PPT question – Achiever Papers

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Learning Resources For the Assignment

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6. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.

Chapter 11, “Group Therapy” (Review pp. 407–428.)

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You will select one of the following articles on group therapy to evaluate for this week’s Assignment
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Assignment: Applying Current Literature to Clinical Practice

Psychiatric mental health nursing practice is one of the newest disciplines to be licensed to provide psychotherapy As such, the majority of psychotherapy research is centered on other disciplines such as psychology, social work, marriage/family therapy, art therapy, psychiatry, and mental health counseling. This makes it essential for you to be able to translate current literature from other disciplines into your own clinical practice. For this Assignment, you practice this skill by examining literature on group work and group therapy and considering its applicability to your own clients.

Learning Objectives

Students will:

· Evaluate the application of current literature to clinical practice

To prepare:

· Review this week’s Learning Resources and reflect on the insights they provide on group work and group therapy.

· Select one of the articles from the Learning Resources to evaluate for this Assignment.

NOTE: In nursing practice, it is not uncommon to review current literature and share findings with your colleagues. Approach this Assignment as though you were presenting the information to your colleagues.

The Assignment

In a 5- to 10-slide PowerPoint presentation, address the following:

· Provide an overview of the article you selected, including answers to the following questions:

· What type of group was discussed?

· Who were the participants in the group? Why were they selected?

· What was the setting of the group?

· How often did the group meet?

· What was the duration of the group therapy?

· What curative factors might be important for this group and why?

· What “exclusion criteria” did the authors mention?

· Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with your own client groups. If so, how? If not, why?

· Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article.

Note:

The presentation should be 5–10 slides, not including the title and reference slides. Include presenter notes (no more than a half page per slide) and use tables and/or diagrams where appropriate. Be sure to support your work with specific citations from the article you selected. Support your presentation with evidence-based literature.

ADOLESCENT AND FEMALE SEXUALITY

Group psychotherapy in women with a history of sexual abuse: what

did they find helpful?

Aslıhan Sayın, Selc�uk Candansayar and Leyla Welkin

Aims and objectives. To define the effects of group psychotherapy in women with a history of sexual abuse, to find possible

predictors for dropout and treatment outcome rates and to find which therapeutic factors of group psychotherapy are per-

ceived by group members to be most helpful.

Background. Sexual abuse of women is a global concern and causes many psychiatric and psychological sequelae. Group

psychotherapy is one of the preferred treatment modalities.

Design. Prospective cohort study.

Methods. Forty-seven women with a history of childhood and/or adulthood sexual abuse were recruited for weekly 12-session

group psychotherapy. Subjects were given the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Cli-

nician Administered Post-traumatic Stress Disorder Scale, the Dissociative Experiences Scale, the Childhood Trauma Ques-

tionnaire and the Group Therapeutic Factors Questionnaire. Re-evaluations were made after the 6th and 12th session and

also at a six-month follow-

up session.

Results. Group psychotherapy significantly reduced participants’ levels of depression (screening/12th session mean scores,

22�45/11�10), anxiety (15�45/4�32) and symptoms of post-traumatic stress disorder (42�27/9�32), and this decline became
statistically significant at the 6th session and tended to persist at the six-month follow-up. Higher levels of dissociative

symptoms at baseline were associated with less response to treatment, but higher levels of attendance at group sessions.

Group members rated existential factors (41�40 � 12�39), cohesiveness (37�42 � 8�32) and universalism (37�56 � 7�11) as
the most helpful therapeutic factors.

Conclusion. Group psychotherapy was significantly effective in reducing levels of depression, anxiety and posttraumatic

stress disorder symptoms in this sample of women. Dissociation had a significant effect on both treatment outcome and

treatment adherence. For this sample of women, group psychotherapy was most helpful for reducing feelings of stigma, iso-

lation and shame.

Relevance to clinical practice. Group psychotherapy can be used as a preferred treatment method for women from different

cultural backgrounds with a history of sexual abuse.

Key words: dissociation, group psychotherapy, post-traumatic stress disorder, sexual abuse, therapeutic factors, women

Accepted for publication: 31 October 2012

Introduction

Sexual abuse is a universal problem, and victims are most

often women. A meta-analysis/ of prevalence of child sexual

abuse in adults using 65 articles from 22 countries reported

that 7�9% of men and 19�7% of women had experienced
sexual abuse prior to the age of 18 (Pereda et al. 2009). In

a random sample of the general population in USA, sexual

assault during adulthood was reported by 22% of women

and 3�8% of men, and risk factors for adult sexual assault

Authors: Aslıhan Sayın, MD, Associate Professor, Psychiatry Dep-

artment, Gazi University Hospital, Ankara; Selc�uk Candansayar,
MD, Professor, Psychiatry Department, Gazi University Hospital,

Ankara; Leyla Welkin, PhD, Independent Scholar, Pomegranate

Connection Program, Ankara, Turkey

Correspondence: Aslıhan Sayın, Associate Professor, Psychiatry

Department, Gazi University Hospital, Bes�evler, Ankara 06500,
Turkey. Telephone: +90 532 5840438.

E-mail: aslihansayin@gmail.com

include younger age, being female, having been divorced,

sexual abuse in childhood and physical assault during

adulthood (Elliott et al. 2004). In Turkey, sexual abuse,

especially intrafamilial sexual abuse, continues to be vastly

under-reported to authorities due to social taboos (Agirtan

et al. 2009). The few published studies report a sexual

abuse prevalence of 11–37% in the adolescent population

(Aras et al. 1996, Alikasifoglu et al. 2006).

Childhood sexual abuse has been associated with long-

term psychiatric problems in adult life, including dissocia-

tive and post-traumatic stress disorders, depression, anxiety,

phobia, substance abuse, eating disorders, suicidal ideation

and behaviours, self-harm behaviours, problems in interper-

sonal and intimate relationships, impaired self-esteem, and

impaired identity formation (for a review, see Heim et al.

2010). Although these psychiatric problems are universal

among sexual abuse victims from all over the world,

women’s coping styles and the treatment for these problems

by mental health providers vary greatly between different

countries and cultures. For example, both legal and tradi-

tional approaches to sexual abuse victims in Turkey may

consider the marriage of an abuser and the victim as a

‘solution’. In some Middle Eastern countries and most com-

monly among Muslim groups like Turkey, family honour is

closely tied to the sexuality of its female members. Accord-

ing to these traditional values, young women are expected

to be virgins when they marry to assure their purity and

moral propriety. In this traditional system, women are not

primarily considered as individuals, and one of their most

important roles is to embody the family’s good reputation

and honour (Arin 2001, Sever & Yurdakul 2001). These

beliefs can be so strong that some families are prepared to

sacrifice the lives of female members in order to restore

family honour. After a rape, society perceives the violated

woman not as a victim who needs protection, but as some-

one whose impurity has debased the family honour. Her

relatives may opt to undo the shame of this violation by

taking her life. But murder is not the only possible remedy.

An alternative to murdering her is to arrange a marriage

for her, preferably with the person who violated her honour

through rape. This procedure of imposing a ‘reparative’

marriage on a violated woman is believed to remedy her

perceived offence against her family. Based on this set of

beliefs, the practice was until very recently legally sanc-

tioned by the Turkish state and was considered to ‘protect

the girl from social stigma’. After such a forced marriage,

the criminal investigation was dropped, although a rapist

could still face criminal charges if he divorced his wife

within five years ‘without a legitimate reason’ (Fledner

2000). Despite changes in the laws, some courts continue

to follow these principles. These local/cultural approaches

may encourage more abuses of victims and may also have

an influence on mental health approaches.

Given that sexual abuse of women is common and has

lifelong psychological effects, efforts have been made to

find effective treatment methods for these women. Group

psychotherapy has been one of the most widely studied

approaches (for reviews see Taylor & Harvey 2010, Trask

et al. 2011). There are many reasons why a group setting

may be a better way of healing sexual trauma. Treatment

groups create a safe and structured environment where each

woman can experience being heard and believed in a sup-

portive community of her peers. Group members may

choose themes that they consider relevant, often including

dealing with anger, self-esteem, sexuality, family-of-origin

issues, assertiveness, relationships, spirituality, perpetrators

and confrontation (Westbury & Tuttly 1999). A group for-

mat lessens the feelings of stigma, isolation and shame that

frequently follow sexual victimisation (Feiring et al. 1996,

Talbot 1996). In addition, a group setting provides partici-

pants with greater opportunities to observe and learn from

one another, especially for the acquisition of new skills.

In this study, we report the results of a group psychother-

apy experience conducted with Turkish women with a his-

tory of sexual abuse. We had two aims before conducting

this work. The first aim was to treat the psychiatric symp-

toms and psychological difficulties of survivors of sexual

trauma using group psychotherapy and also to find possible

predictors for dropout and treatment outcome rates. Sec-

ond, we aimed to find which therapeutic factors of group

psychotherapy would most help the group members. In

addition to these aims, our exploratory goal in this study

was to observe similarities and differences with regard to

responses to sexual trauma-related issues and the group

therapy setting between Turkish women and women from

other countries reported in the literature, because culture

may have an important impact on ways of responding to

and coping with trauma (Bryant-Davis et al. 2009).

Methods

Subjects

Group members (n = 47) were selected from among women

with history of a sexual abuse who applied for psychiatric

outpatient or inpatient treatment at the Psychiatry Depart-

ment of Gazi University Hospital or were staying at one of

the domestic violence shelter houses in Ankara and/or were

private practice patients of two of the authors. Some partic-

ipants learned of the groups by word of mouth. All of the

A Sayın et al.

women were interviewed before inclusion in this study by

one of the authors (A.S.). During this screening interview,

detailed oral information about the purpose and process of

this study was given, and a written informed consent form

was signed by all participants. Then, information about

their socio-demographic characteristics, previous psychiatric

treatment and sexual abuse history was obtained through a

semi-structured interview. The exclusion criteria included

being younger than 16 years of age, having a psychotic dis-

order, active alcohol or substance dependence, mental retar-

dation, severe suicidal thoughts and not signing the written

informed consent form.

