agree.

39. Ignores me, just doesn't notice as at all.

40. Uncaringly lets me go, do what I want.

41. Snarls angrily, hatefully refuses my caregiving, my offers to assist.

42. Filled with rage and/or fear, she does what she can to escape, flee or hide
from me.

43. Believing it's for my own good, she checks on me and reminds me of what I
should do.

44. Gives me her "blessing" and leaves me free to develop my own separate iden-
tity.

45. Forgets me, just doesn't remember our agreements, plans.

46. Gives in and does things the way I want, but sulks quietly with resentment
and anger.

47. Yields, submits, gives in to me.

48. Approaches me very menacingly; hurts me very badly if she gets a chance.

49. Manages, controls me, takes charge of everything.

50. Leaves me to do things on my own because she believes I am competent.

Sl. Expresses her thoughts in a clear and friendly manner so I have every
opportunity to understand her well.

52. Feels, thinks, becomes what she thinks I want.

53. Leaves me to starve, to get what I vitally need all on my own.

54. Actively listens, accepts and affirms me as a person even if our views dis-

agree.

 

 

 

215

Angrily detaches from me, doesn't ask for anything; weeps alone about me.
Pays close attention in order to anticipate all my needs; takes care of
absolutely everything for me.

Ihines, protests, tries to explain, justify, account for herself.
Asserts, holds her own without needing external support.

Avoids me by being busy and alone with her "own thing."

larmly shows how'much she likes and appreciates me just exactly as I an.

 

61.
62.

63.

65.
66.

Halls herself off’from me, doesn't hear, doesn't react.
Relaxes, enjoys, really lets go with me. Feels wonderful about being with

me.

Believing it's for my own good, she tells me exactly what to do, he, think.
Buries her rage and resentment and scurries to appease me to avoid my dis-
approval.

Approaches me with unwarranted, even crazy ideas about me, and doesn’t
notice how or if I respond.

Goes her own separate way.

 

67.

69.
70.
71.
72.

Looks after my interests, takes steps to protect me, actively backs me up.

Freely and openly discloses her innermost self so I can truly know "who she

is."

Is joyful and exuberant and expects to have wonderful fun with me.

Just when she is needed most, she abandons me, leaves me "in the lurch."
Neglects me, my interests, needs.

Leaves me free to do and be whatever I want.

 

 

"h

 

216

For qu°8t10ns 073-144, change from rating her to rating yourself in this rela-
tionship. Continue using the same scale at the top of answer sheet "C."

 

 

 

 

73. I constructively, sensibly, persuasively analyze situations involving her.
74. l have my own separate identity, internal standards.
75. I insist she follow my norms and rules so that she does things "prOPOTIY-"
76. I put her down, tell her she does things all wrong, tell her my HEY! are
superior.
77. I learn from her, take advice from her.
78. I just do things her way without much feeling of my own: I am apathetic.
79. I angrily leave her out, absolutely refuse to have anything to do with her.
80. I warmly, comfortably accept help, caregiving when she offers it.
81. I do my own thing by doing the exact opposite of what she wants.
82. I am straightforward. I clearly express my positions so that she can give
them due consideration. a
83. I enthusiastically show, share myself or "thing" with her.
84. I torture, murder, annihilate her no matter what she does just because she
is who she is.
85. I do strange, irrelevant, unrelated things with what she says or does; I go
on my "own trip."
86. I ecstatically, joyfully, exuberantly, lovingly respond to her sexually.
87. I warmly, cheerfully invite her to be in touch with me as often as she
wants.
88. I warmly, happily keep in contact with her.
89. I freely come and go as I please.
90. Out of great love for her, I tenderly, lovingly touch her sexually if she
seems receptive.
91. I stimulate and teach her, show her how to understand, do.
92. I accuse and blame her; try to get her to admit she is wrong.
93. I enthusiastically, very lovingly show her how glad I am to see her just as
she is.
94. I look to her, depend on her to take care of everything for me.
95. I harshly punish her, take revenge, make her suffer greatly.
96. I understand her well, show empathy and warmth even if she doesn't see
things as I do.
97. I am trusting. I ask for what I want and count on her to be kind and con-
siderate.
98. I willingly accept, yield to her reasonable suggestions, ideas.
99. I scream, agonize, protest desperately that she is destroying, killing me.
100. I gently stroke her verbally and/or physically; I lovingly give her
pleasure with "no strings attached."
101. I intrude, block, restrict her.
102. Even though very suspicious and distrustful of her, I go along with her

arguments, ideas.

