BEHAWOR TI-IEgAPY 25, 407-429, 1994

Marital Functioning and the Anxiety Disorders

PAUL M . G . EMMELKAMP

COBY GERLSMA

University of Groningen, The Netherlands

The present paper provides a review of the literature on the relationship between marital factors and anxiety disorders. The review is based on both a descriptive and quantitative analysis. Studies of the marital relationship and outcome of exposure therapy are reviev~d, as are studies investigating the effects of exposure therapy on the partner and on the marital relationship. Results with respect to the effects of marital distress on outcome are inconclusive. Exposure does not have a negative impact on the partner or the relationship. In agoraphobia, spouse-aided therapy is no more effective than individual exposure therapy. In obsessive-compulsive patients, results are inconclusiv~

The interest in the marital relationship of anxious patients is not of recent date. Both psychodynamically oriented and system-theoretically oriented ther- apists hold that anxiety is the result of conflict. Psychodynamically oriented clinicians regard the phobic symptoms as deriving from interpersonal and in- trapersonal conflicts that are recapitulations of early childhood patterns (e.g., Arieti, 1961; Bowlby, 1969; 1973; Goodstein & Swift, 1977; Symonds, 1971). These conflicts may manifest themselves in the interpersonal relationships of phobic patients. Thus, proponents of this view hold that phobic symptoms are dynamically related to faulty interpersonal patterns.

A basic assumption for communication theorists is that psychiatric symp- toms have interpersonal meaning in relationships. Systems-theoretically- oriented family therapists such as Haley (1963) and Fry (1962) hold that anxiety in the patient may serve the purpose of denying a marital problem. According to Fry (1962), partners of individuals with (agora)phobia are often phobic them- selves, but are reluctant to admit this. In this view, the agoraphobia develops in order to maintain the marriage when it is threatened by a crisis. Haley (1963) and Fry (1962) define the resulting relationship as a compulsory marriage, in which partners do not stay together out of love but are forced to stay together because of the symptoms.

Behavior therapists such as Wolpe (1970) and Lazarus (1966) have also sug- gested that agoraphobia often is associated with marital problems. Lazarus

Requests for reprints should be sent to Paul M. G. Emmelkamp, University of Groningen, Department of Clinical Psychology, Oostcrsingel 59, 9713 EZ Groningen, The Netherlands.

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408 EMMELKAMP & GERLSMA

(1966) stresses the role of social reinforcement in maintaining the agoraphobia: "Theoretically, if a person starts displaying agoraphobic symptoms, but finds no one willing to pander to his insistent orders to 'stay and guard me, look after me and protect me', he will not display persistent agoraphobia, whatever other neurotic symptoms he may develop" (p. 97). Goldstein (1973) reported that 16 of 20 females with agoraphobia felt strong urges to escape their rela- tionship but were unable to do so at the time of the onset of the agoraphobia. In his view, persons with agoraphobia wish to flee the marriage, but cannot because of their fears of being alone. He proposed that the phobic symptoms are the result of psychological avoidance behavior in conflict situations that seem insolvable. This view is in line with early psychoanalytic writings. Fenichel (1945) interpreted the agoraphobic fears as projections of unconscious wishes for sexual adventures. In a subsequent study (Goldstein & Chambless, 1978), it was concluded that agoraphobia onset occurs during times of high inter- personal conflict. Information was gathered from files or therapists' recollec- tions. More recently, Kleiner and Marshall (1985) held structured interviews with 50 individuals with agoraphobia and concluded that conflict with the partner often preceded the onset of agoraphobia.

The interpersonal models discussed so far refer to females with agoraphobia. Liotti and Guidano (1976) analyzed the marital interaction of 15 agoraphobic male patients. Their patients were described as socially extraverted, ambitious, self-assertive, and aggressive, with high levels of aspirations but barely able to communicate emotions directly. Their symptoms developed shortly after marriage or after a minor marital crisis. The wives of the men with agoraphobia were described as introverted, with a fear of any expression of aggressive be- havior. The husbands' symptoms were precipitated by the wives' attempts to become less submissive.

In this article, a review is provided of the studies that have addressed inter- personal issues in the area of anxiety disorder. The following questions will be addressed: (1) whether the relationships of anxious patients are disturbed; (2) whether the partners of these patients are psychologically abnormal them- selves; (3) whether relational distress affects the outcome of behavioral treat- ment; (4) whether successful behavioral treatment leads to relationship prob- lems, and (5) whether spouse-aided therapy is more effective than treatment of the patient alone. Most of the studies involve women with agoraphobia and a few address this issue with obsessive-compulsive patients. This issue has not yet been investigated with patients with other anxiety disorders. In addition to a narrative review of the studies, Cohen's d values will be presented for those studies that provide the necessary data to calculate these values. Cohen's (1988) d effect size estimates the difference between the means found in experimental and control group divided by the pooled-within standard deviation.