The mean age of the participants was 31�74 (minimum
20, maximum 50, standard deviation 7�32). The majority
of them were single (n = 21, 44�7%), had an education
level above 12 years (n = 27, 57�4%), had a job (n = 23,
48�9%), were born in a big city (n = 25, 53�2%), had lived
mostly in a big city during their lives (n = 32, 68�1%) and
were living with family at the time of therapy (n = 33,

70�2%).
A minority 19�1% (n = 9) of the participants had never

received any kind of psychiatric or psychological treatment

before. Among those who had received treatment before,

40�4% (n = 19) had been treated with psychotropic medi-
cation, 38�3% (n = 18) had been treated with both medi-
cation and psychotherapy, and 1 had received only

psychotherapy. A total of 65�9% (n = 31) were still using
psychotropic medicine, 17�0% (n = 8) had been hospita-
lised once in their lives in a psychiatric inpatient clinic,

and 6�4% (n = 3) had been hospitalised more than once.
A total of 51�1% (n = 24) had attempted suicide in the
past. After the screening interview, it was concluded that

23�4% (n = 11) did not have any current psychiatric diag-
nosis. The most common diagnosis was major depression

(n = 20, 42�5%), followed by borderline personality disor-
der (n = 11, 23�4%) and post-traumatic stress disorder
(n = 6, 12�7%). Other psychiatric diagnoses were panic
disorder, eating disorders, vaginismus, social phobia,

obsessive-compulsive disorder and conduct disorder.

According to their sexual abuse history, the majority of

these women were children when their sexual trauma

occurred (n = 19, 40�4%), the most common perpetrators
were first-degree family members (n = 14, 29�8%) and
husbands/lovers (n = 14, 29�8%), most of these women
were raped (n = 28, 80�9%), and most of them were trau-
matised more than once by the same perpetrator (n = 30,

63�8%). Revictimisation had occurred for 40�4% (n = 19)
of the women (‘re-victimisation’ was defined as at least

one additional incident of sexual abuse in both childhood

and adulthood, refer Wyatt et al. 1992). A total of

25�5% of them (n = 12) had never talked about their sex-
ual assault to anyone before this therapy and had not

received professional help after the assault (n = 37,

78�7%).

Instruments

After obtaining the information discussed above, the Ham-

ilton Depression Rating Scale (HAM-D), Hamilton Anxiety

Rating Scale (HAM-A), Clinician Administered Post-trau-

matic Stress Disorder Scale (CAPS), Dissociative Experi-

ences Scale (DES) and Childhood Trauma Questionnaire

(CTQ-28) were administered. All of the instruments

throughout the study were administered by one of the

authors (A.S.), who has 10 years of experience in clinical

psychiatry and is familiar with the scales. Some of the

scales are self-report scales.

The Hamilton Depression Rating Scale

This is a clinician-applied scale with 17 questions,

developed by Max Hamilton (Hamilton 1960). Scores from

8–15 show mild, from 16–28 points show moderate, and

above 29 show severe depression. The Turkish form’s valid-

ity and reliability had been previously established (Akdemir

et al. 1996), with a test–retest reliability coefficient of 0�85
and Cronbach’s coefficient of 0�75.

The Hamilton Anxiety Rating Scale

This is a clinician-applied five-point Likert-type scale with

14 questions (Hamilton 1959). It includes both psychologi-

cal and bodily symptoms of anxiety. The Turkish form’s

validity and reliability had been previously established

(Yazıcı et al. 1998), with a test–retest coefficient of 0�72
and Cronbach’s coefficient of 0�94.

The Clinician Administered Post-traumatic Stress

Disorder Scale

This is a 17-item scale for the assessment of current and

lifetime PTSD symptoms (Blake et al. 1995). The 17

symptoms cluster into three subscales: CAPS-R for re-

experiencing, CAPS-A for avoidance/numbing and CAPS-H

for hyperarousal. A subject is considered ‘positive’ for life-

time symptoms if he/she endorses the symptoms within a

certain amount of time after the traumatic event. A sub-

ject is considered ‘positive’ for current symptoms if he/she

still has these symptoms. The Turkish version of CAPS

has a Cronbach’s alpha of 0�91 for the whole scale, 0�78
for re-experiencing symptoms, 0�78 for avoidance/numbing
symptoms and 0�82 for hyperarousal symptoms (Aker
et al. 1999).

Adolescent and female sexuality Group psychotherapy of sexual abuse

The Dissociative Experiences Scale

This is a 28-question self-report scale. For each question,

participants are asked to rate a sentence related to dissocia-

tive symptoms on a scale between 0–100 (Bernstein & Put-

man 1986). The Turkish version has a Cronbach’s alpha of

0�97 and a test–retest correlation of 0�77, and the cut-off
point for a Turkish population is 30 (Yargıc� et al. 1995).
This scale was used only at screening in this study, because

it evaluates dissociative symptoms experienced within a

lifetime.

The Childhood Trauma Questionnaire

This is a five-point Likert-type self-report questionnaire

developed by Bernstein et al. (1994). It evaluates childhood

trauma history according to five dimensions: physical

neglect, physical abuse, emotional neglect, emotional abuse

and sexual abuse. The Turkish version has a Cronbach’s

alpha of 0�96 (Aslan & Alparslan 1999).

The Group Therapeutic Factors Questionnaire

For this study, Yalom’s 60-item therapeutic factor question-

naire was used (Yalom 1975). The questionnaire contains

60 items, 5 describing each of the 12 factors (a brief

description of each therapeutic factor can be found in Table

3). Patients are asked to consider each of the 12 items (pre-

sented on five separate pages) and rank each item from the

least helpful (1) to the most helpful (12). This questionnaire

had previously been translated into Turkish (transl Tang€or

& Karac�am 1999).
The HAM-D, HAM-A and CAPS were given four times

during the study: at entry (baseline), after the sixth session,

after the final (12th) session and at a follow-up session

(six months after the therapy ended). The DES and CTQ-

28 were given at entry. The Group Therapeutic Factors

Questionnaire was given after the final therapy session.

Group psychotherapy method

An eclectic method of group psychotherapy was applied

that had been developed by one of the authors (L.W.)

and used by her for 20 years. This method uses a combi-

nation of well-validated psychotherapy methods (such as

cognitive behavioural therapy, interpersonal therapy, nar-

rative therapy, psychoeducation, expressive techniques) for

trauma-focused therapies (for a review, see Taylor &

Harvey 2010). It includes 12 90-minute sessions, and each

session has an agenda. Some of the topics from the first

three sessions include group rules, safety issues and effects

of sexual trauma on psychological and interpersonal

well-being. A psychotherapeutic approach for common

psychiatric and psychological responses to trauma was

applied, and some relaxation techniques were introduced.

In sessions 4–7, participants were asked to tell their sex-

ual abuse stories, in an order determined by themselves.

In sessions 8–10, some common themes raised in the

members’ stories were discussed more deeply in the

group. Examples of some of these themes include issues

about self-respect, self-esteem, sexuality, relationships with

men, with family, anger, etc. The 11th and 12th sessions

were closure sessions during which members summarised

their group process, gave feedback to each other and

talked about their future plans. An additional follow-up

session was provided six months after finishing the 12th

session. All of the sessions were conducted by all of the

authors (one therapist and two co-therapists), who have

10–20 years of group psychotherapy experience as thera-

pists and co-therapists.

Statistical analysis

All data were statistically analysed using the SPSS, version

15.0 package (SPSS Inc., Chicago, IL, USA) programme.

For statistical analysis of the differences between the mean

scores of the HAM-A, HAM-D and CAPS during the entire

group process and on follow-up, the general linear model

for repeated measures, chi–square test, and Friedman’s and

Wilcoxon’s analysis with Bonferroni correction were used.

The Mann–Whitney U-test, chi–square test, and Pearson’s

correlation and linear regression analyses were used to

find the variables that had a significant effect on the thera-

peutic factors, treatment efficacy and dropout rates. A

p-value < 0�05 was considered statistically significant.

Results

Treatment adherence

A total of five groups were completed, each consisting of

8–10 members. There were no statistically significant

differences between these five cohorts with regard to socio-

demographic variables, sexual trauma history, scores from

whole scales, and dropout and efficacy rates. Among the

47 women who applied for this study, 32 (68�1%) finished
the whole group process. Seven (14�9%) never attended
group after being screened, and these subjects were

excluded from further statistical analysis. The remaining

eight (17�0%) subjects will be referred as ‘dropouts’,
because these women attended at least one session but did

not finish the whole process. To determine the predictors

A Sayın et al.

for these dropouts, chi-square and linear regression analy-

ses were conducted, and we found that being younger than

33 years of age (median) [odds ratio (OR) = �0�459; 95%
confidence interval (CI) �0�571 to �0�140, p = 0�002] and
a DES score lower than 30 (no dissociation)

(OR = �0�405; 95% CI �0�547 to �0�101, p = 0�006)
predicted a higher dropout rate (Table 1).

Treatment response

The results for the remaining 32 subjects’ mean scores on

the scales given throughout the study, as well as a com-

parison of their scores at the baseline (screening), after

the 6th and the 12th sessions and at the six-month fol-

low-up are shown in Table 2. These analyses were made

Table 1 Regression analysis for treatment adherence

Attendance n (%)

v² p OR Sig (reg)

95% confidence interval

Finished Dropped out Lower bound Upper bound

Age

� 33 years 15 (65�2) 8 (34�8) 7�391 0�007 �0�459 0�002 �0�571 �0�140
>33 years 17 (100) 0

DES

� 27 18 (72) 7 (28) 4�778 0�036 �0�405 0�006 �0�547 �0�101
>27 14 (100) 0

DES, Dissociative Experiences Scale.

