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A comparison of three approaches to reduce marital problems and symptoms of depression

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A comparison of three approaches to reduce marital problems and symptoms of depression
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Huang, Mei-Kuei, 1954-
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xi, 182 leaves : ; 29 cm.

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Counselor Education thesis, Ph. D ( lcsh )
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Thesis (Ph. D.)--University of Florida, 2001.
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Includes bibliographical references (leaves 166-181).
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Printout.
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Vita.
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by Mei-Kuei Huang.

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Full Text
A COMPARISON OF THREE APPROACHES TO REDUCE MARITAL PROBLEMS
AND SYMPTOMS OF DEPRESSION
BY;
MEI-KUEI HUANG
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF [LOR IDA

2001




I dedicate this dissertation to my parents, my sisters, my sons, Dr. Yuen Hon Keung, and Dr. Lung For-Wey, for their love, support, and confidence in me that bring a new yellow rose to this world.




ACKNOWLEDGMENTS
I thank my whole family for their support for my fulfilling this dream.
I would like to express deep appreciation to Dr. Silvia Echevarria Doan, my doctoral research committee chairperson, for her continual support and encouragement during my doctoral study in the United States and this dissertation research. I would like to acknowledge the other members of my committee for their assistance in completing this study. Both Dr. Ellen Amatea and Dr. James Pitts gave me very valuable feedback and guidance to describe my research findings. Dr. Miller guided me through the data analysis and interpretation. This dissertation would not have been completed without their help.
Special thanks are offered to Dr. Yuen Hon Keung, who accompanied me through many difficult moments when I was dealing with statistical problems. His generosity has been limitlessly provided for me both when I was in the United States and when I was back to Taiwan. He also gave me full support and confidence in my abilities to complete my doctoral study throughout the whole process.
I would like to acknowledge Dr. Jim Morgan for his unconditional positive regard to an international doctoral student. His expertise in hypnosis and solution-focused model has been demonstrated in his style of doing




psychotherapy. I have been very fortunate for the opportunity to model from him and obtain the greatest inspiration from him.
Words cannot adequately express the deep gratitude I feel for Dr. Lung For-Wey, the director, and the five treatment teams he leads in the psychiatry department at Military Kaohsiung General Hospital in Taiwan. If not for his permission to conduct this research project in his department, there would not be this dissertation. I also received great mentoring, supervision, and statistical assistance from him. Special thanks are extended to Dr. Tzen Tong-Shun, another supervisor, Dr. Yen Yung-Chien, and Dr. Lieu Chun-Long, whose talents, expertise in psychiatry, and experience in treating patients with depression provided me the strongest support for conducting medical research in this hospital.
I would like to thank Dr. Wen Jung-Kuang in the Chang Gung General Hospital, Dr. Chen Cheng-Chung and Dr. Tang Tze-Chun in the Chung-Ho Memorial Hospital, and Dr. Chou Huang-Chih in the Kai-Suan Psychiatry Hospital, who gave their consent to refer depressed patients to the study and provided me a certain amount of assistance to complete this project.
I would also like to acknowledge the ex-mayor of Kaohsiung City, Wu
Duin-Yee, who granted special approval for my coming to the United States for my doctoral study; Mr. Chen Jung Hua, the former principal secretary of the Education Bureau of Kaohsiung City government, and Mr. Chen Shun Cheng, the chairman of the Social Education Department in the Education Bureau, who




both signed the letter that guaranteed my return to Taiwan to serve the country; and Dr. Chen Yong-Shing, the chief of the Mental Health Bureau of Kaohsiung City government, who assisted me in locating a site for this study after six months of unproductive effort. I am also deeply grateful for the recommendation letters Dr. Jim Shuh-Ren, the President of Chinese Guidance Association; Dr. Tai Chia-Nan, the President of Kaohsiung Normal University; Dr. Tsai ShungLiang, my adviser for the master's thesis; and Shieh San-Huei, the director of Kaohsiung Family Service Center, wrote for me when I was applying for doctoral study in this department.
Finally, I thank all my friends in the United States and Taiwan. Special thanks for all the shared hopes, warmth, caring, and love that I treasure as the light in the dark night go to the staff members in IRB-01, my colleagues in HoPing Junior High School, my clients in several sites, the Statistic Consultation Team led by Dr. Wu Yu-Yee in Kaohsiung Normal University, and everyone whom I met on this academic journey.




TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS ........................................................ ii
ABSTRACT ..................................................................... x
CHAPTERS
I INTRODUCTION ....................................................1
Depression................................................................ 4
Treatment for Depression ................................................ 8
Treatment of Marital Issues for Depressed Clients................. 10
Definitions of Terms ............................................... 11
11 LITERATURE REVIEW............................................ 13
Etiology of Depression ............................................ 14
The Biological Model of Depression........................ 15
The Psycho-Social Model of Depression................... 16
The Bio-Psycho-Social Model of Depression ............... 18
Depression and Marital Issues..................................... 18
The Relationship between Depression and Marital Discord ... 19 Marital Discord Model of Depression........................ 21
Spousal Abuse and Depression............................. 21
Treatment for Depression within Marriage......................... 22
Antidepressant Medications................................ 23
The Choice for Psychotherapy............................. 26
Cognitive-behavioral therapy....................... 27
Interpersonal therapy .............................. 28
Choosing a therapy group modality..................30
Solution-focused brief therapy .................... 31
Comparative Effectiveness of Treatments for Depression......... 46
Active Treatment vs. Non-active Treatment ................46
Psychotherapy vs. Pharmacotharapy...................... 47
Combination Treatment vs. Psychotherapy or
Pharmochotherapy ............................ 49
Comparisons between Different Combinations............ 50
Comparisons between Different Psychotherapies.......... 50
Summary......................................................... 51




Page
T he P u rpose ...................................................................... 53
Null Hypotheses ................................................................. 54
III METHODOLOGY ............................................................... 56
Introd uctio n ........................................................................ 56
Research Design ................................................................. 57
Participant Recruitment ......................................................... 57
Screening for group members ................................................ 58
Instrum e nts ........................................................................ 59
Beck Depression Inventory ............................................. 59
Structured Clinical Interview for DSM-111-R-Patient Edition.....61 Dyadic Adjustment Scale ................................................ 61
Marital Status Inventory ................................................ 62
Conflict Tactics Scale ..................................................... 63
Scaling Questions ......................................................... 64
Measurement Procedure ...................................................... 64
Treatment Conditions ........................................................... 64
Group Leader ............................................................... 65
Antidepressants Medication (AM) Group ........................... 66
Solution-Focused Brief Therapy (SFBT) Group ................... 66
The AM+SFBT Group .................................................... 71
D ata A na lysis ..................................................................... 7 1
IV R E S U LT S ........................................................................... 7 3
Descriptive Information ......................................................... 73
Demographic Information ............................................... 73
Descriptive Statistics ..................................................... 75
Description of the Change Process ................................. 76
Statistical Results of the Research Hypotheses ......................... 78
Test for Pretreatment Difference ....................................... 78
Test for Depression Symptoms Elimination ......................... 79
Test for Marital Adjustment .............................................. 82
Test for Marital Status Dissolution ..................................... 83
Test for Spousal Abuse Reduction .................................... 84
Test for Goal Performance Scaling .......................................... 86
Summary of the Research Findings ......................................... 87
V CONCLUSION .................................................................... 89
Discussion of Research Results ............................................. 89
Treatment Effect for Depression ..................................... 89