Quantitative Review The number of empirical studies is too small for a meta-analysis in the clas-

sical sense, i.e., with the aim of computing an overall weighted effect size; such

MARITAL FUNCTIONING 409

an overall effect size would be too unreliable to yield meaningful information. As Shadish and Sweeney (1991) recently put it when referring to the impor- tance of mediator and moderator effects in meta-analyses of therapy outcome research: "Knowledge of average effects says nothing about when, where, why, and how therapy works" (19. 883). Given the diversity in samples, procedures, treatment, and measures used in the studies available in this case, one can easily imagine quite a number of mediators and moderators influencing effect sizes derived from each individual study. In order to assess the influence of such mediators and moderators, larger numbers of studies are required.

In view of the diversity mentioned, it would, however, be informative to compare the empirical research available with a common yardstick, i.e., a stan- dardized effect size, thus enhancing the comparability of results across studies. Furthermore, the computation of standardized effect sizes allows comparison of results within studies. One might, for instance, find that patients participating in a partner-assisted treatment program improve more than their counterparts in the individual treatment condition on measures of self-reported anxiety, but not on behavioral (observational) measures of anxiety. Such differences are not readily interpretable from the studies' summaries of means and stan- dard deviations. Moreover, most studies report significant effects only, which yield no information about the magnitude of the differences found, nor does it tell anything about the magnitude of differences 'not found', i.e., effects not (quite) reaching the required level of significance. 'Not finding' effects might also be due to the small sample sizes used in most studies and the resultant lack of statistical power (e.g., Hsu, 1989; Kazdin & Bass, 1989); in other words, differences might be there, but are shortchanged in studies relying on statistical significance where statistical power is poor.

In sum, the present review in which the data available are reanalyzed in terms of effect sizes is of an exploratory nature. Insight into the effect sizes found thus far might be a help in planning future research, for instance, by suggesting particularly sensitive outcome measures, mediators and moderators, and sample sizes required to detect particular effects. In view of these aims, we computed effect sizes for all of a particular study's measures considered to be relevant with regard to the research question. It should be noted that the resultant d's (within studies) are therefore not independent. In a classical meta-analysis, multiple d's would generally be averaged (e.g., Shadish & Sweeney, 1991); in view of the exploratory aims of this study, such averaging would involve loss of information (Chambless, 1989).

Selection of Studies for Quantitative Review Literature search. Our literature search for 'older' research published until

1987 was based on the meta-analysis by Dewey and Hunsley (1990) and studies referred to in the relevant literature. An on-line literature search of the data- bank PsychLit was undertaken for papers published between 1986 and 1993.

Inclusion criteria. Only one study was included if different studies appeared to have used (part of) the same sample(s). In such cases, we chose the study that yielded most information, i.e., was based on the largest sample size, and/or provided most extensive or most suitable data; in case of an even draw, we

410 EMM]ELKAMP & OEKLSMA

used the most recently published study. Furthermore, studies could be included in the quantitative part of the review only if data amenable for d-computation were provided. For the three different research questions the following data were required:

(1) differences between relationships involving an agoraphobic or obsessive compulsive patient and relationships in the general community: pretreat- ment data of a measure for relational quality for patients and/or their partners, and either similar data for a nondistressed control group, or norms of the relational measure in the general community;

(2) influence of relational distress on efficacy of treatment of agoraphobia and obsessive compulsive disorder: outcome data for patients reporting relational distress and for patients reporting no relational distress, or correlations of relational quality with pre- to posttreatment change in outcome;

(3) differences between partner-assisted and individual treatment of agora- phobia and obsessive-compulsive disorder: data for outcome of partner- assisted and individual treatment.

Cohen's d estimates were computed from means and standard deviations, from t- and F-statistics and from Pearson's Product Moment correlation coefficient r according to the formulas described by Hedges and Olkin (1985). In a few cases, an F- or a t-statistic was derived from the level of significance reported in the text, and d was subsequently computed using those test statistics. However, cursory remarks like 'the difference was not significant', 'n.s.' or 'p > .05' were considered insufficiently precise for d-calculation.

Studies included and excluded. Studies included in the quantitative part of the review are summarized in Tables 1, 2, and 3. Because our second and third research questions address issues similar to those reviewed in Dewey and Hunsley's (1990) meta-analysis, it should be noted that quite a few studies in- cluded in that meta-analysis were excluded in the quantitative part of our re- view, even though our criteria for inclusion were not substantially different. The discrepancy was due to various reasons, as will be outlined below.