Table 2 Mean scores of Hamilton Depression Rating scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Clinician Administered

Post-traumatic Stress Disorder Scale-Total (CAPS-T) (subtitles re-experiencing symptoms CAPS-R, avoidance symptoms CAPS-A, hypera-

rousal symptoms CAPS-H), Dissociative Experiences Scale (DES) and Childhood Trauma Questionnaire (CTQ-28) at screening (1), after 6th

session (2), after 12th session (3) and six-month follow-up (4)

Scale Mean SD v² p* Z p†

HAM-D1 22�45 11�1 48�363 0 HAM-D1/2 �4�889 0
HAM-D2 14�64 9�89 HAM-D2/3 �4�725 0
HAM-D3 8�55 8�13 HAM-D3/4 �2�445 0�002
HAM-D4 5�55 4�95
HAM-A1 15�45 8�9 41�533 0 HAM-A1/2 �4�62 0
HAM-A2 9�82 9�17 HAM-A2/3 �4�173 0
HAM-A3 5�09 6�61 HAM-A3/4 �0�683 0�082
HAM-A4 4�32 2�44
CAPS-T1 42�27 19�68 42�823 0 CAPS-T1/2 �4�42 0
CAPS-T2 26�64 25�95 CAPS-T2/3 �3�503 0
CAPS-T3 13�77 24�21 CAPS-T3/4 �0�669 0�167
CAPS-T4 9�32 11�84
CAPS-R1 10 9�25 6�596 0�086 CAPS-R1/2 �1�255 0�069
CAPS-R2 9�55 11�32 CAPS-R2/3 �1�725 0�028
CAPS-R3 6�36 10�48 CAPS-R3/4 �1�074 0�094
CAPS-R4 3�95 7
CAPS-A1 20�55 10�25 40�026 0 CAPS-A1/2 �4�341 0
CAPS-A2 10�18 11�57 CAPS-A2/3 �3�481 0
CAPS-A3 3�82 10�63 CAPS-A3/4 �1�153 0�083
CAPS-A4 0�91 2�52
CAPS-H1 11�73 9�42 17�112 0�001 CAPS-H1/2 �3�23 0
CAPS-H2 6�91 8�22 CAPS-H2/3 �3�126 0
CAPS-H3 3�59 6�26 CAPS-H3/4 �0�306 0�253
CAPS-H4 4�45 7�75

*Friedman’s test.
†Wilcoxon’s test with Bonferroni correction.

Adolescent and female sexuality Group psychotherapy of sexual abuse

in two steps. First, a nonparametric analysis for

K-repeated samples (Friedman) was performed to analyse

the changes in scores from baseline to follow-up. Second,

to find exactly when a significant decrease in scores

had occurred, nonparametric analysis for 2-Related

Samples (Wilcoxon’s test with Bonferroni correction) was

performed. According to these results, the significant

decline in HAM-D (mean = 22�45 versus 14�64,
p < 0�001), HAM-A (15�45/9�82, p < 0�001), CAPS-total (CAPS-T) (42�27/26�64, p < 0�001), CAPS-A (20�55/10�18, p < 0�001) and CAPS-H (11�73/6�91, p < 0�001) began during the first six sessions. This tendency to decline

continued through the follow-up session, and the statisti-

cal significance was lost between 12th session and the

six-month follow-up, except for the HAM-D (8�55/5�55,
p = 0�002). CAPS-H scores increased between the 12th
session and the six-month follow-up session without a

statistically significant difference. For the CAPS-R scores,

a significant decline began between the 6th and the 12th

sessions (9�55/6�36, p = 0�028), and this significance was
lost between the 12th session and the six-month follow-

up session.

As shown in Table 2, the standard deviations were

high, which suggests that there were some extreme cases

that did not respond to therapy. To find predictors for

treatment outcome, we divided the subjects into two

groups with regard to treatment efficacy. For those sub-

jects whose scores from all scales decreased more than

50% between baseline and the end of therapy (12th ses-

sion), the treatment could be considered ‘efficacious’

(n = 25, 78�1%). Chi-square and linear regression analy-
ses were performed to find the predictors for treatment

outcome. The only significant result was for DES scores:

for the majority of those who had a DES score of <30

(no dissociation), the treatment was efficacious (n = 17,

94�4%), while for the 42�9% (n = 6) of the women who
had a DES score above 30, the treatment was not effica-

cious (OR = �0�448; 95% CI = �0�651 to �0�095,
p = 0�010).

Understanding the therapeutic factors

Table 3 shows the results of the Group Therapeutic Factors

Questionnaire. Existential factors (mean � standard devia-
tion, 41�40 � 12�39), universality (37�56 � 7�11) and cohe-
siveness (37�24 � 8�32) were rated as the most helpful
therapeutic factors in the group process, while identification

(23�56 � 7�90), interpersonal learning – input (24�64 �
8�70) and interpersonal learning – output (25�80 � 7�91)
were rated as the least helpful factors.

Discussion

We were able to fulfil the three aims we had for this study.

The first aim was to help these women to heal from their

trauma-related psychiatric and psychological difficulties.

Most of these women had severe psychiatric symptoms at

screening, including depression, anxiety, post-traumatic

stress disorder and dissociation. Their symptom patterns

were similar to those previously reported for comparable

populations (for a review, see Barker-Collo & Read 2003).

As shown in Table 2, most of the group members had sig-

nificantly less depressive, anxiety and post-traumatic stress

disorder symptoms, both immediately after and six months

after this therapy. These results show that group psycho-

therapy was effective for this sample, a result that is in

accord with previous literature (for reviews see Taylor &

Harvey 2010, Trask et al. 2011). A significant decline in

symptoms began as early as the 6th session for depression

and anxiety, along with their overall symptoms of PTSD,

primarily avoidance and hyperarousal symptoms. The only

exception was the re-experiencing of symptoms of PTSD,

which showed a small decline at the 6th session evaluation,

but this decline became significant at the 12th session

evaluation. We think that the possible reason for this ‘late’

decline in re-experiencing symptoms is that from sessions

4–7, participants were asked to tell their sexual abuse sto-

ries. Telling their trauma stories in front of other members,

as well as listening to the other members’ stories, may have

caused a temporary increase in some participants’ re-experi-

encing symptoms. But as group members became ‘de-sensi-

tised’ to the telling and hearing of stories, their symptoms

begin to decline.

We found that this treatment was efficacious for 78�1%
of these women. This rate is similar to the rates reported in

the literature, because a large meta-analysis of 26 studies

Table 3 Mean scores of Group Therapeutic Factors Questionnaire

Therapeutic factors Mean SD

Altruism 29�24 10�12
Cohesiveness 37�24 8�32
Universality 37�56 7�11
Interpersonal learning – input 24�64 8�70
Interpersonal learning – output 25�80 7�91
Guidance 26�00 8�15
Catharsis 30�48 7�14
Identification 23�56 7�90
Family re-enactment 34�32 11�59
Self-understanding 42�32 11�35
Hope instillation 36�40 9�61
Existential factors 41�40 12�39

A Sayın et al.

including 44 treatment conditions for psychotherapy of

PTSD reports that, of patients who completed treatment,

67% no longer meet the criteria for PTSD (Bradley et al.

2005). What is interesting is that none of the variables had

a significant effect on treatment efficacy. The only signifi-

cant result was for dissociation at baseline; the treatment

was significantly more effective for members who had a

lower score for dissociation at baseline, as compared to

those who had higher dissociation scores. This finding is in

contradiction to results from previous studies which have

shown that more severe dissociative symptoms at baseline

are associated with the same or even better outcomes for

psychological treatments for PTSD (Lynch et al. 2008,

Hagenaars et al. 2010). Dropout rates were also similar to

the rates reported in the literature (Bradley et al. 2005). A

younger age and having lower levels of dissociation at

baseline predicted a higher dropout rate. Dissociation is a

complex symptom and may have a significant negative

effect on individual’s daily life and functioning. This may

have created a higher level of motivation for treatment,

which is reflected in a lower dropout rate.

Our second aim was to find how different characteristics

of group members affected their understanding of the group

process, especially the therapeutic factors of group psycho-

therapy. In this sample, group members reported that exis-

tential factors, universality and cohesiveness were the most

helpful therapeutic factors. This finding supports the ratio-

nale for using group psychotherapy in trauma treatment,

because, as previously stated, a safe and structured group

environment helps members to feel supported, heard and

believed and lessens their feelings of stigma, isolation and

shame (Feiring et al. 1996, Talbot 1996, Westbury &

Tuttly 1999).

We have two hypotheses to explain why group members

chose these particular factors. First, we believe that the set-

ting had a significant effect upon ‘cohesiveness’. The groups

were run in the private office of one of the authors. Mem-

bers were permitted to come half an hour before the group

started. Many group members chose to do this, and they

often brought food with them, drank coffee and talked with

each other. This somewhat resembles ‘women’s day’ in

Turkish culture, social events where women come together

regularly to eat, drink and talk with each other. We believe

these ‘before-the-group’ talks encouraged the occurrence of

cohesiveness. In addition, most of the group members con-

tinued to meet regularly after the whole group process

ended. Some of them even began to organise community

education programmes. Second, we think that ‘culture’ had

an important effect on ‘universality’. The most common

perpetrators for our sample were first-degree family

members (29�8%) and husbands/lovers (29�8%). Incest is a
major social taboo in Turkey, and usually, both the victims

and their families would rather ‘keep it a secret’ instead of

talking about such abuse. Incest may even result in murders

within families. Sexual abuse by husbands/lovers is some-

times not considered illegal in Turkey. For these reasons,

women in Turkey who are sexually abused by first-degree

relatives and/or husbands usually do not share their trauma

story with anyone else. Shame and fear may be the main

emotions for women who choose to remain silent after this

kind of sexual abuse. Understanding this helps us to under-

stand why these women might choose ‘universality’ as one

of the most helpful therapeutic factors. Hearing other

women’s stories and realising that they are not the only

people who have had to face such an event may have less-

ened these women’s feelings of isolation, and this may have

helped them through their healing process. This is also

closely related to the ‘existential factors’; these women may

have learned that ‘life is not always fair’ by listening to

other women’s stories. Existential well-being, defined as

having a sense of being unique, having a purpose in life

and finding meaning in a ‘hostile and hurtful’ world, has

previously been shown to be an important factor in recov-

ery from sexually abusive experiences (Feinauer 2003, Shaw

et al. 2005). Rating existential factors as one of the most

helpful therapeutic factors in group psychotherapy suggests

that group participants were able to make meaning in their

lives that has become more significant to them than their

sexually abusive experiences. They were able to see them-

selves as having survived a difficult and destructive experi-

ence resulting from another person’s disturbance. Once

freed from self-blame, these women could believe they have

an opportunity to change their lives and could put their

traumatic experiences into the past. This finding is beauti-

fully reflected in a comment made by one of our group

members: ‘I used to carry my life on my shoulders like a

burden. Now I am ready to flow with it’.

We had a third exploratory goal in this study and that

was to observe similarities and differences with regard to

responses to sexual trauma–related issues and the group

therapy setting between Turkish women and women from

other countries reported in the literature. One of our thera-

pists (L.W.) had run groups with sexually abused women in

the USA for 20 years, so she had a chance to compare these

similarities and differences. Another paper compares obser-

vations of group patterns for sexual abuse survivors in

these two countries with significantly different cultures.