Page
Treatment Effect for Marital Problems...................... 91
Self-Evaluation of Goal Achievement....................... 92
Implications ....................................................... 92
Limitations ........................................................ 95
Recommendations for Future Research .......................... 97

APPENDICES
A
B C D E
F
G
H
I

CRITERIA FOR MAJOR DEPRESSIVE EPISODE............. 100
CRITERIA FOR DYSTHYMIA DISORDER ..................... 101
THE COGNITIVE MODEL OF DEPRESSION .................. 102
THE MARITAL/FAMILY DISCORD MODEL OF DEPRESSION ... 103 CONDITIONS AND INTRVENTIONS OF DEPRESSION ........ 104 DOCUMENTS FOR INSTITUTIONAL REVIEW BOARD -01..105 THE SCALING QUESTION IN PRETREATMENT.............. 134
THE SCALING QUESTION IN POSTTREATMENT............ 135
READING MATERIALS: DEPRESSION........................ 136
GROUP WORKBOOK........................................... 138

REFERENCES................................................................... 166
BIOGRAPHICAL SKETCH ....................................................... 182




LIST OF TABLES

Table pg~
1 Demographic Information of the Participants Demographics ........ 73
2. Means and Standard Deviations for Pretest and Posttest in Each
Group...............................................................7
3. The Percentage of Reported Treatment Goals in Pretreatment ....77
4. Analysis of Variance for the Pre-intervention Scores in BDI, DAS,
MSI, and CTS for Different Groups ................................. 79
5. Test of Homogeneity of Common Slop in BDI and MSI in Each
Group ............................................................... 79
6. Analysis of Covariance for BDI....................................... 80
7. The Adjusted Means of the Three Treatment Groups ............... 81
8. Multiple Comparisons of Mean Differences among Groups in the
BDI ..................................................................81
9. T Test for Pretest and Posttest in Each Group for BDI ............... 82
10. Analysis of Covariance for DAS...................................... 82
11. T Test for Pretest and Posttest in Each Group for DAS .............. 83
12. Analysis of Covariance for MSI ...................................... 84
13. T Test for Pretest and Posttest in Each Group for MSI............... 84
14. Analysis of Covariance for CTS ...................................... 85
15. T Test for Pretest and Posttest in Each Group for CTS .............. 85
16. Analysis of Covariance for Scaling Scores .......................... 86
17. T Test for Pretest and Posttest in Each Group by Scaling Scores ...87




Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment
of the Requirements for the Degree of Doctor of Philosophy
A COMPARISON OF THREE APPROACHES TO
REDUCE MARITAL PROBLEMS AND SYMPTOMS OF DEPRESSION
By
Mei-Kuei Huang
December 2001
Chairperson: Silvia Echevarria-Doan Major Department: Counselor Education
This study evaluated the effectiveness of three treatment groups provided for depressed patients in Military Kaohsiung General Hospital (MKGH) in Taiwan. The three treatment groups were (a) antidepressants medication (AM) alone, (b) Solution-Focused Brief Therapy (SFBT) group alone, and (c) the combined treatment of the two (AM+SFBT). Thirty-nine participants composed the sample. Psychiatrists working in MKGH and other psychiatry departments in several general hospitals referred these subjects to the researcher. They had diagnosed these patients as having affective disorder(s) such as minor depression, major depression, and dysthymia.
The purpose of this study was to determine whether there were any
differences among participants of the three treatment groups (AM only, SFBT only, AM and SFBT) in reducing depression symptoms, stopping the dissolution




of marital status, improvement in dyadic adjustment, or reduction of conflict tactics after eight weeks of treatment.
This study was a quasi-experimental design with a pretest/posttest. A selfreport questionnaire included (a) a demographic questionnaire, (b) the Chinese version of the Beck Depression Inventory, (c) the Chinese version of the Dyadic Adjustment Scale, (d) the Chinese version of the Conflict Tactics Scale, (e) the Chinese version of the Marital Status Inventory; and (f) the SFBT scaling questions.
Analyses of covariance (ANCOVA) were conducted, with posttest scores as the dependent variables and pretest scores as the covariant. Significant differences were found among the three groups in terms of reduced depression symptoms. Results of post hoc analyses indicated that the SFBT group was more effective than the AM group. However, there were no differences either between the AM group and the AM+SFBT group or between the SFBT group and the AM+SFBT group. There were no significant differences among the three groups in terms of stopping the dissolution of marital status, improving dyadic adjustment, or reducing spouse abuse. A dependent sample t-test was used to examine the differences between pretest and posttest scores in each variable for every group. Significant differences indicated treatment effects were found in the BDI of both the SFBT group and the combined group. Scaling scores of each group also decreased significantly in the posttest.




CHAPTER 1
INTRODUCTION
Research efforts in the treatment of depression, although extensive, still leave room for more in-depth study that can be addressed in several different ways. These include "the comparative effectiveness of psychological and pharmacological treatments, as well as combination treatments, for treating depression" (Barlow & Hoffmann, 1997, p.102). In this study, the efficacy of three different approaches in the treatment of depression was tested with clients who were also experiencing marital difficulties. Treatment effects of both standard methods (e.g., medication) and less-tested, more innovative methods of treatment like Solution-Focused Brief Therapy (SFBT) were compared in terms of differences in outcome over an eight-week period. The three comparison groups consisted of subjects treated with antidepressant medication (AM) alone, SFBT alone, and SFBT added to AM.
The intent of this study was to collect valid and reliable data to determine which types of treatments for depressed patients made a difference in their wellbeing after a two-month treatment period. The information gained from this study offers mental health providers further information on the efficacy of interventions with depressed patients who also experience marital difficulties. It may be especially useful in the treatment of those patients who reject antidepressants as a standard treatment. The effects of an alternative SFBT approach, a standard