We found a number of studies that appeared to have used the same, or part of the same patient sample. As was mentioned by Arrindell, Emmelkamp, and Sanderman (1986), contributions of Hafner c.s. are not based on inde- pendent data sets (i.e., Hafner, 1976, 1977a, 1977b, 1979, 1982, 1983, 1984; Hafner & Ross, 1983; Milton & Hafner, 1979). Only the study by Milton and Hafner (1979) was included in the review with regard to the influence of rela- tional distress on the efficacy of behavioral treatment of agoraphobia. Fur- thermore, we included the study of Cerny, Barlow, Craske, and Himadi (1987), that used the sample reported on by Barlow, O'Brien, and Last (1984), and Himadi, Cerny, Barlow, Cohen & O'Brien (1986); the latter two studies were both included in the Dewey and Hunsley (1990) meta-analysis.

Furthermore, there were a number of studies included in the Dewey and Hunsley (1990) meta-analysis on the effectiveness of partner-assisted exposure that did not seem to compare partner-assisted with individual treatment. In particular, we did not include the study by Arnow, Taylor, Agras, & Telch (1985)

MARITAL FUNCTIONING 411

because it compared the patients in two treatment conditions, i.e., relaxation training and communication training after spouse assisted exposure in vivo training. Hence, both treatment conditions had participated in partner-assisted treatment, prohibiting the comparison of partner-assisted with individual treat- ment. For a similar reason, the study reported by Jannoun, Munby, Catalan, & Gelder (1980) was excluded. Here, a 'programmed practice' treatment is com- pared with 'problem solving' treatment but the authors note that "in both treat- ments, the partner was actively involved in planning treatment targets and rein- forcing diligent practice at the tasks" (p. 296). In the Oatley and Hodgson (1987) study, treatment of patients with agoraphobia by either the husband as co-therapist or a close female friend as co-therapist is compared, which (strictly speaking) does not preclude the comparison of spouse-involved versus spouse-noninvolved treatment, but it does prohibit the comparison of partner- assisted versus individual treatment.

Finally, some studies mentioned in the Dewey and Hunsley (1990) study were excluded in the present review because data were not available to com- pute an effect size. In the Cobb, Mathews, Childs-Clarke, and Blowers (1984) study, we found only a concluding remark on the difference in outcome be- tween spouse-involved and individual treatment (i.e., "it is concluded that there were no convincing differences in outcome between the two treatments"; p. 284) that might explain the d-value of 0 in the Dewey and Hunsley review. A similar situation arose with regard to the Emmelkamp (1980) study. We chose to exclude these studies rather than to report d-- 0 based upon the assumption that the effect size most probably was not 0. In the Munby and Johnston (1980) study, we found t-statistics for the within-subjects change in spouse-assisted treatment (p. 422) that do not, however, allow the comparison of partner- assisted versus individual treatment. Furthermore, we found means and stan- dard deviation (Table III in Munby & Johnston, 1980) that would be amenable for d-computation but for the fact that these data concerned only a selection of patients (i.e., those who improved at least 3 points on a phobic severity rating). These data were excluded from the analysis. The Arrindell, Em- melkamp, and Sanderman (1986) study was omitted because the reported t-statistics referred to regression-weights (fl's) that are not readily amenable to d-computation.

Evidence for Relationship Difficulties In this section we will review the available evidence that the relationships

of patients with agoraphobia and their partners are disturbed. Although it has often been stated that patients with agoraphobia have poor (marital) rela- tionships, relatively few studies have addressed this issue directly. Most of the studies emphasizing the importance of marital conflict in the etiology of agoraphobia (e.g. Fry, 1962; Goldstein, 1973; Goldstein & Chambless, 1978; Hafner, 1982; Holmes, 1982; Liotti & Guidano, 1976; Webster, 1953)lack ade- quate control groups, are retrospective in nature, and are based on interviews of unknown reliability and validity.

The first controlled study was reported by Buglass, Clarke, Henderson,

412 EMMELKAMP & GERLSMA

Kreitman, and Presley (1977), involving 30 married women who were agora- phobic and 30 control couples. There were no differences found with respect to the quality of the marriage. Women who were agoraphobic did not differ from controls in their sexual adjustment prior to the development of the phobia. Furthermore, there were no differences between couples with agoraphobia and control couples in terms of decision making. Also, ratings were made for two independent dimensions of the interactions between husband and wife during the interview: (1) assertion-compliance, and (2) affection-dislike. There was little difference between the assertion and affection scores of wives who were phobic and control wives. The husbands of women who were phobic were somewhat less assertive than the husbands of controls.