But, to summarise, we report that although groups from

these two countries were overwhelmingly similar in many

ways, differences emerged in expression and containment of

Adolescent and female sexuality Group psychotherapy of sexual abuse

effect, cohesion and relatedness, perceptions of reaction to

authority and power, and external/internal locus of control

(L. Welkin, S. Candansayar and A. Sayın, unpublished

results). Religiously and culturally determined contrasts in

perception, attitude, communication and behaviour may

have significant effects on patients’ perceptions about thera-

peutic factors (Salvendy 1999). Turkish culture is often

described as a culture of relatedness or collectivism where

interpersonal relations are of central importance, in con-

trast to a culture of separateness and individualism where

personal autonomy is more highly valued (Ka�gıtc�ıbas�ı
1994). People in more relational cultures are thought to

seek high levels of relatedness and moderate levels of

autonomy to maintain their mental health, while people in

more individualistic cultures seek high levels of autonomy

and moderate levels of relatedness (Sato 2001). Universality

and cohesiveness are, we believe, therapeutic factors that

can be closely related to ‘relatedness’. In a study conducted

with Turkish psychiatric inpatients, it was reported that

patients rated existential factors, instillation of hope and

universality as the most helpful group therapeutic factors

(Sayin et al. 2008). To our knowledge, there is no other

study about therapeutic factors in sexual abuse survivor’s

groups, but it would be interesting to compare our results

with results from more individualistic countries.

Although our results are promising, this study has some

major limitations. First, our sample is small and is not

representative of all Turkish sexual abuse victims, because it

includes only women living in the capital city of Turkey. Sec-

ond, this is not a controlled study, and we did not compare

the therapeutic effect of group psychotherapy to any other

form of treatment or a waiting list. Third, all the treatment

outcome ratings were performed by one of the therapists in

the group and that may have created a bias.

Conclusion

We believe that this study, despite its limitations, provides

further support for the effectiveness of group psychotherapy

for women from different cultural backgrounds with a his-

tory of childhood sexual abuse. Group psychotherapy was

significantly effective for reducing levels of depression, anxi-

ety and PTSD symptoms in this sample of women. Dissoci-

ation had a significant effect on both treatment outcome

and treatment adherence. Further studies conducted with

sexually abused women from different countries would

surely enrich the literature and help us to understand better

how to help victims of sexual abuse.

Relevance to clinical practice

Mental health treatment for sexually abused women should

be planned with careful consideration of both local cultural

differences and universal human fundamentals. Group psy-

chotherapy can be a preferable treatment for these women,

because it especially helps to reduce feelings of stigma,

isolation and shame.

Contributions

Study design: AS, SC, LW; data collection and analysis: AS

and manuscript preparation: AS, SC, LW.

References

Agirtan CA, Akar T, Akbas S, Akdur R,

Aydin C, Aytar G, Ayyildiz S, Baskan

S, Belgemen T, Bezirci O, Beyazova U,

Beyaztas FY, Buken B, Buken E,

Camurdan AD, Can D, Canbaz S,

Cant€urk G, Ceyhan M, Coskun A, Celik

A, Cetin FC, Coskun AG, Da�gc�inar A,
Dallar Y, Demirel B, Demirogullari B,

Derman O, Dilli D, Ersahin Y, Es�iyok
B, Evinc G, Gencer O, G€okler B, Hanci

H, Iseri E, Isir AB, Isiten N, Kale G,

Karadag F, Kanbur N, Kilic� B, Kultur
E, Kurtay D, Kuruoglu A, Miral S,

Odabasi AB, Oral R, Orhon FS, Ozbes-

ler C, Ozdemir DF, Ozkok MS, Ozmert

E, Oztop DB, Ozy€urek H, Pasli F,

Peksen Y, Polat O, Sahin F, Rifat Sahin

A, Salacin S, Suskan E, Tander B, Tekin

D, Teksam O, Tiras U, Tomak Y,

Tumer AR, Turla A, Ulukol B, Uslu R,

Tas FV, Vatandas N, Velipasaoglu S,

Yagmur F, Ya�gmurlu A, Yalcin S,

Yavuz S & Yurdakok K; Contributing

Multidisciplinary Teams (MDT)

(2009) Establishment of interdisciplin-

ary child protection teams in Turkey

2002–2006: Identifying the strongest

link can make a difference. Child Abuse

and Neglect 33, 247–255.

Akdemir A, €Orsel S, Da�g _I, T€urkc�apar H,
_Is�can N & €Ozbay H (1996) Hamil-
ton depresyon derecelendirme €olc�e�gi
(HDD €O)’nin gec�erlilik, g€uvenilirli�gi
ve klinikte kullanımı. 3P Dergisi 4,

251–259 [in Turkish].

Aker AT, €Ozeren M, Bas�o�glu M, Kapt-
ano�glu C, Erol A & Buran B (1999)

Klinisyen tarafından uygulanan trav-

ma sonrası stress bozuklu�gu €olc�e�gi
(TSSB- €O) gec�erlilik ve g€uvenilirlik
c�alıs�ması. Turkish Journal of Psychia-
try 10, 286–293 [in Turkish].

Alikasifoglu M, Erginoz E, Ercan O,

Albayrak-Kaymak D, Uysal O & Ilter

O (2006) Sexual abuse among female

high school students in Istanbul,

Turkey. Child Abuse and Neglect 27,

1161–1178.

Aras Z, Aksel S & Alkaynak S (1996) Sex-

ual behavior in adolescents. Psychol-

ogy Seminars 11, 89–94.

Arin C (2001) Femicide in the name of

honor in Turkey. Violence against

Women 7, 821–825.

Aslan SH & Alparslan ZN (1999) C�ocukluk
€Orselenme Yas�antıları €Olc�e�gi’nin bir
€universite €o�grencisi €ornekleminde gec�er-

A Sayın et al.

lilik, g€uvenilirlik ve fakt€or yapısı. Turk-

ish Journal of Psychiatry 10, 275–285

[inTurkish].

Barker-Collo S & Read J (2003) Models of

response to childhood sexual abuse.

Trauma, Violence, and Abuse 4, 95–

111.

Bernstein EM & Putman PW (1986) Devel-

opment, reliability and validity of a

dissociation scale. Journal of Nervous

and Mental Disorders 174, 727–735.

Bernstein D, Fink L, Handelsman L, Foote

J, Lovejoy M, Wenzel K, Sapareto E

& Ruggiero J (1994) Initial reliability

and validity of a new retrospective

measure of child abuse and neglect.

American Journal of Psychiatry 151,

1132–1136.

Blake DD, Weathers FW, Nagy LM,

Kaloupek DG, Gusman FD, Charney

DS & Keane TM (1995) The develop-

ment of a clinician administered PTSD

scale. Journal of Trauma and Stress 8,

75–90.

Bradley R, Greene J, Russ E, Dutra L &

Westen D (2005) A multidimensional

meta-analysis of psychotherapy for

PTSD. American Journal of Psychiatry

162, 214–227.

Bryant-Davis T, Chung H & Tillman S

(2009) From the margins to the center:

Ethnic minority women and the mental

health effects of sexual assault. Trauma,

Violence, and Abuse 10, 330–357.

Elliott DM, Mok DS & Briere J (2004)

Adult sexual assault: Prevalence,

symptomatology, and sex differences

in the general population. Journal of

Trauma and Stress 17, 203–211.

Feinauer L (2003) Existential well-being as

a factor in the adjustment of adults sexu-

ally abused as children. The American

Journal of Family Therapy 31, 201–213.

Feiring C, Taska L & Lewis M (1996) A

process model for understanding adap-

tation to sexual abuse: the role of

shame in defining stigmatization. Child

Abuse and Neglect 20, 767–782.

Fledner Y (2000) “Honor” murders- why

the perps get off easily. Middle East

Quarterly 6, 41–50.

Hagenaars MA, vanMinnen A & Hoog-

dwin KAL (2010) The impact of dis-

sociation and depression on the

efficacy of prolonged exposure treat-

ment for PTSD. Behavioral Research

and Therapy 48, 19–27.

Hamilton M (1959) The assessment of anxi-

ety states by rating. British Journal of

Medical Psychology 32, 50–55.

Hamilton M (1960) A rating scale for

depression. Journal of Neurology,

Neurosurgery, and Psychiatry 23,

56–65.

Heim C, Shugart M, Craighead WE &

Nemeroff CB (2010) Neurobiological

and psychiatric consequences of child

abuse and neglect. Developmental

Psychobiology 52, 671–690.

Ka�gıtc�ıbas�ı C� (1994) A critical appraisal of
individualism-collectivism: Toward a

new formulation. In Individualism and

Collectivism: Theory, Method and Appli-

cations (Kim U & Hakhoe HS eds).

Sage, Beverly Hills, CA, pp. 52–65.

Lynch SM, Forman E, Mendelsohn M &

Herman J (2008) Attending to dissoci-

ation: assessing change in dissociation

and predicting treatment outcome.

Journal of Trauma and Dissociation

9, 301–319.

Pereda N, Guilera G, Forms M & Gomez-

Benito J (2009) The prevalence of

child sexual abuse in community and

student samples: a meta-analysis. Clin-

ical Psychology Reviews 29, 328–338.

Salvendy JT (1999) Ethnocultural consider-

ations in group psychotherapy. Interna-

tional Journal of Group Psychotherapy

49, 429–464.

Sato T (2001) Autonomy and relatedness

in psychopathology and treatment: A

cross-cultural formation. Genetics,

Social, and General Psychology

Monograms 127, 89–127.

Sayin A, Karslioglu EH, Surgit A, S�ahin S,
Arslan T & Candansayar S (2008) Per-

ceptions of Turkish psychiatric

inpatients about therapeutic factors of

group psychotherapy. International

Journal of Group Psychotherapy 58,

253–263.

Sever A & Yurdakul G (2001) Culture of

honor, culture of change: a feminist

analysis of honor killings in rural

Turkey. Violence against Women 7,

964–998.

Shaw A, Joseph S & Linley PA (2005)

Religion, spirituality, and posttrau-

matic growth: a systemic review.

Mental Health, Religion & Culture 8,

1–11.

Talbot NL (1996) Women sexually abused

as children: the centrality of shame

issues and treatment implications.

Psychotherapy 33, 11–18.

Tang€or A & Karac�am €O (transl) (1999)
Grup Psikoterapisinin Teori ve Prat-

i�gi. Kabalcı Yayınevi, Kadikoy, _Istan-

bul [in Turkish].