2
treatment, and a combination of SFBT with standard medication were examined in this study.
A comparatively brief psychotherapy (SFBT), which involves fewer than six sessions, is said to be enough to bring positive change by therapists who use this approach (de Shazer, 1991; Lee, 1997). This treatment period is shorter than what is believed to be the natural three- to six-month course of depression (Eaton et al., 1997; Fennell, 1991; Leonard, 1997). A brief form of therapy that could benefit depressed clients in less time is worthy of study.
The results of this study have implications for mental health providers,
researchers, and policymnakers. The results also may be helpful for purposes of treatment planning, program development, and service delivery in Taiwan.
Depression, known historically as melancholia, was noted in Hippocratic
writing as early as the fifth and fourth centuries B.C. (Jackson, 1986). It is now the most common psychiatric disorder seen by mental health professionals in the United States (Dobson & Jackman-Cram, 1996). Depression has been referred to as the "common cold of mental illness" (Gelman, 1987; Shorter, 1999). It is the second most disabling ailment (after heart disease) in Western countries (Marano, 1999) and the world's fourth most disabling disease according to Murray and Lopez (1997). Epidemiological studies indicate that the prevalence of depression is increasing in many countries (Cross-National Collaborative Group, 1992). The effects of depression can devastate the lives of individuals, particularly their work, family and marital relationships. There is a great need for effective treatments of serious mental health problems such as depression in order to prevent the massive personal and societal costs they present.




3
In the United States, 26% of adult women and 12% of adult men experience a major depressive episode sometime during their lives (National Institutes of Health, 1991). The American Psychiatric Association (APA, 1994) reported that the lifetime risk for a major depressive disorder in community samples varies from 10 to 25% for adult women and 5 to 12% for adult men.
According to these data, women are prone to experience depression at least twice as frequently as men. Among women in Western countries, major depression is the most common illness (Shorter, 1999). It also is one of the five psychiatric causes of the top 10 chronic diseases in women (Harvard's New School of Public Health Global Burden of Disease study, cited in Shorter, 1999). However, it is necessary to note that the ratios may be a methodological artifact because women are more willing to acknowledge difficulty and they express more help-seeking behaviors than men. Further, people express depression in many ways. Men may have different diagnosed behaviors associated with depression than those seen in women. They may turn to substance abuse or alcohol, or they may become aggressive. These are not behaviors generally associated with depression in women (Aneshensel, Rutter, & Lachenbruch, 1991).
One of the epidemiological studies conducted in Taiwan from 1981 to 1986 revealed that the lifetime prevalence rate for major depression was significantly lower than that in most of the United States (Hwu, Yeh, & Chang, 1989). Nonetheless, these findings could reflect cultural differences in that people in Taiwan may not be as likely to seek professional help for psychological problems unless they are causing some kind of physical pain. In studies of




persons living in Taiwan, somatization of mental problems has been found to be a normative behavior of illness (Wen, 1998).
Beach et al. (1990) reported that experiencing marital distress and having interpersonal disputes were two of the six vulnerability factors found in depressed patients. In a meta-analysis, Meichenbaum (1996) concluded that there was a relationship between depression and marital distress based on the work of Beck, Rush, Shaw, and Emery (1979), Beach et al. (1990), and Hollon and Beck (1993). Meichenbaum (1996) noted that 20% of all married couples were distressed in the marriage, 50% of the patients who requested psychotherapy did so because of marital discord, 30% of marital problems involved at least one spouse who was clinically depressed, 50% of those who requested treatment for depression also evidenced marital discord, and 50% of discordant couples had a depressed spouse. Coyne, Kahn, and Gotlib (1987) also reported that 40% of the spouses were sufficiently distressed by their depressed partners to warrant treatment themselves.
As more individuals seek treatment for depression, these studies indicate that there are growing concerns about the effects of depression on marital relationships as well. This research was based on the study of effective methods of intervention in the treatment of depressed patients who are experiencing marital problems.
Depression
Clinical descriptions of depression have been consistent despite some
shifts and changes (Jackson, 1986). From observations of Hippocrates to present research findings, the most salient features of depression are described as




5
exhibiting depressed mood and loss of interest, dysfunctional negative cognition (including pessimism and dejection), and reduced behavioral activation (including withdrawal, silence, and irritability) (Dobson & Jackman-Cram, 1996; Hamnmen, 1997; Stefanis & Stefanis, 1999).
A depressed mood generally is viewed as normal or common after one experiences a loss. In contrast, symptoms of major clinical depression are characterized by a persistent depressed mood or loss of interest and pleasure in activities, accompanied by changes in appetite, weight, sleep, and psychomnotor agitation or retardation, decreased energy, tiredness, and fatigue, feelings of worthlessness or guilt, difficulty in thinking, concentration, and decision making, and recurrent thoughts of death or suicidal thoughts, plans, or attempts (APA, 1994) (see Appendix A). According to the fourth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (APA, 1994), before making the diagnosis of major depression, it should be determined that five or more of the symptoms described above have been present during the same two-week period. The symptoms also should present a change from previous functioning.
Brady (1999) reported that after administering a screening questionnaire for depression, a core subset of four symptoms should be used to effectively diagnose depression. These four symptoms, sleep disturbance, anhedonia, low self-esteem, and decreased appetite, accounted for virtually all of the symptomrelated variance in functional status and well-being of depressed patients. The associated features found in individuals with a major depressive episode frequently are presented as tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of pain




(e.g., headaches or joint, abdominal, or other pain) (APA, 1994).
The degree of impairment associated with depression varies. The
individuals may experience some interference in social, occupational, or other important areas of functioning even in mild cases. If the impairment is severe, the person may lose social or occupational functions. In more extreme cases, the person may not be able to maintain or perform minimal self-care or self-hygiene (APA, 1994).
A Taiwanese study of the illness behavior of depressed patients achieved similar findings with insomnia being the most frequently reported symptom, followed by depressed mood, low self-confidence, decreased appetite, and thoughts of death (Lee & Wen, 1998). In contrast to studies of Western subjects, depressed mood mixed with psychological and somatic terms, such as "discomfort inside heart and liver," were more likely to be expressed (Lee & Wen, 1998).
Recent research efforts have investigated the effects of depression on both partners in a marital relationship. If neither partner shows evidence of depression, both experience more satisfaction in their marital life (McLeod & Eckberg, 1993). Premarital dysphoria was associated with later marital dissatisfaction (Beach & O'Leary, 1993). Heim and Snyder (1991) found that disaffection accounted for one-third of the variance of depressive symptoms in couples. Whisman and Jacobson (1989) noted that depressed wives showed greater inequality in decision making. Halloran (1998) supported this finding and delineated the interrelationship of inequity of marital power with depression and marital distress. Stress in marital interactions may change depressive symptoms and result in unfavorable reflected appraisals, low competency, low self-efficacy,