Another controlled study was reported by Arrindell and Emmelkamp (1986). Thirty women with agoraphobia and their partners filled out a number of questionnaires, including the Maudsley Marital Questionnaire (MMQ), and a communication questionnaire, measuring intimate communication, destruc- tive communication, discongruent communication, and avoidance of com- munication. Three control groups were included in this study: (1) non-phobic psychiatric controls and their partners, (2) maritally distressed females and their partners, and (3) maritally non-distressed females and their partners. The results revealed that wives with agoraphobia and their spouses tended to be more comparable to happily married subjects on marital and sexual ad- justment and satisfaction and quality of communication, whereas non-phobic psychiatric patients were more comparable to maritally distressed couples. Fisher and Wilson (1985) found no difference between patients with agora- phobia and controls on the Locke Wallace Marital Adjustment Scale.

There are a few more studies that are of some relevance with respect to this issue. Emmelkamp, van Dyck et al. (1992) provide means and standard devia- tions of patients with agoraphobia and their partner on marital measures for which norms are available. The scores on marital satisfaction (MMQ) of the patients with agoraphobia and their partner in the Emmelkamp et al. (1992) study are comparable to those of the Dutch population in general. Two other studies found some evidence that agoraphobic couples were more distressed than normal couples. Lange and van Dyck (1992) found that agoraphobic couples differed from the norms for Dutch couples on interpersonal problem solving as assessed by the Interpersonal Problem Solving Inventory (IPSI). It should be noted, however, that interpersonal problem solving is only one specific aspect of marital distress. Finally, patients with agoraphobia in the Kleiner, Marshall, and Spevack (1987) study showed substantially lower mar- ital adjustment than normal couples.

The d-values of a number of the studies reported here are summarized in Table 1. The results suggest that there are some differences between agoraphobic couples and controls, effects sizes ranging from small to large. It should be noted that in the Kleiner et al. (1987) study, patients with agoraphobia were rather atypical, being characterized as much more maritally distressed than in the other studies.

Two studies provide data that are relevant with respect to this issue with obsessive-compulsive patients. If the scores on the MMQ and the IPSI of the patients and their partners in the study of Emmelkamp, de Haan, and Hoog-

MARITAL FUNCTIONING 413

duin (1990) are compared to the norms for the Dutch population, the marital relationship of the patients appears to be disturbed. There is a large difference in marital distress and a medium difference in interactional problem-solving capacity between obsessive-compulsive couples and normals. Riggs, Hiss, and Foa (1992) provide means and standard deviations on the Locke-Wallace MAT. A comparison of these scores with those of the 'norms' of Peterson, Baucom, Elliott, and Farr (1989) for nonclinical couples reveal that there is a large differ- ence in terms of marital adjustment, the OCD couples being less adjusted.

The Partners of Agoraphobic Patients As noted earlier, several authors have suggested that the partners of

agoraphobic patients are psychologically abnormal or have phobic symptoms themselves. Fry (1962) described the partners a s " . . , typically negativistic, anxious, compulsive with strong withdrawal tendencies." These partners were further described as phobic themselves. In contrast, Hafner found the partners of agoraphobic patients not neurotic but hostile (Hafner, 1977a) and abnor- mally jealous (Hafner, 1979). Because no control group was involved in these studies and the data in the Fry (1962) and Hafner (1979) studies were based on clinical interviews, conclusions are not warranted. Our review of this part of the literature is descriptive rather than quantitative because of the lack of the necessary data and the variety of measures used.

Controlled studies do not support the view that the partners of patients with agoraphobia are psychologically abnormal themselves. In three studies (Agulnik, 1970; Arrindell & Emmelkamp, 1986; Buglass et al., 1977), the partners of patients with agoraphobia were not different from controls on neu- rotic complaints. Only one study (Schaper, 1973) found the partners of pa- tients with agoraphobia to be more neurotic than controls, but a number of methodological problems make the results of this study difficult to interpret. In the Arrindell and Emmelkamp (1986) study, partners of 32 women with agoraphobia were compared with the partners of non-phobic psychiatric con- trols and non-patient normal controls on a large number of variables. The results revealed that the partners of women with agoraphobia cannot be charac- terized as more defensive than those of non-phobic psychiatric or normal con- trols. Furthermore, no evidence was found that partners of individuals with agoraphobia were more socially anxious or more obsessive than partners of controls. Although the partners of patients with agoraphobia were found to be more intropunltive than the partners of non-patient controls, further anal- yses revealed that their scores fell within normal ranges. In contrast to the suggestion of Fry (1962), there was no evidence found that the partners of patients with agoraphobia were phobic themselves.