Taylor JE & Harvey ST (2010) A meta-

analysis of the effects of psychother-

apy with adults sexually abused in

childhood. Clinical Psychology

Reviews 30, 749–767.

Trask EV, Walsh K & DiLillo D (2011)

Treatment effects for common out-

comes of child sexual abuse: A current

meta-analysis. Aggression and Violent

Behavior 16, 6–19.

Westbury E & Tuttly LM (1999) The effi-

cacy of group treatment for survivors

of childhood abuse. Child Abuse and

Neglect 23, 31–44.

Wyatt GE, Guthrie D & Notgrass C

(1992) Differential effects of

women’s child sexual abuse and sub-

sequent revictimization. Journal of

Consulting and Clinical Psychology

60, 167–173.

Yalom ID (1975) The Theory and Practice

of Group Psychotherapy. Basic Books,

New York, NY.

Yargıc� L_I, Tutkun H & S�ar V (1995) The
reliability and validity of the Turkish

Version of Dissociative Experiences

Scale. Dissociation 8, 10–12.

Yazıcı MK, Demir B, Tanrıverdi N, Kar-

ao�glu E & Yolac� P (1998) Hamilton
Anksiyete De�gerlendirme €Olc�e�gi,
de�gerlendiriciler arası g€uvenilirlik ve

gec�erlik c�alıs�ması. Turkish Journal of
Psychiatry 9, 114–117 [in Turkish].

Adolescent and female sexuality Group psychotherapy of sexual abuse

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The American Journal of Family Therapy, 43:

103

–118, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926187.2014.956614

The Effect of Cognitive-Behavioral Group
Marital Therapy on Marital Happiness

and Problem Solving Self-Appraisal

CLAUDE BÉLANGER
University of Quebec in Montreal (UQAM), Montreal, Canada,

McGill University, Montreal, Canada, and
The Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse

(CRIPCAS), Montreal, Canada

LISE LAPORTE
McGill University Health Center, Montreal, Canada

STÉPHANE SABOURIN
The Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse

(CRIPCAS), Montreal, Canada, and Laval University, Quebec City, Canada

JOHN WRIGHT
The Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse

(CRIPCAS), Montreal, Canada

Problem solving self-appraisal affects problem solving performance
and marital adjustment. This study investigated the effects of
cognitive-behavioral group marital therapy on couples’ adjustment
and their self-appraisal of problem solving activities. Sixty-six cou-
ples participated in group couples therapy. Subjects were randomly
assigned to an experimental or a waiting list control group. They
completed the Problem Solving Inventory and the Marital Happiness
Scale. Therapy was effective in improving global couple adjustment
and problem solving self-appraisal. The program had a differential
effect on the improvement of self-perceived problem solving abili-
ties depending on the spouses’ initial self-appraised problem solving
ability level.

Address correspondence to Claude Bélanger, Département de Psychologie, Université du
Québec à Montréal, C.P. 8888 succursale Centre-ville, Montréal, QC H3C 3P8, Canada. E-mail:
belanger.claude@uqam.ca

103

104 C. Bélanger et al.

Marital therapy based on social learning principles aims to enhance com-
munication and/or to teach problem solving skills, with the expectation
that such behavioral changes will lead to an increase in marital satisfaction
(Woodin, 2001). However, increased attention has been devoted to the
role of individual cognitive variables in mediating the relationship between
communication/problem solving behaviors and marital distress (Bélanger,
Sabourin & El-Baalbaki, 2012). The importance of cognitive processes in the
development and maintenance of marital dysfunction has been confirmed in
several investigations of the implications of spouses’ cognitions in outcome
research (Dunn & Schwebel, 1995).

Researchers have evaluated problem solving self-appraisal as a deter-
minant of individuals’ adaptational outcomes (Godshall and Elliott, 1997;
Heppner, Kampa, & Brunning, 1987). Problem solving self-appraisal refers
to a relatively stable attitude toward one’s personal problem solving reper-
toire as well as toward the self-regulatory processes at work while a problem
is being solved (Heppner & Krauskopf, 1987).

Social problem solving abilities are used in social contexts, and they af-
fect interpersonal adjustment (Elliott & Grant, 2008). For instance, family care-
givers demonstrating effective problem solving styles reported greater rela-
tionship satisfaction (Shanmugham, Cano, Elliott & Davis, 2009). Self-efficacy
in response to personal problems is related to the way the person appraises
his or her problem solving skills. Accordingly, to develop good coping ca-
pacities, it is important for a person to be able to appraise his or her problem
solving skills and style (Heppner & Dong-Gwi, 2009). Moreover, Bandura’s
work strongly supports the notion that people’s perception of self-efficacy af-
fects their motivation to face challenges, their decision-making behaviors and
their emotional reactions in difficult situations (Bandura, 1986; Carré, 2004).
Perceived self-efficacy has also been related to many personal difficulties
such as depression (Dreer, Elliott, Fletcher, & Swanson, 2005; Rivera et al.,
2007; Nezu, Kalmar, Ronan & Clavijo,1986), psychosocial impairment (Shan-
mugham, Elliott & Palmatier, 2004) and alcoholism (Elliott, Grant & Miller,
2004); it has also been associated with psychological adjustment (Heppner &
Anderson, 1985), physical health (Heppner, Kampa, & Brunning, 1987) and
personality (D’Zurilla, Maydeu-Olivares & Gallardo-Pujol, 2011).

The well-established links between problem solving self-appraisal and
relationship satisfaction have led researchers to investigate problem solving
capacities and self-appraisal in relation to coping skills and the marital
relationship. These studies were based on the basic premise that, for most
people, the quality of their marital relationship is an important predictor of
their general well-being (Hertzog, 2011). When facing stressful life events,
partners use joint efforts in problem solving interactions and other coping
strategies to reestablish satisfaction and maintain marital adjustment. A
failure in these cognitive and behavioral adaptation mechanisms often leads
to marital distress.

Impact of Group CBT on Marital Happiness and Self-Appraisal 105

Dyadic coping strategies encompass both the cognitive and behavioral
components that influence marital satisfaction. Therefore, it is necessary
to understand the relationships between the cognitive strategies and so-
cial behaviors that partners adopt during their problem solving interactions.
If there is such a link, then what is the exact nature of this interrelation,
and in what ways do these cognitive (problem solving self-appraisal) and
behavioral (problem solving efficacy) strategies influence marital satisfac-
tion? The preoccupation with understanding the cognitive and behavioral
problem solving determinants of marital adjustment can be found in a lim-
ited number of studies that have addressed these particular issues (Baucom
& Kerig, 2004). In line with these questions, an investigation in our lab-
oratory showed that problem solving self-appraisal differentiates distressed
from non-distressed partners (Sabourin, Laporte, & Wright, 1990). Distressed
spouses expressed less problem solving confidence, a stronger tendency to
avoid different problem solving activities, and less control over their behav-
ior than their non-distressed partners (Sabourin et al., 1990). Another study
that was run by the same team (Lussier et al., 1997) examined the rela-
tionship between spouses’ attachment styles, coping strategies, and marital
satisfaction. These researchers pinpointed many links between attachment
strategies, coping skills and marital adjustment. These results are consistent
with Bodenmann et al. (2006), who reported several studies showing that
positive dyadic coping significantly correlates with a better quality of mari-
tal relationship, lower levels of stress and better physical and psychological
well-being, and in some studies, these correlations are stronger for women
than for men. Kurdek (1991) tried to conceptualize these variables into a
model in which he assessed the role of cognitively and behaviorally ori-
ented problem solving determinants on the relationship satisfaction of gay
and lesbian partners. His results support a problem solving model in which
relationship satisfaction is related to strategies used by partners to resolve
their conflicts.

In a recent study, Bélanger and his colleagues (2012) investigated the
mutual contributions of a self-reported cognitive strategy, coping, observed
problem solving behaviors, and marital adjustment. In line with Kurdek
(1991), they hypothesized that the specific coping strategies would be re-
lated to the quality of the problem solving behaviors and that both these
variables would be related to marital satisfaction. Their results propose that,
for both men and women, there are significant relationships between cog-
nitive and coping strategies, problem solving behaviors displayed during
marital interactions, and marital adjustment.

Thus, because empirical studies have demonstrated that problem solving
self-appraisal is directly related to problem solving performance (Heppner
& Dong-Gwi, 2009), spouses should not only possess the problem solving
skills necessary to confront and alleviate their marital difficulties but also
believe in their capacity to do so. To be of maximum value, marital therapy

106 C. Bélanger et al.

should therefore not only aim to enhance specific problem solving skills but
also should work to alter spouses’ appraisal of their problem solving abilities.
To the best of our knowledge, very few outcome studies have investigated
such an effect of couples’ cognitive-behavioral therapy on the partners’ self-
appraisal of their problem solving abilities and marital satisfaction.

Accordingly, the main purpose of this paper is 1) to evaluate the overall
effectiveness of cognitive-behavioral group marital therapy in bringing about
positive changes in marital satisfaction and 2) to study the effects of such a
program on partners’ self-appraisal of problem solving abilities.

The specific hypotheses were that group marital therapy subjects would
report changes in a) their marital satisfaction; b) the overall appraisal of
their problem solving abilities; c) their problem solving confidence; d) their
approach to problem solving activities; and e) their strategies to control their
behavior when they try to solve a problem.

The second purpose of this study is to examine the differential effects
of cognitive behavioral group marital therapy on appraisal from spouses as
being effective or ineffective problem solvers (Nezu, 1985).

It was hypothesized that, following the program, partners who initially
appraised their problem solving as ineffective and who believed that they
had problem solving deficits would report more changes in their marital
adjustment level (Marital Happiness Scale) and in their problem solving skills
(Problem Solving Inventory) than subjects who initially appraised themselves
as effective problem solvers.

METHOD

Subjects

Sixty-six French-Canadian couples participated in the study. The subjects had
been living together an average of 12.8 years (SD = 8.7 years, range 1 to
31 years), and their age ranged from 20 to 76 years (M = 38.2 years, SD =
1.7 years). The mean number of children for the sample was 1.2 (88% of the
couples had children). The average education level was 14.5 years (SD =
2.9 years) for women and 15.7 years (SD = 3.7 years) for men.