and low self-esteem. Both depression and self-efficacy may negatively mediate self-concept disconfirmation with marital happiness, and therefore individuals with lower levels of self-efficacy are more depressed (Schafer, Wickrama, & Keith, 1998).
In a study of the relationships between major depression and marital satisfaction, Cascardi, O'Leary, Lawrence, and Schlee (1995) reported that for both abused and nonabused women seeking treatment for marital discordant problems, there was a tendency for abused women to have higher lifetime rates of depression prior to their current marriages than those found in maritally satisfied and nonabused women. Further, Aseltine and Kessler (1993) identified the association between marital disruption and depression. Finally, Weissman (1987) stated that a spouse of either sex in a discordant marriage is 25 times more likely to be depressed than one from a nondiscordant marriage.
Results from a study testing the Stress Generation Model highlighted the cyclical course of dysphoria and stress among wives in 154 newlywed couples (Bradbury, Davila, Tochluk, & Cohan, 1997). The presence of an extended family was related to depression in both men and women (Gerstel & Gallagher, 1993). It was found that depression rates increased because of interference from members in the extended family.
In summary, the literature suggests that effects of depression, including dysfunctional cognition, retardation of physical activities, negative affect, somatic disturbance or pain, and impaired relationships with others, can significantly impact marital relationships (e.g., in terms of marital satisfaction or disaffection, power issues, self-appraisal, marital conflicts, and marital disruption).




Treatment for Depression
Interventions for solving human problems such as depression vary in
accordance with how people conceptualize the problems. For decades, treatment for depression has been divided into two fundamental models (Shorter, 1999). The biological model stresses neuroscience and an emphasis on brain chemistry and medication. According to this model, symptoms of depression arise from a biologically influenced imbalance in one's neurotransmitters. The psychosocial model attributes the symptoms of depression to a psychological process, which may be activated when a person has difficulty in adjusting to social problems or personal stressors.
To date, training in psychiatry favors pharmacological treatment for depression. Shorter (1999) noted that there is growing confidence in seeing psychiatry as a specialty of medicine. Antidepressant medication is the most commonly administered treatment (Fava & Rosenbaum, 1995; Williams, 1997). Although the vast majority of major depression episodes subside eventually, they tend to recur whether treated or not (Hammen, 1997). Recent findings suggest that the lowest recurrence rates require patients to continue at the dosage levels used to achieve remission (Kupfer et al., 1992).
On the other hand, using psychotherapies to treat depression also has been proven to be effective (Barlow & Hoffmann, 1997; Dobson, 1989; Hamnmen, 1997; Rush & Thase, 1999). Among them, the most dominant orientation in depression research and theory has been the cognitive approach led by Aaron Beck and his colleagues (Beck, 1967, 1976, 1993; Beck et al., 1979; Beck & Weishaar, 1989). This is a time-limited, structured approach based on the




assumption that an individual's thoughts and ideas determine his/her affect (Papolos & Papolos, 1987). Therefore, by modifying the activities of the mind, mood and emotion are modified.
There are two other models that also are predominant in treating depression. First is the psychodynamic approach of therapy. This approach emphasizes the impact that past experiences have on current life, and how one's unconscious conflicts may result in difficulties as well. The second is the interpersonal approach of therapy. This approach focuses on the relationship between depression and interpersonal difficulties. It is also a time-limited, shortterm psychotherapy. The psychodynamic treatment for depression has been regarded as difficult and unhelpful (Hammen, 1997). However, two other approaches, cognitive and interpersonal therapies, are commonly reported as efficient and useful.
Despite the large number of treatment approaches available utilizing these more traditional methods, this study will examine the effectiveness of a relatively new model of psychotherapy known as SFBT (Berg, 1994; de Shazer, 1986; de Shazer & Berg, 1997; de Shazer & Molner, 1984). The SFBT focuses on generating solutions instead of attempting to delineate how problems evolve from pathological cognitive functioning. In contrast to pathology-focused models, SFBT emphasizes the client's competence and resources (e.g., O'Hanlon & WeinerDavis, 1989; Walter & Peller, 1992) and tries to capitalize on these elements to improve clients' lives. The SFBT therapist listens very carefully to what the client reveals in interviews, and views the client as the expert in his/her life (e.g., Berg & De Jong, 1996). Therefore, therapy is "a mutual search for new options and




understanding" (Nichols & Schwartz, 1995, p. 452). The main reason for the present researcher to study this model is because SFBT utilizes what has been identified as the most important factors of "what works" in therapy (Lambert, 1992). These factors are personal strength, talent, beliefs, resources, and social support. According to Lambert (1992), client factors contribute to 40% of successful therapeutic outcomes. The other three factors are therapist factors, such as a therapist's empathy, acceptance, and warmth (contributing 30% of outcomes); expectancy factors such as hope and expectations for change (contributing 15% of outcomes); and, finally, model/technique factors employed by therapists (contributing 15% of outcomes).
Treatment of Marital Issues for Depressed Clients
Since marital issues fall into a psychosocial area, it is not surprising that there is no agreement as to what kind of antidepressant medication is better for treating marital problems. However, from a biological perspective, depression is an illness that causes the depressed person's "demoralization" (Klein & Wender, 1993). In cases where marital problems are associated with depression, medication may offer an alternative. In other words medication can improve one's physical, cognitive, affective, and behavioral state in ways that can help one deal with marital problems more effectively (Mays & Croake, 1997). Psychotherapy may be seen as a way of accelerating the healing process (Klein & Wender, 1993).
Psychotherapy deals with psychosocial issues directly with the hope that depression eventually will disappear. Marital issues have been emphasized in the treatment of depression. Beach, Jouriles, and O'Leary (1985) suggested that in 50% of couples experiencing marital problems, one spouse is clinically depressed.




In more than 50% of unhappy marriages, at least one spouse is depressed (O'Leary & Beach, 1990).
O'Leary and Beach (1990) developed the marital discord model of
depression and a cognitive-behavioral marital therapy designed to deal with both the marital issues and the problems associated with depression at the same time. Those using interpersonal psychotherapy suggest that by working through marital issues, the client will both resolve the marital dilemma and treat the depression (Swartz & Markowitz, 1995). A group form of therapy is also suggested for the treatment of depressed clients with mild or moderate depression as they deal with interpersonal difficulties (Luby, 1995). As for the SFBT approach, there are still very few empirical research findings concerning its effectiveness for both marital difficulties and depression.
Definition of Terms
Depression in this study is defined as described in the DSM-IV (APA,
1994): sessions of major depressive disorder, with mild and moderate specifiers (see Appendix A) and dysthymic disorder (see Appendix B). Depression with psychotic features, depression with suicide or homicide attempts, and depression with clinical bipolar recursive episodes were excluded from this study. Additionally, a score on the Beck Depression Inventory (BDI) (Beck et al., 1979) of 10 or greater was used as an inclusion criterion.
Depressed clients are defined as those who were interviewed by a
psychiatrist utilizing the Chinese version of the Structured Clinical Interview for DSM-III-R-Patient Edition (Spitzer, Williams, Gibbon & First, 1990) and who were found to meet the DSM-IV criteria.