In sum, there is no evidence that the partners of individuals with agoraphobia are psychologically disturbed.

Interpersonal Problems and Behavior Therapy Two issues have received attention by behavioral researchers. First, is marital distress prior to behavior therapy a factor which decreases the effectiveness of behavior therapy for anxiety disorders? Second, does successful treatment

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have adverse effects on the marital relationship or on the partner, as held by system theories therapists?

Marital Relationship and Treatment Outcome

Several studies investigated the extent to which interpersonal problems affect the outcome of exposure in vivo procedures. Nearly all studies involved indi- viduals with agoraphobia. Hudson (1974), working with patients with agora- phobia who received drug-assisted exposure in vivo, found that patients from "sick families" showed much less improvement than patients from "well- adjusted" families. However, this study has several methodological confounding variables. Allocation to different family categories was made on the basis of data gathered in a loosely structured interview. Moreover, half the visits took place prior to treatment, the remaining within 1 week of discharge. Thus, in those latter cases, the categorization of families might have been influenced by the immediate effects of treatment.

Milton and Hafner (1979) treated 14 patients with prolonged exposure in vivo and found that patients whose marriages were rated as unsatisfactory before treatment improved less during treatment and were more likely to re- lapse during follow-up than those patients with satisfactory marriages. Un- fortunately, no objective criterion for marital distress was used.

Bland and Hallam (1981) also related the level of marital satisfaction as- sessed prior to treatment with response to exposure in vivo treatment and found a significant difference between "good marriage" and "poor marriage" groups with respect to phobic severity. At 3-month follow-up, the "poor marriage" group showed significantly greater tendency to relapse compared to the "good marriage" group. Interestingly, improvement was found to be associated with the patient's satisfaction with spouse. Spouse's dissatisfaction with the pa- tient was not related to outcome of treatment. Monteiro, Marks, and Ramm (1985) found that better initial marital adjustment predicted better outcome of phobias at follow-up, 2 years after treatment.

In contrast, a number of other studies (Arrindell et al., 1986; Cobb et al., 1984; Craske, Burton, & Barlow, 1989; Emmelkamp, 1980; Emmelkamp, van Dyck et al., 1992; Himadi et al., 1986; Peter & Hand, 1988; Thomas-Peter, Jones, Sinnott, & Fordham, 1983) have investigated the relationship between marital distress at pretreatment and outcome after exposure therapy, and they all found no significant relationship between initial marital distress and out- come. Chambless and Gracely (1988) reported two studies with slightly conflicting results. In their study at the American University, no significant relationship between marital distress and improvement of phobia was found, whereas in their study at Temple University marital distress predicted improve- ment at posttest but not at follow-up. The relationship, however, was rather small.

Expressed emotion (Camberwell Family Interview) as predictor of treat- ment response in patients with agoraphobia was investigated by Peter and Hand (1988). Patients with critical spouses improved more than patients with less critical spouses, whereas no significant relationship was found between mar- ital dissatisfaction and outcome. The study by Thomas-Peter, Jones, Sinnott,

MARITAL FUNCTIONING 417

and Fordham (1983) is of particular interest. Although no significant correla- tion was found between marital distress and outcome, results revealed that the management effectiveness of the 'significant others' (usually the partner) correlated significantly with improvement of agoraphobia. Treatment was more successful when partners were supportive and encouraged and reinforced in- dependent activity of the patient.

Three studies investigated this issue with obsessive-compulsive patients. In a study by Riggs, Hiss, and Foa (1992), marital distress was not found to be related to outcome of treatment. Both Emmelkamp, Kloek, and Blaauw (1992) and Steketee (1993) investigated whether criticism of the partner was related to relapse, respectively, 2 years and 9 months after treatment. In the Em- melkamp et al. (1992) study, patients' perceptions of their partners were as- sessed with the Level of Expressed Emotion Scale (Gerlsma, van der Lubbe, & van Nieuwenhuizen, 1992). Expressed emotion (high criticism) predicted relapse significantly, whereas frequency of general social support did not pre- dict relapse. Steketee (1993) found also little evidence that general social sup- port predicted relapse. However, criticism and anger of significant others as- sessed in an interview were related to relapse.