Procedure

Subjects were recruited through publicity in various media. Couples who
expressed interest were briefly informed of the nature of the program and
invited to an assessment interview. To be selected, couples had to be living
together, free of any important individual psychopathology, free of drug or
alcohol problems, free of primary sexual dysfunctions, not in intense marital
crisis (no pending divorce or physical abuse) and not currently following
another therapy. During the assessment interview, all couples completed
a battery of questionnaires that included a demographic questionnaire, the

Impact of Group CBT on Marital Happiness and Self-Appraisal 107

Problem Solving Inventory (Heppner & Petersen, 1982), and the Marital
Happiness Scale (Azrin, Naster, & Jones, 1973). Partners completed the ques-
tionnaires independently. A research assistant remained in the same room as
the couple during the task and was available to help participants. Subjects
were ensured of the confidentiality of their responses.

Couples were randomly assigned to the experimental group (n = 30 cou-
ples) or to the control group waiting list (n = 36 couples). After completing
the program, all couples were administered the same self-report measures.
Couples on the waiting list then received the same assessment and treatment
procedures.

Treatment

The Couples Survival Program is a group marital therapy program based
on a cognitive-behavioral approach to solving marital difficulties designed
by researchers in our laboratory (Wright, 1986). Couples are taught skills
focused on effective communication, problem solving, exchange of positive
experiences and anger expression. The cognitive and behavioral compo-
nents of problem solving skills were taught for two sessions (6 hours) in
which couples learned different problem solving stages through reading, in-
structions, modeling rehearsal, dyadic practices, feedback, cognitive restruc-
turing, group discussions, and homework assignments (Dattilio & Epstein,
2005)

Each group comprised four couples. They met once a week, for nine
consecutive weeks, in three hour sessions. Each group was led by a licensed
psychologist with a minimum of two-years experience in marital therapy and
group intervention. The co-therapist had at least a master’s degree in clinical
or counseling psychology. All group leaders received 30 hours of training
and weekly supervision between sessions.

Measures

The Problem Solving Inventory (PSI; Heppner & Petersen, 1982) is a 32-
item measure that evaluates perceptions of personal problem solving behav-
iors and attitudes. It yields an overall score as well as three factor scores:
problem solving confidence (11 items), approach-avoidance style (16 items),
and personal control (5 items). High scores indicate that the subject per-
ceives himself/herself as having ineffective problem solving abilities and thus
has little problem solving confidence, tendencies to avoid different problem
solving activities, and a lack of personal control. Reliability estimates (alpha
ranges from .72 to .85) are adequate, and acceptable validity coefficients have
been reported in several investigations (Heppner & Anderson, 1985; Nezu &

108 C. Bélanger et al.

Ronan, 1988; Tracey, Sherry, & Keitel, 1986). Moreover, PSI scores have been
found to correlate significantly with observational ratings of problem solving
competence (Heppner et al, 1982). The French version of the PSI (Laporte,
Sabourin, & Wright, 1989) has demonstrated equally sound psychometric
properties (alpha ranges from .65 to .86).

The Marital Happiness Scale (Azrin, Naster, & Jones, 1973) is a self-report
questionnaire that allows the subject to rate his satisfaction on nine aspects
of his marital life (household responsibilities, money management, etc.) and
to give an overall assessment of his happiness within the relationship. The
scores range from 1 to 10, with a higher score indicating a higher level of
marital happiness. The instrument possesses good reliability and discriminant
validity. The Marital Happiness Scale has been found to be highly correlated
(.85) with the Locke-Wallace Marital Adjustment Test (Locke & Wallace,
1973), and inter-item correlations (p < .05 for all correlations) suggest the presence of an underlying single dimension (Libman, Takefman, & Brender, 1980). The French version of the questionnaire has been demonstrated to have equally sound psychometric qualities (alpha ranges from .71 to .80) (Bourgeois, Sabourin, & Wright, 1990).

Pre-Treatment Equivalence

Independent t-tests were conducted to determine if there were any sig-
nificant differences between the experimental and control groups in terms
of sociodemographic variables. The results indicated that the experimental
group participants were significantly younger (t (137) = –2.38, p < .02), had more children (t (130) = 6.02, p < .0001) and had been living together for a shorter period (t (125) = –5.09, p < .0001) than their control group counterparts. There were no significant differences between the two groups in terms of income or educational level.

Data showed that a randomization of couples to groups at the onset
of the treatment did not produce optimal matching of sociodemographic
variables such as age, children and length of relationship. However, Pear-
son product-moment correlation coefficients established that the correlations
between those variables and the scores on the dependent variables under
investigation were very low. There were no significant correlations between
socioeconomic variables and problem solving self-appraisal scores (range
from .01 to .20), and there was a small relationship between the Marital
Happiness Scale’s scores and the ages of the men (p < .02). A two-way analysis of variance was performed on the pretest scores of the experimen- tal and the control groups to determine if there were any initial differences between the groups in the self-appraisal of problem solving abilities and marital adjustment prior to the program. The results indicated that there were no significant differences between the two groups in problem solving

Impact of Group CBT on Marital Happiness and Self-Appraisal 109

TABLE 1 Means and Standard Deviations of Pretest and Posttest for the Experimental and
the Control Group

Male Female

Group Experimental Control Experimental Control

Time T1 T2 T1 T2 T1 T2 T1 T2

PSI total M 91.3 77.0 86.9 80.9 94.8 82.1 102.5 97.1
SD 23.8 18.5 28.9 26.8 20.7 17.1 21.7 24.8

PSI M 24.7 23.0 26.0 23.5 27.0 22.9 29.0 28.2
Confidence SD 8.9 7.1 10.3 9.1 7.5 6.6 9.5 10.6
PSI M 49.4 39.1 44.1 42.4 48.5 42.5 52.7 50.4
Approach SD 15.1 9.3 15.5 15.2 13.5 10.2 11.9 13.0
PSI M 17.2 15.0 16.7 14.9 19.4 16.6 21.0 18.5
Control SD 5.6 4.3 6.6 5.2 4.3 3.9 4.3 4.4
Marital M 6.3 7.3 6.3 6.6 6.2 6.9 5.9 6.3
Happiness SD 1.3 1.1 1.1 1.4 1.3 1.2 1.5 1.6

Note. M = mean; SD = standard deviation; PSI = Problem Solving Inventory.

self-appraisal (F(3,60) = 0.8, p <.5) or marital adjustment (F(1, 63) = 2.2, p < 0.14).

Effectiveness of the Program

To determine the effect of treatment and sex on problem solving self-
appraisal and marital satisfaction, three series of analysis of variance were
performed. The means and standard deviations for the men and women of
the experimental and the control groups are presented in Table 1.

MARITAL HAPPINESS SCALE

A 2 (male vs. female) × 2 (pre vs. post) × 2 (experimental vs. control)
analysis of variance (ANOVA) was conducted on this scale using sex as a
repeated measure because of the interdependence of husbands’ and wives’
scores (Kenny & Cook, 1999). The results indicated a significant main effect
for Time (F(1, 63) = 26.2, p <.01), which was qualified by a significant Group × Time interaction effect (F(1,63) = 4.1, p < .05). There was no significant Group × Time × Sex interaction effect. The mean scores revealed that cou- ples from the experimental group had significantly higher marital adjustment following the program than couples on the waiting list (see Table 1).

PROBLEM SOLVING SELF-APPRAISAL

First, an ANOVA was conducted on the overall score of the PSI. The results
revealed a significant effect for Time (F(1,64) = 21.8, p < .0001), which

110 C. Bélanger et al.

TABLE 2 Means and Standard Deviations of Pre-Waiting Period, Post-Waiting Period, and
Post Program for the Subjects of the Control Group

Male Female

Moment T1 T2 T3 T1 T2 T3

PSI total score 86.5 81.2 71.4 102.9 96.8 84.3
SD 30.0 27.7 22.4 22.6 24.7 25.5
PSI Confidence 25.8 23.8 21.9 29.2 28.3 25.6
SD 10.4 9.3 9.6 9.7 10.8 8.9
PSI Approach 44.2 42.4 37.1 52.9 50.0 42.4
SD 16.0 15.6 11.8 12.4 12.9 13.5
PSI Control 16.5 15.0 12.4 20.8 18.5 16.3
SD 6.8 5.4 4.9 4.4 4.5 5.0
Marital Happiness 6.3 6.5 7.4 5.9 6.2 7.0
SD 1.3 1.3 1.2 1.6 1.5 1.6

Note. T1 = pre-waiting; T2 = post-waiting; T3 = post-treatment; SD = standard deviation; PSI = Problem
Solving Inventory.

was qualified by a significant Group × Time effect (F(1,64) = 3.9, p < .05). The Group × Time × Sex interaction effect was not significant. Couples who participated in the program generally appraised themselves as more effective problem solvers than couples who were on the waiting list.

To further explore the nature of treatment gains, a two-way MANOVA
was conducted on the three problem solving subscale scores. The results in-
dicated a significant main effect for Time (F(3, 62) = 11.16, p< .0001), which was qualified by a significant Group × Time interaction effect (F(3, 62) = 3.11, p < .03). The Group × Time × Sex interaction effect was not signifi- cant. Subsequent ANOVAs revealed that, compared to subjects on the waiting list, spouses who followed the group marital therapy reported a significantly stronger tendency to approach diverse problem solving activities (F(1, 64) = 7.2, p < .009). However, they did not rate themselves as approaching prob- lem solving activities more readily or as having more personal control than the subjects who did not received treatment (see Table 1).

Quasi Replication Analysis

The effect of the program on couples on the waiting list provided an own-
control analysis and represented a partial replication of the study. ANOVAs
with repeated measures were performed on the data with pre-waiting scores,
post-waiting scores and post-treatment scores as the 3 time points. Table 2
summarizes the means and standard deviations for all measures.

The 3 (pre-waiting vs. post-waiting vs. post-program) × 2 (male vs. fe-
male) analysis of variance showed a significant main effect of Time for the
Marital Happiness Scale (F(2, 31) = 23, p < .0001), for the overall score of the Problem Solving Inventory (F(2, 31) = 16, p < .0001), and for all

Impact of Group CBT on Marital Happiness and Self-Appraisal 111

PSI subscales (F(6, 26) = 9, p < .0001). The Time × Sex interaction ef- fect was not significant. To determine the source of these differences, two series of analyses of variance were conducted. The first analyses assessed the changes from the pre-waiting to the post-waiting period, whereas the second provided the evaluation of the effect of the program (post-waiting to post-program).