Marital status is defined by scores on the Chinese version of the Marital Status Inventory (MSI) (Weiss & Cerreto, 1980). Higher scores on the inventory indicate a greater potential for disruption of the marital relationship.
Dyadic adjustment is defined by the total scores on the Chinese Dyadic
Adjustment Scale (C-DAS) (Shek, Lam, Tsoi, & Lam, 1993; Spanier, 1976). Higher scores on the scale represent better dyadic adjustment.
Spousal abuse is defined by scores on the Chinese version of the Conflict Tactics Scale (C-DAS) (Straus and Gelles, 1988). Higher scores on the scale reflect more serious conflict between partners/spouses.
Antidepressants in this study fall within three categories: tricyclic
antidepressants, monoamine oxidase inhibitors, and serotonin reuptake inhibitors (SSRIs), such as Trazodone (Desyrel), Amoxapine (Asendin), and Fluoxetine (Prozac).
Solution-Focused Brief Therapy is a treatment model created by Steve de Shazer and Insoo Kim Berg in 1980 (de Shazer & Berg, 1997). They suggest that when SFBT is used in a research context, it is important to include the four characteristic features of asking the miracle question, scaling questions, breaking from sessions to consult with the team, and concluding sessions with compliments and homework tasks (frequently called experiments) (de Shazer & Berg, 1997).




CHAPTER 2
LITERATURE REVIEW
Hippocrates first described depression clinically in the fourth century B.C. as melancholia (Beck, 1967). Since then, philosophers and physicians have placed great effort in the search for the cause and treatment of this disorder, and an extensive body of knowledge about depression has emerged. In this chapter a review of the epistemology regarding depression will be presented, followed by theories and research findings regarding the relationships between depression and marital issues. Several treatment models for depression will then be reviewed by describing the basic concepts, techniques, and research findings as related to each spousal relationship area. The discussion regarding treatment will first address the use of antidepressant medications, followed by a description of several types of therapeutic interventions. Greater emphasis will be placed on SFBT. Other descriptions will include Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT). The reasons SFBT was chosen as the focused treatment model will be delineated. The modality of group therapy as part of any psychotherapy approach also will be described. Comparisons of the effectiveness of various treatment modalities for depression will be discussed. Finally, a summary of the literature review will be presented, and the purpose as well as the research hypotheses will be stated in the end of this chapter.




Etiology of Depression
There is no single theory in the etiology of depression (Kendell, 1999). The occurrence of depression may result from interactions among many factors. The onset and course have been shown to relate to a variety of biological, historical, environmental, and psychosocial variables. These variables include disturbances in neurotransmitter functioning, atrophy of the left side of the prefrontal cortex (PFC), a greater flow in amygdala, a family history of depression or alcoholism, early parental loss or neglect, recent negative life events, a critical or hostile spouse, lack of a close confiding relationship, lack of adequate social support, and long-term lack of self-esteem (e.g., Hammen, 1999; Marano, 1999; Shorter, 1999). Over the past 30 years, depression gradually has ceased to be regarded as a purely psychological disorder. Instead, it has been well accepted that depression may be associated with important biological abnormalities (DeBattista & Schatzberg, 1995).
Depression has been divided by practitioners into the endogenous type (i.e., no apparent external cause) and the reactive type (i.e., an identifiable external cause), or the biological versus the psychosocial model (e. g., Leonard, 1997; Kendell, 1999; Shorter, 1999). The first model stresses neuroscience, placing a greater interest in brain chemistry, brain anatomy, and medication. The origin of psychic distress is associated with the biology of the cerebral cortex. The psychosocial model focuses on the events in people's lives. In this model the origins of depression are associated with adjustment related social problems or other psychosocial issues.




Biological Model of Depression
Research regarding the endogenous/biological bases of depression has concentrated mainly on four major areas (DeBattista & Schatzberg, 1995; Glass, 1999; Kendell, 1999; Leonard, 1997; Papolos & Papolos, 1987; Short, 1999; Thase & Howland, 1995). Recently, research findings in neurodegenerative disorders also have contributed new theories about how depression occurs.
The first area constitutes changes in biogenic amine neurotransmitters. Two neurotransmitters have most often been implicated in depression: norepinephrine and serotonin. In a depressive state there are too few norepinephrine or serotonin neurotransmitter molecules being synthesized and released, and therefore not enough molecules to ferry the impulse across the synaptic cleft (Papolos & Papolos, 1987). The neurotransmitters act on specific sites called receptors. The level of receptor sensitivity to these neurotransmitters has been reported to be a dynamic interaction with neurotransmitters. Consequently, it is not just the quantity of neurotransmitters that matters in mood disorders but also the low level of receptor sensitivity (Thase & Howland, 1995).
Second, there are changes in cerebrospinal fluid (CSF) concentrations of amine metabolites (Leonard, 1997). These changes have been reported to occur in the CSF of untreated depressed patients. The rate of accumulation of these metabolites is reduced with untreated depression and can return to normal following clinical treatments.
Third, hypersecretion of cortisol that is not readily amenable to suppression has been widely advocated as a biological marker of depression (Leonard, 1997). The hypothalamic-pituitary release of cortisol adrenal (HPA) axis controls the




16
release of cortisol. Cortisol readies the body for "fight or flight." Depressed patients secrete more cortisol than nondepressed people, and an oversupply of cortisol is maintained in the bloodstream.
The fourth factor concerns the circadian rhythms in our body. Mood
disorders, including those of depressed patients, are temporal disorders in which the timing of biological rhythms is temporarily and pathologically altered. This is observed in a number of behavioral, automatic, and neuroendocrine aspects, including temperature, blood pressure, hormonal secretions, blood sugar, and many other bodily activities. Many of the circadian rhythms are molded by the daily light-dark cycle. It has been suggested that depressed persons may have conflicting body pacemakers, lack the capacity to process time and light cues, or have a disturbance in the melatonin circadian secretion pattern (Papolos & Papolos, 1987).
The newest evidence presented by neuroscientists shows that a disorder in nerve circuits may cause depressive symptoms (Marano, 1999). Depression is seen as a neurodegenerative disorder. Emotions take shape in a neural circuit. Faulty circuitry fails both in generating positive feelings and inhibiting disruptive negative ones (Marano, 1999).
Psychosocial Model of Depression
The psychosocial model addresses the stress events one has experienced or certain psychological traits in one's personality. A psychoanalyst may stress the pathological influence of early childhood events, which are a predisposition to later depression. For instance, an adult depressed person may have repressed childhood sexual memories and fantasies that caused the neurosis. In this case,