The results of the quantitative review are presented in Table 2. The d-values presented show considerable variability, ranging from - 1.28 to + 1.59. There are a number of methodological problems that preclude the drawing of firm conclusions. First, a number of studies (e.g., Bland & Hallam, 1981; Em- melkamp, 1980; Cobb et al., 1984; Himadi et al., 1986; Milton & Hafner, 1979) have made use of a median split on a measure for marital distress. Whereas this would be appropriate when (nearly) half of the marriages were disturbed, the median-split provides a serious problem in the light of the finding that many marriages involving persons with agoraphobia are essentially normal, as discussed above. Presumably, in these studies a number of couples with agoraphobia have been classified incorrectly as maritally distressed. The me- dian split allows for a discussion of more versus less distress, but does not insure that a common meaning is applied across studies. Another confound concerns the fact that in a number of studies (i.e., Hudson, 1974; Milton & Hafner, 1979; Monteiro et al., 1985) treatment consisted of drug-assisted ex- posure. The effects found can be equally attributed to the drugs taken as to the exposure treatment received. Another problem in the studies of Bland and Hallam (1981), Craske et al. (1989), Hudson (1974), Milton and Hafner (1979), and Monteiro et al. (1985) concerns the outcome criterion used (Chambless & Gracely, 1988). In all of these studies, raw outcome rather than (residual) change scores were used. Because marital distress may be associated with more severe agoraphobia at the start of treatment (e.g., Monteiro et al., 1985), the results of studies that do not control for pretreatment differences are difficult to interpret.

Effects o f Behavior Therapy on Marital Relationship and Partner Given the variety of measures used, we restrict ourselves in this section to

a descriptive review. Hand and Lamontagne (1976) analyzed the relationship between phobia removal and the exacerbation of interpersonal problems in

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patients with agoraphobia treated with exposure in vivo. In a few cases, removal of the phobia was followed by a marital crisis. In half of the patients who reported marital problems, phobia removal was not followed by increased severity of the marital problems and sometimes even led to an improvement of their interpersonal relationship. Hafner (1976; 1977a; 1977b) investigated the interpersonal problems of women with agoraphobia and their husbands after exposure in vivo. It was found that a deterioration of the most hostile husbands at 3 months follow-up coincided with a maximum improvement in their wives' phobic symptoms. Some husbands were adversely affected by their wives' improvement, but improved when their partner relapsed.

Milton and Hafner (1979) reported that: "the marriages of nine (out of 15) patients appeared to be adversely influenced by their symptomatic improve- ment" (p. 807). However, inspection of their data (Milton & Hafner, Table 1, p. 808) reveals a different picture: Both patients and their partners show an improvement rather than a deterioration on marital and sexual adjustment. Thus the idea of a worsening of the relationship was based on a clinical anec- dotal material, rather than on the more objective measures used.

The better controlled studies in which the conclusions are based on more objective measures come to a different conclusion. Arrindell et al. (1986) and Monteiro et al. (1985) found that the marital and sexual relationship remained stable after successful exposure therapy. Other studies found that improve- ment in agoraphobia leads to a slight improvement in marital and/or sexual aspects of the relationship (Bland & Hallam, 1980; Cerny et al., 1987; Cobb, McDonald, Marks, & Stern, 1980; Cobb et al., 1984; Emmelkamp, 1980; Mon- teiro et al., 1985). In obsessive-compulsive individuals, marital distress remains stable (Emmelkamp & de Lange, 1983; Emmelkamp et al., 1990) or slightly improves (Riggs et al., 1992) after exposure therapy.

In the studies by Arrindell et al. (1986), Emmelkamp, van Dyck et al. (1992) study, Himadi et al. (1986), and Oatley and Hodgson (1987), the effects of treatment on the spouse of the agoraphobic patient were assessed. In none of these studies was there any evidence that phobia removal led to an exacer- bation of problems in the panner of the phobic patient. In the Emmelkamp, van Dyck et al. (1992) study, partners improved on SCL-90, social adjustment, and communication, irrespective of whether they were involved in the treat- ment or not. Similar results were found with partners of patients with obsessive- compulsive disorder receiving exposure treatment (Emmelkamp, de Haan, & Hoogduin, 1990). In the Arrindell et al. (1986) study, a reduction of anxiety in the agoraphobic patient did not lead to change in the social adjustment of the panner. In the Oatley and Hodgson (1987) study, husbands of women with agoraphobia did not become more anxious or depressed after successful treatment of their wives. Thus the picture that emerges with respect to the effects of exposure therapy on the partner of the phobic and obsessive- compulsive patient is quite consistent across these studies.

In summary, although clinical anecdotes suggest that phobia reduction might lead to an exacerbation of interpersonal problems or to psychological prob- lems in the panner of the patient, no objective data are provided to support these ideas. The studies using more objective measures reveal that after suc-

MARITAL FUNCTIONING 421

cessful treatment of agoraphobia and obsessive-compulsive disorder, the rela- tionship either remains stable or even slightly improves and that reduction of the anxiety does not affect psychological problems in the partner.

