Open and read the attached..
Learning Resources For the Assignment
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.)
8. https://class.content.laureate.net/57f61f74442d169269a11e30faea865d.pdf OR
You will select one of the following articles on group therapy to evaluate for this week’s Assignment.
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.
· Evaluate the application of current literature to clinical practice
· 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.
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.
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
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: [email protected]
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 22, 3249–3258, doi: 10.1111/jocn.12168 3249
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).
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
© 2013 John Wiley & Sons Ltd
3250 Journal of Clinical Nursing, 22, 3249–3258
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,
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,
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
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).
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 22, 3249–3258 3251
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
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.
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 © 2013 John Wiley & Sons Ltd 3252 Journal of Clinical Nursing, 22, 3249–3258 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
� 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
†Wilcoxon’s test with Bonferroni correction.
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 22, 3249–3258 3253
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 © 2013 John Wiley & Sons Ltd 3254 Journal of Clinical Nursing, 22, 3249–3258 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 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: [email protected] 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 …