depression arose from unconscious conflicts over long-past events. The depressive episodes may be seen as repetitions of childhood experiences with significant others (Karasu, 1990). The interpersonal model of psychotherapy postulates that depression is essentially relational in nature (Joiner, Coyne, & Blalock, 1999). Interpersonal psychotherapy holds the assumption that depression evolves from a person's current interpersonal issues (e.g., marital conflict, loss of a job, loss of a spouse) (Swartz & Markowitz, 1995). The crucial factor in depression is the social network or interpersonal relationships of the patient. It assumes that disturbed social roles and unsatisfactory interpersonal relationships can be antecedents to and/or consequences of a depressive disorder (Karasu, 1990).
Cognitive behavior therapy, led by the work of Aaron T. Beck and his
associates (Beck, 1967, 1976, 1993; Beck et al., 1979; Beck & Weishaar, 1989), provides a very well-structured conceptualization about both the cognitive and behavioral models of depression. In the cognitive model, an individual has disturbances of thought content and thought process. The thought content of depressed people is characterized by automatic negative thoughts (ANTs) and feelings about the self, the world, and the future (Beck's cognitive triad). In states of acute depression, ANTs fall into two thematic domains, reflecting issues of competence or lovability. These two themes reflect an unconscious level of cognition referred to as depressogenic schemata. The problematic schemata are shaped by the interaction of aptitude, temperament, and experience. An intermediate level between ANTs and depressogenic schemata is referred to as dysfunctional attitudes or beliefs. Dysfunctional attitudes may be most relevant for chronically depressed patients (Thase, 1995). Another intermediate cognition




construct is attributional style. Depressed persons are prone to attribute events to internal factors instead of external ones, global factors instead of specific causality, and enduring factors instead of transient situations. This process is illustrated in the figure of the cognitive model of depression (see Appendix C). The informationprocessing distortions in a depressed person's cognition may include an overestimation of losses or limitations, undervaluation of one's strengths and resources, and increased recall of negative experiences. Bio-Psychosocial Model of Depression
In a living system such as a human being, it is difficult to separate mind
and brain. Efforts have been made to unite the biological and psychosocial models of depression. In those physical parts of the system such as the brain, we see that nerve circuits, including the prefrontal cortex, amygdala, and hypothalamus, color psychosociological events positively and negatively (Marano, 1999). Conversely, the brain reacts to stress-related events. For instance, ongoing research in animals and humans demonstrates that early stress can alter the nerve circuits that control emotion, exaggerating the neurochemical and behavioral changes that occur later in depression. In other words, it leads to chronic overactivation of the system (Marano, 1999). With respect to the causes of depression, the biopsychosocial model would address the multiple factors already described in both the biological and psychosocial models. It does not hold a single cause theory for depression.
Depression and Marital Issues
Marital discord plays an important role in the etiology and course of
depression (Anderson, Beach, & Kaslow, 1999; Beach, 2000; Jacobson & Gurman,




1995). There is a consistent association between marital distress and depression (Rounsaville, Weissman, Prusoff, & Herceg-Baron, 1979; Whisman, 2000). Related research findings in marital satisfaction, marital dissolution, and marital conflict may give a clearer idea with regard to the intertwined relationship among them.
Relationship Between Depression and Marital Discord
From a temporal and causal perspective, there are four hypotheses about the relationship between marital distress and depression. First, marital discord causes later depression. Marital disruption is frequently observed just prior to incidents of depression. Marital distress may be implicated directly in the development of a depressive episode, or it may interact with stressful life events and lead to a depressive episode, either by increasing the total level of stress experienced or by failing to provide an adequate buffer against the impact of the events (Hobfoll & Lieberman, 1987). Marital satisfaction was found to have a significant effect on depression in a study on women working full time (Beach et al., 1996). Women who experienced low levels of marital satisfaction showed greater depressive symptoms after one year. Results from a study conducted by Fincham, Beach, Harold, and Osborne (1997) also showed that the flow of causality from marital dissatisfaction to depression in the wife was different than the husband when compared in cases where depression occurs before marital dissatisfaction. Brown and Harris (1978) found that married women who lacked close, confiding relationships with their partners were four times more likely to develop major depression when faced with a major stressor than stressed women who had such a relationship. Marital status also had an impact on a person's well-being




20
(Whisman, 2000). It was not just being in an unhappy marriage that puts a person at high risk. Those who divorced also had significantly higher levels of depression than those who were either continuously married or never married (Smith & Weissman, 1992).
Second, depression may cause marital discord and even marital dissolution. Merikangas (1984) found the divorce rate in depressed patients two years after discharge to be nine times that of the general population. Another research finding concerned the effect of premarital dysphoria on marital discord (Beach & O'Leary, 1993). Relationship satisfaction and level of dysphoria were assessed in both spouses prior to marriage, 6 months after marriage, and 18 months after marriage. Results suggested that premarital dysphoria was associated with the subsequent deterioration of marital relationships. When studying the perception and affective responses to depressed partners, Sacco, Dumont, and Dow (1993) suggested that spouses of depressed wives had a generalized negative view of their wives. This negative view may include dispositional attributions, seeing the partner as a burden (Coyne et al., 1987), and viewing the depressed partner's behavior as putting the spouse in an unpleasant bind (Biglan, Rothlind, Hopes, & Sherman, 1989). A different relationship causal path for men was found to be quite opposite from the path for women in that the association emerged from depression to marital satisfaction.
Third, marital discord may be concomitant with depression (Prince & Jacobson, 1995). Beach et al. (1985) suggested that in 50% of couples experiencing marital problems, one spouse is clinically depressed. In more than 50% of unhappy marriages, at least one spouse is depressed (O'Leary & Beach,




1990). Studies indicate that depressive symptomnatology and marital conflict can, and frequently do, occur simultaneously (Prince & Jacobson, 1995).
Finally, it is proposed that depression and marital discord may be mutually connected. It is not just a linear relationship; both can be the cause and effect of each other (Bradbury, Davila, Tochluk, & Cohan, 1997). Unresolved marital conflicts are predictive of rapid relapse (Rounsaville & Chevron, 1982). A vicious cycle may develop in which marital difficulties expand or prolong depression, and depression makes the difficulties even worse. Prince and Jacobson (1995) suggested that couple therapy for depression be used clinically. Marital Discord Model of Depression
The Marital Discord Model presented by Gotlib and Beach (1995)
delineates a reciprocal relationship between marital discord and depression (see Appendix D). There are six support provisions in a marital system: (a) cohesion, (b) acceptance of emotional expression, (c) coping assistance, (d) self-esteem support, (e) spousal dependability, and (f) intimacy. Marital discord decreases these provisions and increases five hostility and stress-produced areas: (a) aggressive behavior, (b) threats of separation, (c) denigration and criticism, (d) disruption of routines, and (e) other marital stressors. These nine factors could precipitate depression, and depression leads to poorer social skills, increased avoidance of conflict issues, and increased interpersonal friction. After these occur, one is expected to experience marital discord (Gotlib & Beach, 1995). Spousal Abuse and Depression
Severe marital conflict including verbal abuse and physical abuse has been associated with depression (Arias, Lyons, & Street, 1997; Fischbach &