Spouse-Aided Therapy Studies investigating the effects of spouse-aided therapy in individuals with

agoraphobia lead to conflicting results. In the study of Cobb et al. (1984) and in the Emmelkamp, van Dyck et al. (1992) study, spouse-aided therapy was as effective as treatment by the patient alone. In the Cerny et al. (1987) study, however, it was reported that spouse-aided therapy was more effective than treatment by the patient alone. There are a number of important differences between the Cobb et al. study (1984) and the Emmelkamp, van Dyck et al. (1992) study, on the one hand, and the Cerny et al. study (1987) on the other. First of all, treatment in the Cobb et al. and Emmelkamp et al. study was based on the manuals of Mathews, Gelder, and Johnston (1981). In contrast, treatment in the Cerny et al. study consisted of group therapy rather than in- dividual therapy. In addition, treatment in the Cerny et al. study consisted not only of exposure in vivo, but cognitive therapy was also included in the package. Whether spouse-aided therapy is more effective when combined with cognitive therapy and conducted in a group format is a question of further study. Furthermore, not all patients in the Cerny et al. study were randomly assigned across groups. The study of Oatley and Hodgson (1987) is also of some interest. Here, spouse-aided therapy was slightly less effective than when treatment was conducted with the help of a female friend.

To date, three studies have investigated this issue with obsessive-compulsive patients. A study by Emmelkamp and de Lange (1983) found exposure by the patient alone to be less effective than partner-assisted exposure at posttest, but 1 month later this effect had disappeared. Numbers were rather small. Em- melkamp et al. (1990) in a much larger series of patients found no better results for partner-assisted exposure than for exposure by the patient alone. Mehta (1990), however, found some evidence that involving a significant other, not necessarily the partner, enhanced treatment effects. Treatment consisted not only of exposure but also of relaxation.

The quantitative review is presented in Table 3. There is great variability in d-values both between and across studies. Thus, results are inconclusive. Taking together the results of studies that have been conducted thus far, there is no need to include the spouse in the exposure treatment of patients with agoraphobia or obsessive-compulsive behavior.

Discussion The present review reveals that, on average, the marriages of individuals

with agoraphobia are not much different from that of normal individuals. The differences between agoraphobic couples and normal couples are small to medium (Cohen, 1988), with a notable exception of the study of Kleiner et al. (1987). It is questionable whether the differences found should be ascribed to the agoraphobia per se. In the Arrindell and Emmelkamp (1986) study, the

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marriages of non-phobic patients were clearly more disturbed than those of patients with agoraphobia. Given the robust finding across studies that depres- sion is related to marital distress (Beach, Wishman, & O'Leary, this issue), there is a clear need to study the role of depression as moderator variable in the quality of the relationship of patients with agoraphobia. It is quite pos- sible that in those cases where there is a relationship between agoraphobia and marital distress, this link is not due to agoraphobia but to depression. The finding that there is some marital distress in some agoraphobic couples does not necessarily imply that marital conflict was causal in the etiology of agoraphobia. It may well be that a severe condition such as agoraphobia puts some stress on the relationship, as would any other chronic incapacitating disease.

Few data are available on the marriages of individuals with obsessive- compulsive disorder. The available evidence suggests that the marriages of patients with obsessive-compulsive disorder are more disturbed than those of patients with agoraphobia. Again, this does not necessarily imply a causal role for marital distress in causing the obsessive-compulsive disorder. Here also depression may be an important moderator variable, and obsessive- compulsive disorder might place an even heavier burden on the family than does agoraphobia.

There is almost no evidence that exposure therapy has adverse effects on the relationship or the partner of the patient with agoraphobia or obsessive- compulsive disorder. The evidence provided is mostly of an anecdotal nature. The controlled studies in this area concur that the relationship remains stable or slightly improves, with no exacerbation of symptoms in the partner of the patient. Thus, the system-theoretic conceptualization is not supported by the empirical evidence. However, it should be noted that the few studies that found some evidence for adverse effects on the partner involved flooding in vivo rather than gradual exposure in vivo as it is now usually applied. Flooding in vivo may lead to dramatic improvement in even a few days. After rapid phobia removal, the patient's self-concept and the role the partner has in the family system have to change also in a few days, that might be too rapid for some couples. For some cases, it may be preferable to strive toward gradual improve- ment in order to equalize changes of self-concept and family system with phobia removal (Emmelkamp, 1979) or to have the partner assist in the treatment of the patient.