The results of the first series of analyses of variance (pre- to post-
waiting) indicated a significant Time effect for marital adjustment (F(1.34) =
7.5, p < .01) and for overall PSI score (F(1, 35) = 8.1, p < .007). At the second evaluation, waiting list subjects reported a slight increase in mari- tal adjustment and in the appraisal of their problem solving abilities. The MANOVA conducted on the PSI subscale scores revealed another significant Time effect (F(4, 31) = 3.6, p < .02). Subsequent analyses revealed that subjects reported a significant increase in their problem solving confidence (F(1, 34) = 11.7, p < .002) following the waiting period (see Table 2).

The second series of analyses, which evaluated the effect of the treat-
ment, demonstrated a significant Time effect for marital adjustment (F(1,
32) = 26.2, p < .0001) and for PSI total score (F(1, 32) = 14.5, p < .001). MANOVAs conducted on the PSI subscales revealed another significant Time effect (F(429) = 9.6, p < .001). Univariate analyses demonstrated substantial changes following the program on all subscales: problem solving confidence (F(1.32) = 5.2, p < .03), approach to problem solving activities (F(1, 32) = 15.5, p < .0001) and strategies to control their behaviors (F(1, 32) = 2.62, p < .02). As shown in Table 2, score increments recorded by the group follow- ing the program were consistently superior to those reported by the same group during the control period. The data confirm that participation in the group marital therapy increased marital adjustment and enhanced spouses’ self-perceived problem solving efficacy.

Differential Effectiveness of the Program

To investigate the effects of group marital therapy on spouses who appraise
their problem solving as either effective or ineffective, three 2 (PSI: effective
vs. ineffective) × 2 (pre vs. post) analyses of variance were conducted on the
Marital Happiness Scale and on the Problem Solving Inventory (total score
and subscales). Because the analyses require a within-group comparison,
experimental and control group data were combined to examine the changes
from pre- to post-program. Because men and women’s Problem Solving
scores had different distributions (respectively, 33 to 161 and 47 to 154), and
because they differed significantly from one another (F(1, 61) = 9.8, p < .003), analyses were conducted separately for the sexes using the split half overall PSI score of both groups (men = 83 and women = 94) to subdivide them into effective and ineffective PSI scorers.

112 C. Bélanger et al.

TABLE 3 Means and Standard Deviations of Pre-Program and Post-Program for Effective and
Ineffective Scorers

Male Female

Group Ineffective Effective Ineffective Effective

Time pre post pre post pre post pre post

PSI total M 104.3 81.5 64.5 65.4 112.6 92.4 77.5 73.1
SD 20.0 21.3 12.6 16.2 16.9 23.7 10.8 13.7

PSI M 28.7 23.9 18.9 20.6 33.6 27.1 21.2 21.4
Confidence SD 9.1 8.8 5.5 7.9 8.6 9.3 4.5 4.7
PSI M 56.7 42.6 32.9 32.7 58.5 47.7 39.2 36.6
Approach SD 12.3 10.4 6.7 8.3 9.4 12.8 8.0 7.5
PSI M 18.9 15.0 12.7 12.0 20.5 17.7 17.1 15.1
Control SD 5.1 5.1 4.1 3.8 12.8 4.4 4.0 4.2
Marital M 6.2 7.3 6.6 7.4 5.9 6.7 6.5 7.1
Happiness SD 1.3 1.3 1.2 1.3 1.4 1.5 1.3 1.2

Note. M = mean; SD = standard deviation; PSI = Problem Solving Inventory.
MARITAL HAPPINESS SCALE

The results indicated an absence of a significant difference between the
effective and ineffective scorers on the Marital Happiness scale (respectively,
for men and women, F(1, 61) = .66, p < .3); F(1, 61) = .38, p < .5)). The mean scores revealed that both groups of men and women (effective and ineffective scorers) reported similar improvement in their marital satisfaction following the program (see Table 3).

PROBLEM SOLVING INVENTORY

Analyses of the Problem Solving Inventory total scores revealed a significant
PSI Group × Time effect for men (F(1, 61) = 18.55, p < .0001) and women (F(1, 61) = 11.05, p < .001). Following the program, women who initially perceived themselves as ineffective problem solvers reported more changes in the overall appraisal of their problem solving abilities than women who, before the program, perceived themselves as effective problem solvers. Sim- ilarly, men who initially appraised themselves as ineffective problem solvers reported more improvements in their overall PSI score following the program than men who initially perceived themselves as effective problem solvers (see Table 3).

The results of the MANOVAs conducted on the Problem Solving Inven-
tory subscales revealed a significant PSI Group × Time effect (F(3, 59) =
6.26, p < .001) for women and for men (F(3, 59) = 6.2, p < .001). Univari- ate analyses of variance conducted on the group of women indicated that, following the program, women who initially appraised themselves as inef- fective problem solvers noted more improvement in their problem solving

Impact of Group CBT on Marital Happiness and Self-Appraisal 113

confidence (F(1, 37) = 9.3, p < .004) and in their approach to problem solv- ing activities (F(1, 37) = 8.03, p < .007) than women who initially appraised themselves as effective problem solvers. The two groups of women (effective and ineffective) did not differ, however, in their perceived personal control following the treatment (see Table 3).

As for the men, subsequent univariate analyses indicated that only the
ineffective problem solvers reported improvement in their problem solving
confidence (F(1, 61) = 10.5, p < .002), in their approach to problem solving activities (F(1, 61) = 18.4, p < .0001) and in their personal control (F(1, 61) = 9.4, p < .004) following the program (see Table 3).

DISCUSSION

The results of this study generally support the hypothesis that couples’
marital happiness increases significantly following participation in cognitive-
behavioral group marital therapy (Baucom, Epstein, Kirby & LaTaillade, 2010;
Butler, Chapman, Forman, & Beck, 2006). Furthermore, the program was
shown to significantly alter spouses’ appraisal of their problem solving effi-
cacy. More specifically, the results indicated that, following the intervention,
partners reported a significant improvement in their capacity to confront dif-
ferent problem solving activities. Moreover, in the analyses that measured
their perception of control, all measures demonstrated a significant change
in the expected direction. After completing the program, spouses appraised
themselves as having more confidence in their problem solving capacities, a
stronger tendency to face problem solving activities rather than avoid prob-
lems, and better personal control of their behaviors while solving problems
related to their dyadic interactions. Both the experimental versus control
group analyses and the perception of control analyses yielded substantially
similar results. Although from the perception of control analyses, there was
a significant change in some variables from the pre- to post-waiting period,
the impact of the treatment was made clear by the important gains in all
measures from post-waiting to post-program. This small initial gain between
the pre- and post-waiting period could have been due to habituation to the
testing situation and to the instruments and does not challenge the efficacy
of the treatment.

The results also suggest that the program helped couples improve their
marital adjustment independently of how they initially appraised their prob-
lem solving abilities. However, the results indicate that cognitive-behavioral
group marital therapy had a differential effect on the improvement of self-
perceived problem solving capacities depending on the sex of the partic-
ipant and on the initial self-appraisal of his/her problem solving abilities.
Generally, the program had a favorable impact on women’s perception of
self-efficacy, and women who initially perceived themselves as ineffective

114 C. Bélanger et al.

problem solvers reported even more positive changes following the program
than those who initially appraised themselves as effective problem solvers.
As for men, only those who initially appraised their problem solving abili-
ties as ineffective reported improvement in their problem solving appraisal
after completion of the program. However, as was the case for women, the
program was less useful in helping men who initially perceived themselves
as effective problem solvers to change their cognitions.

These results suggest that cognitive-behavioral marital therapy should
include cognitive strategies targeting self-appraisal of problem solving ac-
tivities if and only if spouses appraise themselves as ineffective problem
solvers before the beginning of the intervention. With partners who appraise
themselves as effective problem solvers, this strategy would not be pertinent,
and other targets should be identified during the initial assessment. These
data are consistent with the results of previous studies that have noted the
utility of training for subjects who perceived certain problem solving deficits
(Heppner et al., 1988). A possible explanation for the lack of improvement
in these spouses could be that they had little room for improvement. For
example, the optimal functioning score on the PSI is 32, whereas the highest
score, 192, reflects the worst functioning. Men who initially perceived their
problem solving abilities as effective had a mean score of 64.5 with a mini-
mum approximate score of 51.9, while women had an average score of 77.5
with a minimum approximate score of 66.6. Compared to Heppner’s sample
(lowest score of 60; Heppner et al., 1988), it seems that our group of effective
problem solvers had particularly strong perceptions of their problem solving
abilities. However, both groups reported similar appraisal of their problem
solving abilities following treatment.

It is also possible that the program itself might be designed to be a better
fit for the needs of subjects who initially perceived themselves as ineffec-
tive problem solvers. Group leaders focused on cognitive (beliefs, self-talk,
self-monitoring) and behavioral skills (effective concrete steps of problem
solving) during instructions, modeling rehearsal, feedback and homework
assignments. Yet, because the sessions were conducted in groups of four
couples (eight individuals) and two therapists, it was impossible to con-
stantly create individualized learning experiences. It is possible that a more
individualized focus on participants’ self-appraisal of problem solving abili-
ties would have produced higher gains in the spouses who initially perceived
themselves to be effective problem solvers.

The findings of the present study are interesting for several reasons.
First, the results support the effectiveness of group marital therapy in altering
the cognitive process of self-perceived ineffective problem solvers. Even if
treatments for couples paradigms recognize the role of cognitive variables,
very few outcome studies have paid attention to this particular aspect.

These results dovetail nicely, on one hand, with a study by Heppner
and his colleagues (1982), who have demonstrated that problem solving

Impact of Group CBT on Marital Happiness and Self-Appraisal 115

self-appraisal is directly related to problem solving competence and, on the
other hand, with a previous study by Sabourin and his colleagues (1990),
who demonstrated that problem solving self-appraisal is also related to mar-
ital adjustment and to specific coping efforts. This research showed that
distressed spouses showed less problem solving confidence, a tendency
to avoid different problem solving activities, and poor strategies to con-
trol their behavior. Thus, in the clinical evaluation of the partners before
starting couple therapy, it would be important to verify the couple’s ap-
praisal of their problem solving abilities. If partners demonstrate a lack of
empowerment, learned helplessness or self-perception of a low capacity
to solve problems, the proposed therapeutic intervention should have a
positive effect on the development and maintenance of effective problem
solving behaviors and consequently on the long-term improvement of their
relationship.