Herbert, 1997; Gilbert, Bassel, Schilling, & Friedman, 1997; Orava, McLeod, & Sharpe, 1996). In 1981 a national survey in the United States showed that 26% of respondents admitted to being involved in violence during the previous year, and up to 60% of couples reported being exposed to violence from their spouses at some time (Randall, 1990). Randall (1990) also estimated that approximately 33% of abused women suffer from depression. Tang (1998) found that psychological abuse of Chinese wives correlated with depression, anxiety, marital dissatisfaction and negative mental health measures of general psychological symptoms. When examining the relationship between a woman's history of experiencing violence and current psychological health, Orava et al. (1996) found that 21 abused subjects had lower beliefs in self-efficacy, were more depressed, and had lower self-esteem than 18 comparison subjects. Depression, stress-related syndromes, chemical dependency, and suicide are consequences observed in the context of violence in women's lives (Fischbach, & Herbert, 1997). Whether depressed women are prone to be abused by their husbands or partners is a topic still to be investigated. However, correlations among depression, spousal abuse and longlasting psychological impacts such as the depressed symptomology in children who have witnessed parental abuse (Cummings, DeArth-Pendley, Schudlich, & Smith, 2000; Jaffe & Sudermann, 1995; O'Leary & Cano, 2000) suggest that treatment for depressed clients who suffer from severe marital problems is critical.
Treatment for Depression Within Marriage
Differences in the treatment of depression can be attributed to the choices made by practitioners based on assumptions about depression. Until the mid-70s, conceptualizations of depression emphasized disturbance in mood and was not as




23
an illness (Fennell, 1991). To date, the biological model of depression has gained roots in this area after many scientific researchers achieved substantial new findings from biochemical technology. Shorter (1999) reported that the average psychiatrist in America now prescribes psychoactive drugs. The general outpatient psychiatry practice in Taiwan provides only 10 minutes per session. However, a great many Taiwanese psychotherapists prefer a nonpathological point of view with this disorder. Different forms of psychotherapy may be their preferred forms of treatment. In line with the bio-psychosocial model of depression, it has been possible to establish a rationale for the use of combined physical and psychotherapeutic methods for the treatment of depression over the past two decades. Mays and Croake (1997) presented a multimodel intervention diagram to illustrate the continuum of biological dimensions involved in the conditions of depressive mood disorder, and they suggested interventions (see Appendix E). Mays and Croake suggested that more severe cases of depression are best treated with a psychotropic approach, while psychosocially based problems should be treated using psychotherapy. This review of treatment modalities will begin with antidepressant medications, move to a review of psychotherapy approaches, and end with combined methods.
Antidepressant Medications
The biological theory upon which somatic therapy is based proposes that depression may be seen as caused by (a) lower levels of specific neurochemicals, such as a deficiency of norepinephrine or serotonin, (b) reduced rates in cerebrospinal fluid concentrations of amine metabolites, (c) hyperactivity of the endocrine system and the hormone cortisol, (d) disregulated circadian rhythms, in




which the timing of biological rhythms is temporarily altered (Papolos & Papolos, 1987), and (e) atrophy and retraction of nerve dendrites (Marano, 1999). In this regard, somatic therapy will serve to adjust or regulate those factors that cause the physical dysfunction.
Somatic therapy for treating depression may include medication and electroconvulsive therapy. This review addressed only the first type of therapy because electroconvulsive therapy is only used for severely depressed patients with strong suicidal intention, and these symptoms are beyond the scope of this study.
Three types of antidepressants have been described by many to be used in the treatment of depression (e.g., Bech, 1999). Initially, monoamine oxidase inhibitors were used to counteract the depletion of certain neurotransmitters, particularly norepinephrine (NE), serotonin (5HT), and dopamine (DA). Monoamine oxidase inhibitors were proved to be effective. However, the side effects and the risk of toxicity create problems for some users (Mays & Croake, 1997). The second type drugs often used are tricyclic antidepressants. Used for 40 years, these were until recently the first drugs that a psychiatrist would try with a newly diagnosed depressed patient. Tricyclic antidepressants are thought to work by preventing the secreting cells from reabsorbing such neurotransmitters as serotonin and norepinephrine (Klein, & Wender, 1993). They also have side effects (Mays & Croake, 1997),
including cardiotoxicity, anticholinergic effects, such as blurred vision, dry
mouth, constipation, sexual dysfunction, and urinary retention;
antiadrenergic effects, such as dizziness, certain forms of tachycardia, and




effects on blood pressure; and antihistaminic effects, such as weight gain, sedation, and a lowering of blood pressure. Tricyclic antidepressants can
also interact with other drugs" ( p.106).
A new generation of antidepressants began to appear in the 1980s.
Among them were Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine). These drugs are generally called selective serotonin reuptake inhibitors, or SSRIs. These medicines produced both therapeutic benefits and better side-effect profiles. They have been found to be effective in treatment of depression, especially in the less severe and nonpsychotic varieties (e.g., May & Croake, 1997). However, this group of antidepressents can cause a "serotonin syndrome" referred to by Lejoyeau, Ades, and Rouillon (1994). This condition includes diarrhea, confusion, restlessness, hypomania, myoclonus, and sometimes lack of coordination and fever (cited in May & Croake, 1997). Klein and Wender (1993) made the following additional comments about antidepressants:
1. Antidepressant drugs have little effect on normal mood. When
taken by normal persons, they do not produce a "high."
2. Antidepressant drugs are "normalizing" in contrast to other drugs
affecting moods. They do not have the antidepression effect on
normal persons.
3. The three major antidepressants mentioned above have not been
abused because they do not produce high, elated feelings in
normal people.
4. Most patients with depression can stop taking the medication and
remain without symptoms and do not become dependent on the




drug.
5. When antidepressants are effective, patients usually continue to
Derive benefit from them and do not become tolerant to their
effects.
6. The major effects of antidepressants rarely begin before two to four
weeks of treatment. Maximum benefits may take two to three
months to develop.
7. Side effects often begin when medication is started, before the
positive effects begin.
8. No laboratory or chemical tests can predict which drug will be best
for a particular individual.
9. At times, various drugs must be combined. 10. The most effective dose for each individual varies considerably. 11. Antidepressants do not affect the natural history-the life span-of
the depressive illness. They just control the symptoms while nature
is taking its healing course.
There is no theory that presents a direct relationship between treatment with antidepressants and their effect on marital discord. However, they are assumed to relieve an individual's suffering by treating the underlying disease and offering improvement in physical condition as well as increasing courage, morale, and cognitive functioning to deal with his/her marital problems. The Choice for Psvchotheragy
According to Rush and Thase (1999), psychotherapy may have several objectives, including improved adherence to medication (or other disease