 

 

 

217

 

 

 

 

103. I obey her preferred rules, standards, routines.

104. I rip her off, gouge her, grab all I can from her.

105. Pleasing her is so important that I check with her on every little thing.

106. I am obviously terrified, very fearful of her; I am extremely wary.

107. I mislead, deceive, delude and divert her.

108. In a very grouchy, surly manner, I go along with her needs and wants.

109. I provide for, nurture, take care of her.

110. I let her speak freely and can be trusted to negotiate fairly 0V9" if '9
disagree.

111. I ignore her, just don't notice her at all.

112 I uncaringly let her go, do what she wants.

113. I snarl angrily, hatefully refuse her caregiving, her offers to assist.

114. Filled with rage and/or fear, I do what I can to escape. flee, or hid!
from her.

115. Believing it's for her own good, I check on her and remind her of what she
should do. ‘

116. I give her my "blessing" and leave her free to develop her own separate
identity.

117. I forget her, just don't remember our agreements, plans.

118. I give in and do things the way she wants, but sulk quietly with resent-
ment and anger.

119. I yield, submit, give in to her.

120. I approach her very menacingly; I hurt her very badly if I get a chance.

121. I manage, control her, take charge of everything.

122. I leave her to do things on her own because I believe she is competent.

123. I express my thoughts in a clear and friendly manner so she has every
opportunity to understand me well.

124. I feel, think, become what I think she wants.

125. I leave her to starve, to get what she vitally needs all on her own.

126. I actively listen, accept and.affirm her as a person even if our views
disagree.

127. I angrily detach from her, don't ask for anything; I weep alone about her.

128. I pay close attention in order to anticipate all her needs; I take care of
absolutely everything for her.

129. I whine, protest, try to explain, justify, account for myself.

130. I assert, hold my own without needing external support.

131. I avoid her by being busy and alone with my "own thing."

132. I warmly show how much I like and appreciate her just exactly as she is.

 

 

 

133.
134.

135.
136.

137.
138.

218

I well myself off from her, don't hear, don't react.
I relax. enjoy, really let go with her. I feel wonderful about being with

Believing it's for her own good, I tell her exactly what to do, be, think.
I bury my rage and resentment and scurry to appease her to avoid her dis-
approval.

I approach her with unwarranted, even crazy ideas about her; I don't
notice how or if she responds.

I go my own separate way.

 

139.
140.

141.
142.
143.
144.

I look after her interests, take steps to protect her. actively back her

up. .

I freely and openly disclose my innermost self so she truly can know "who
I am." '

I am joyful and exuberant and expect to have wonderful fun with her.

Just when I am needed most, I abandon her, leave her "in the lurch."

I neglect her, her interests, needs. '

I leave her free to do and be whatever she wants.

 

 

10.
11.

12.

'13.
14.
15.
16.
17.

18.

19.
20.
21.

22.
23.

Subject O

User 0

1219

ANSWER SHEET
Date

Sequence

Be sure to use this answer sheet with the questionnaire labeled INTREX FORM
Use oencil and completely fill in the circle which best describes your view 0 :

 

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221

APPENDIX N
Introduction to Participant Couples

I am Paula C. McNitt of Charleston, Illinois. As
part of my work for a doctoral degree in Psychology I am
conducting a study of married couples, aged 20 to 60. I
am interested in what husbands and wives who are getting
along fairly well together, and who are not having
serious emotional or relationship problems, have to say
about their marriages. I will be asking one or
preferable both partners to complete several
questionnaires. These should take about one hour to
complete. The questions are all pretty straightforward;
there's nothing sneaky about them. So, if you fit this
description and have not been separated from your spouse
very much during the past three months, feel that your
marriage has been free of serious problems during the
past two years, and if you (and/or your spouse) are
willing to participate, please give me your name and
telephone number (pass sign up sheet).

As a graduate student, I regret that I cannot really
pay for your participation; however, I can offer the
following to all couples who participate, a "thank. you"
of $5.00, a feedback session in which I will review and
interpret your questionnaire responses, and my sincere

gratitude.

l.

222

APPENDIX 0

Survey of Problem

During the past two _s_ have you received or sea-imp gm: about ask-
ing for professionanfizlrp with any of the following problem? Protessiual
help aeans a doctor. psychiatrist. psychologist, social worker. mlor.
or sinister. Check all that apply.

Castant. severe nervous tnsionuvith luadsches. staunch problns.
probleas sleeping. appetite problees.

My attacks. this includes hyperventilation palpitatius. choking.
shortness of breath, extra-e tension.

Extra-e irrational fears tlut keep'you frm doing the things yonnead
or want to do-ofear of flying. fear of traveling or leaving the house
by yourself. fear of crowds.

Mivethoughtsorfeers: thesearethooghts thatyoucalalotcal-
trol em though they seen silly.

Comlsive. ritual behaviors: things you have to do. cannot help not
doing. but which aha little sense.

Depressim: ertr-e feelings of sadness. loss of interest in life.
sleep and appetite probleas.

Alcoholis- or proble- drinking.

,Drugdqodency.

Sexual probleas.

Marriage probleas.

Your child's notional or behavior problens.
Other problees getting along with people.
Other.

Areyoonovtakingaynedicinestohelp'ymfeellessnximorless
depressedor to help you to think clearly? If so. which?

3. lhve you ever. since the age of 21. been hospitalized for psychiatric rea-
sons?

 

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