This study has some limitations. There was no follow-up after the con-
clusion of treatment to verify if changes in self-appraisal remained in the ab-
sence of therapy. Future research should replicate these findings and assess
the long-term effects of cognitive-behavioral group marital therapy on the
maintenance of effective problem solving self-appraisal and marital satisfac-
tion. Furthermore, given the interaction between the initial levels of problem
solving self-appraisal and the amount of perceptual change, it would also
be important to study subjects who are initially different in their levels of
perceived and observed problem solving efficacy (Baucom & Kerig, 2004;
Heyman, 2001). It is also possible that this treatment is not unique in its
effect on the person’s sense of self-appraisal and that individual therapy, use
of homework in therapy, and even other forms of couple therapy may also
have improved these skills.

Another limitation is related to the nature of the measurement used
for appraising problem solving abilities. Because this study focused on self-
report of problem solving efficacy, inferences regarding related changes in
overt problem solving skills are not yet warranted. Future research should
examine if problem solving self-appraisal bears a relation to the actual prob-
lem solving behaviors of spouses. Therefore, as suggested by Bélanger and
his colleagues (2012), behavioral modifications of problem solving inter-
actions should be included in future studies. Along these lines, our team
recently investigated the relationship between specific coping strategies and
problem solving/communication behaviors in close relationships (Bélanger
et al., 2012). Observed behaviors were coded using a macroscopic coding
system for dyadic interactions (Belanger et al., 1993). For both men and
women, results showed significant relationships between coping strategies,
problem solving, marital interactions, and marital adjustment (Bélanger et al.,
2012). It would be interesting to test how these interactions may change af-
ter a cognitive behavioral marital program such as the one we tested in this
research.

116 C. Bélanger et al.

It might also be of interest to see if a cognitive behavioral program for
couples that incorporated dyadic coping skills would be helpful for predict-
ing marital adjustment. Bodenmann and his colleagues (2001) tested such
a program, the Couples Coping Enhancement Training for couples. These
researchers showed that following the intervention, couples reported a sig-
nificant increase in their appraisal of a number of domains and an increase in
the quality of their marital relationship (Bodenmann, Charvoz, Cina, & Wid-
mer, 2001). It would be interesting for future studies to integrate appraisals
of coping skills and problem solving and of the actual behavioral capacities
to get involved and solve problems (Bélanger et al., 1993).

REFERENCES

Azrin, M. H., Master, B. J., & Jones, P. (1973). Reciprocity counselling: A learning
based procedure for marital couselling. Behavior Research and Therapy, 11,
365–382.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive
theory. Englewood Cliffs, NJ: Prentice-Hall.

Baucom, D. H., Epstein N., Kirby, J. S., & LaTaillade, J. J. (2010). Cognitive-behavioral
couple therapy. In K. S. Dobson (Ed.), Handbook of cognitive behavior therapy
(pp. 411–444). New York, NY: Guilford Press.

Baucom, D. H., & Kerig, P. K. (2004). Coding couples’ interactions: Introduction and
overview. In P. K. Kerig & D. H. Baucom (Eds.), Couple observational coding
systems (pp. 3–10). Mahway, NJ: Lawrence Erlbaum.

Bélanger, C., Sabourin, S., & El-Baalbaki, G. (2012). Behavioral correlates of coping
strategies in close relationships. Europe’s Journal of Psychology (EJOP), 8(3),
449–460.

Bélanger, C., Sabourin, S., Laughrea, K., Dulude, D., & Wright, J. (1993). Macroscopic
marital interaction coding systems: Are they interchangeable? Behavior Research
and Therapy, 31(8), 789–795.

Bodenmann, G., Charvoz, L., Cina, A., & Widmer, K. (2001). Prevention of marital
distress by enhancing the coping skills of couples: 1-year follow-up-study. Swiss
Journal of Psychology, 60(1), 3–10.

Bourgeois, L., Sabourin, S., & Wright, J. (1990). Predictive validity of therapeutic
alliance in group marital therapy. Journal of Consulting and Clinical Psychology,
58(5), 608–613.

Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status
of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology
Review, 26(1), 17–31.

Carré, P. (2004). De l’apprentissage social au sentiment d’efficacité personnelle :
autour de l’oeuvre d’Albert Bandura [Social learning to self efficacy: Albert
Bandura and his writings]. L’Harmattan Eds.

Dattilio, F. M., & Epstein, N. B. (2005). The role of cognitive-behavioral interventions
in couple and family therapy [Edited special section]. Journal of Marital and
Family Therapy, 31(1), 7–13.

Impact of Group CBT on Marital Happiness and Self-Appraisal 117

Dunn, R. L., & Schwebel, A. I. (1995). Meta-analytic review of marital therapy out-
come research. Journal of Family Psychology, 9, 58–68.

Dreer, L., Elliott, T., Fletcher, D., & Swanson, M. (2005). Social problem solving
abilities and psychological adjustment of persons in low vision rehabilitation.
Rehabilitation Psychology, 50, 232–238.

D’Zurilla, T. J., Maydeu-Olivares, A., & Gallardo-Pujol, D. (2011) Predicting social
problem solving using personality traits. Personality and Individual Differences,
50(2), 142–147.

Elliott, T., & Grant, J. (2008). Social problem solving and health. Biennal Review of
Counseling Psychology, 1, 295–309.

Elliott, T., Grant, J., & Miller, D. (2004). Social problem solving abilities and behav-
ioral health. In E. Chang, T. J. D’Zurilla, & L. J. Sanna (Eds.), Social problem
solving: Theory, research, and training (pp. 117–133). Washington, DC: Ameri-
can Psychological Association.

Godshall, F. J., & Elliott, T. R. (1997). Behavioral correlates of self-appraised prob-
lem solving ability: Problem solving skills and health-compromising behaviors.
Journal of Applied Social Psychology, 27, 929–944.

Heppner, P., & Dong-Gwi, L. (2009). Problem solving appraisal and psychological
adjustment. In C. R. Snyder & S. J. Lopez (Eds.), The Oxford handbook of positive
psychology (2nd ed.). New York, NY: Oxford University Press.

Heppner, P. P. (1986). Manual for the Problem Solving Inventory (PSI). Palo Alto,
CA: Consulting Psychologists Press.

Heppner, P. P., & Anderson, W. P. (1985). The relationship between problem solving
self-appraisal and psychological adjustment. Cognitive Therapy and Research,
9, 415–427.

Heppner, P. P., Baumgardner, A. H., Larson, L. M., & Petty, R. E. (1988). The util-
ity of problem solving training that emphasises self-management principles.
Counselling Psychology Quarterly, 1, 129–143.

Heppner, P. P., Kampa, M., & Brunning, L. (1987). The relationship between prob-
lem solving self-appraisal and indices of physical and psychological health.
Cognitive Therapy and Research, 11, 155–168.

Heppner, P. P., & Krauskopf, C. J. (1987). An information-processing ap-
proach to personal problem solving. The Counselling Psychologist, 15, 371–
447.

Heppner, P. P., & Petersen, C. H., (1982). The development and implication of
a personal problem solving inventory. Journal of Counselling Psychology, 29,
66–75.

Hertzog, S. M. (2011). Is marriage good for your health? The influential role of mar-
ital quality and life events on individual-level health and well-being (Doctoral
dissertation). Retrieved from ProQuest Dissertations and Theses database. (UMI
No. 3429830)

Heyman, R. E. (2001). Observation of couple conflicts: Clinical assessment appli-
cations, stubborn truths, and shaky foundations. Psychological Assessment, 13,
5–35.

Kenny, D. A., & Cook, W. (1999). Partner effects in relationship research: Con-
ceptual issues, analytic difficulties, and illustrations. Personal Relationships, 6,
433–448.

118 C. Bélanger et al.

Kurdek, L. A. (1991). Correlates of relationship satisfaction in cohabiting gay and les-
bian couples: Integration of contextual investment and problem solving models.
Journal of Personality and Social Psychology, 61, 910–922.

Laporte, L., Sabourin, S., & Wright, J. (1989). L’inventaire de résolution de problèmes
personnels: une perspective métacognitive [The Problem Solving Inventory: A
metacognitive perspective]. Journal International de Psychologie, 23, 569–581.

Libman, E., Takefman, J., & Brender, W. (1980). A comparaison of sexually dysfunc-
tional, maritally disturbed and well-adjusted couples. Personality and Individual
Differences, 1, 219–227.

Locke, H. J., & Wallace, K. M. (1959). Short marital adjustment and prediction test:
Their reliability and validity. Marriage and Family Living, 21, 251–255.

Lussier, Y., Sabourin, S., & Turgeon, C. (1997). Coping strategies as moderators of
the relationship between attachment and marital adjustment. Journal of Social
and Personal Relationships, 14, 777–791.

Nezu, A. M. (1985). Differences in psychological distress between effective and
ineffective problem solvers. Journal of Counseling Psychologist, 32, 135–138.

Nezu, A. M., Kalmar, K., Ronan, G. F., & Clavijo, A. (1986). Attributional correlates of
depression: An interactional model including problem solving. Behavior Ther-
apy, 17, 50–56.

Nezu, A. M., & Ronan, G. F. (1988). Social problem solving as a moderator of stress-
related depressive symptoms: A prospective analysis. Journal of Counseling
Psychology, 35, 134–138.

Rivera, P., Elliott, T., Berry, J., Oswald, K., & Grant, J. (2007). Predictors of care-
giver depression among community-residing families living with traumatic brain
injury. NeuroRehabilitation, 22, 3–8.

Sabourin, S., Laporte, L., & Wright, J. (1990). Problem solving self-appraisal and
coping efforts in distressed and nondistressed couples. Journal of Marital and
Family Therapy, 16(1), 89–97.

Shanmugham, K., Cano, M., Elliott, T., & Davis, M. J. (2009). Social problem solving
abilities, relationship satisfaction, and distress among family caregivers of stroke
survivors. Brain Injury, 23, 92–100.

Shanmugham, K., Elliott, T. R., & Palmatier, A. (2004). Social problem solving abili-
ties and psychosocial impairment among individuals recuperating from surgical
repair for severe pressure sores. NeuroRehabilitation, 19(3), 259–269.

Tracey, T. J., Sherry, P., & Keitel, M. (1986). Distress and help-seeking as a function
of person-environment fit and self-efficacy: A causal model. American Journal
of Community Psychology, 14, 657–676.

Woodin, E. M. (2011). A two-dimensional approach to relationship conflicts: Meta-
analytic findings. Journal of Family Psychology, 25(3), 325–335.

Wright, J. (1986). Survival strategies for couples. Rochester, NY: Prometheus.

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