The finding that spouse-aided therapy was not more effective then individual therapy is more of practical than of theoretical interest. Involving the spouse in exposure therapy does not imply that the treatment focuses on interper- sonal problems. In order to provide a more meaningful test of the interper- sonal theories, treatment is needed that focuses on the relationship, but only two studies have evaluated the effects of treatment focusing on the relation- ship rather than on the anxiety disorder. Cobb, McDonald, Marks, and Stern (1980) contrasted in vivo exposure with marital therapy. Subjects were patients with agoraphobia and obsessive-compulsive disorder who also manifested mar- ital discord. Results indicated that exposure led to improvements in both the phobic or the obsessive-compulsive problems and the marital relationship,

MARITAL FUNCTIONING 425

whereas marital therapy affected only the marital relationship. Arnow, Taylor, Agras, and Telch (1985) investigated the effects of communication training on agoraphobic patients. Communication training enhanced the improvement in phobic symptoms gained via exposure therapy but did not affect marital satisfaction. This is not surprising, because the training focused on commu- nications about the phobia rather than on other relationship problems. Given the limited number of studies that focused on the relationship of anxious pa- tients, firm conclusions cannot be drawn.

Research in this area is hampered by the fact that each investigator uses his/her own measure to assess marital conflict. These have included the Mar- ital Questionnaire (Bland & Hallam, 1981), the Marital Deprivation Scale (Em- melkamp, 1980), the Maudsley Marital Questionnaire (e.g., Arrindell et al., 1986; Cobb et al., 1984; Emmelkamp, van Dyck et al., 1992, Monteiro et al., 1985); the Marital Happiness Scale (Craske et al., 1989); the Locke Wallace MAT (Himadi et al., 1986); Dyadic Adjustment Scale (Peter & Hand, 1988), independent observer rating of marital quality (Arrindell et al., 1986), and a number of communication measures and measures of expressed emotion. Although it is tempting to assume that these different assessment devices assess the same construct of marital distress, there are no data to support this. Craske, Burton, and Barlow (1989) examined the relationship among measures of couples interactions in agoraphobic couples. Marital happiness had little rela- tionship to communication, as assessed by the Marital Interaction Coding System (MICS) (Hops, Wills, Patterson, & Weiss, 1972) and the Couples In- teraction Checklist. Only 6 correlations out of 30 were found to be significant, explaining nearly 25% of common variance. Similarly, communication and MMQ have only 25% variance in common (Arrindell, Emmelkamp, & Bast, 1983). There is a clear need that researchers in this area reach consensus on the measures used to assess marital conflict, marital distress, and communica- tion. Results of many studies are not comparable because of the idiosyncratic measures used.

Although there is no evidence that the marriages of most patients with agoraphobia are disturbed, there may be a proportion of patients in which the agoraphobia has interpersonal meaning. Anxiety and relationship prob- lems may be related in a number of ways (Emmelkamp, 1982) that deserve close scrutiny by the therapist in treatment planning. When anxiety and rela- tionship problems are unrelated, there is no need to treat the relationship first. When the development of panic disorder and obsessive-compulsive disorder is clearly connected to relationship problems (e.g., Goldstein & Chambless, 1978; Kleiner & Marshall, 1985) and the relationship problems maintain the anxiety disorder, treatment should deal with both of these problems. Given the finding that criticism of the spouse may be related to relapse at follow-up (Emmelkamp, Kloek, & Blaauw, 1992; Steketee, 1993), this may require spe- cial attention to communication training. If both partners acknowledge the marital problems, this usually causes no major problem. However, when one or both denies the marital conflict, therapy may best proceed by having the partner "assist" in the treatment of the patient, unless there is so much tur- moil and criticism of the partner that such an approach would be counter-

426 EMMELKAM]P & GERLSMA

productive. Therapists should be aware of the fact that in a number of cases, marital conflict may have played a part in the development of the disorder, but does not "feed" it any longer. Treatment should then be directed on the anxiety disorder. In some cases, the anxiety disorder developed for reasons unrelated to marital distress, but the disorder has placed a heavy burden on the relationship, leading to marital distress. Treatment directed at overcoming the anxiety disorder eventually may lead to increased marital satisfaction. Fi- nally, in some dependent unassertive patients with agoraphobia who have con- current marital problems, it may be therapeutically wise to focus treatment on the assertiveness problems (Emmelkamp, van den Hout, & de Vries, 1983) rather than on the marital problems. In a number of couples in which the patient is dependent on the partner, it is hard to deal therapeutically with rela- tionship problems if the patient is too anxious to criticize behavior of the partner. Assertiveness training may then be needed to teach the dependent patient to express his or her emotions directly. Future research is needed to determine whether the present suggestions are supported by experimental evidence.

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RECEn~D: September 7, 1993 ACCEPTED: March 14, 1994