27
management procedures), symptom reduction or attainment of symptom remission, reduction of disability (e.g., improved marital/occupational/social functioning), prevention of relapses/recurrences, or prevention or delay of the onset/progression of depression conditions. The choice of psychotherapy is to attain any of these goals. Many studies indicate that patients with severe depression are less likely to respond to psychological therapies (e.g., Roth & Fonagy, 1996).
In this section, three models of psychotherapy will be reviewed. They are CBT, IPT, and SFBT. The group therapy modality also will be reviewed. Cognitive-behavioral therapy
Cognitive-behavioral psychotherapy has been considered as one of the standard treatments for unipolar depression. The basic assumptions for conducting CBT are: (a) a depressive individual's affect and behavior are largely determined by the way in which he/she views the world; (b) cognition (thoughts, beliefs, fantasies, images, etc.) can be self-monitored by the client and communicated; and (c) the modification of cognition will lead to changes in affect and behavior (Beck et al., 1979). Cognitive-behavioral psychotherapy is designed to be a time-limited, short-term treatment. General guidelines suggest 15 to 25 (50-minute) sessions at weekly intervals. A series of highly specific learning experiences is incorporated into treatment. Each session consists of a review of reactions to and results of the previous session, planning, specific tasks, and assignment of homework. Before each session the client is assigned reading materials on coping with depression and is asked to report on a weekly activity schedule (Karasu, 1990).
Sacco and Beck (1995) recommended that clients' level of depression be




28
assessed throughout treatment to monitor their progress. There are six frequently used techniques in CBT (Williams, 1997), including thought catching, task assignment, reality testing, cognitive rehearsal, and alternative therapy, dealing with underlying fears and assumptions. Specifically, Beck et al. (1979) described five steps for CBT:
Step 1: Identify and monitor dysfunctional automatic thoughts. Step 2: Recognize the connections among thoughts, emotions, and
behaviors.
Step 3: Evaluate the reasonableness of the automatic thoughts. Step 4: Substitute more reasonable interpretations for the dysfunctional automatic inference.
Step 5: Identify and alter dysfunctional silent assumptions.
It suggested that all clients receive a thorough diagnostic evaluation and case formulation prior to the beginning of treatment (Beck et al., 1979). The research findings show that nonbipolar, nonpsychotic depressed clients are well suited for CBT (Sacco & Beck, 1995). In cases of severe marital discord, O'Leary and Beach (1990) suggested that marital therapy be used in addition to CBT. Interpersonal psychotherapy
Interpersonal psychotherapy, developed by Klerman, Weissman, Rounsaville, and Chevron (1984), attempts to alleviate depressive symptoms and to improve interpersonal functioning by improving such as clarifying, refocusing, and renegotiating the interpersonal context associated with the onset of depression (Joiner,1994; Joiner & Metalsky, 1995; Weissman & Klerman, 1990).
Interpersonal psychotherapy also is a time-limited, short-term therapy,




generally taking 12 to 16 weeks. There are three phases in IPT In the first phase, the therapist works on assessment and forming treatment goals in the first few sessions. During this phase the patient is taught the "sick role," learning about depression as an illness and receiving encouragement to continue regular activities, but without the expectation of performing normally. The second phase identifies and targets interpersonal problems thought to contribute to the depression. The third phase focuses on consolidating what has been learned and anticipating the use of the skills during future times of difficulty.
According to the assumptions of IPT (KIerman, Weissman, Rounsaville, & Chevron, 1984), there are four areas associated with the onset of depression. They are (a) abnormal grief reaction (i.e. severe or unusual bereavement in response to the death of a significant other), (b) interpersonal role disputes, (i.e. unreasonable, nonreciprocal expectations of or by significant others, especially disagreements about sex roles), (c) difficult role transition or unsuccessful attempts to cope with developmental landmarks or significant life events (positive or negative), such as getting married or divorced, having a child, graduating from school, changing careers, or retiring, and (d) interpersonal deficits, including inadequate social skills and a history of social isolation or transient relationships. Information is gathered concerning the patient's functioning in the four areas. Interpersonal psychotherapy helps the persons identify their problems and their consequences and acquire new behaviors. In general, IPT therapists make use of nondirective exploration, encourage expression of affect, teach the patient more effective methods of interpersonal communication, and they attempt to alter depressive behaviors through insight, providing information, and role playing




(Hammen, 1997).
Choosing a therapy group modality
According to Lewin (1970), groups have an impact on individual behaviors, feelings, and perceptions. Decisions made in a group setting have more power than do individual decisions (Bloom, 1992). Yalom (1995) further identified 11 therapeutic forces that characterize the healing process in group therapy. Several of them seem to particularly "fit" the treatment of depression patients. The 11 therapeutic factors include (a) instillation of hope, (b) universality, (c) altruism, (d) development of socializing techniques, (e) catharsis, (f) interpersonal learning, (g) corrective recapitulation if the primary family group, (h) imitative behavior, (i) imparting of information, (j) group cohesiveness, and (k) existential factors. These factors will be discussed in terms of their therapeutic force in dealing with the fundamental psychological characteristics of depression: pessimism, hopelessness, withdrawal, and lack of motivation (Luby, 1995).
Hope vs. hopelessness. Hopelessness is one of the salient emotions for depressive patients. It may dot be easy to deal with in an individual therapy session. The clients often claim that no one is able to understand their feelings of hopelessness unless this person is another victim. In a group setting, a member has an opportunity to witness the progress of peers. Confidence that the depressive state is changeable is built, and hope is instilled. Members are encouraged if they see the group help others with problems similar to theirs.
Universality vs. shame and guil The awareness of the similarity of other's emotional experiences, a sense of universality that "we are in the same boat," also may have a liberating impact on depressed patients (Luby, 1995). Group members




can free themselves from the feelings of shame and guilt once they have heard other members talk about their similar difficulties.
Altruism vs. self-disrespect. Depressed patients often suffer from doubts about their self-worth and competence. It is through the encouragement of the group leader that members discover their ability to contribute positively to others' lives and reestablish their self-esteem.
Experiential acceptance vs. victimization. When sharing each other's life stories, members learn to accept an imperfect life by experiential factors in group. They understand that life is at times unfair and unjust. They can recognize that there is no escape from some of life's pain. Consequently, they may learn that they must take ultimate responsibility for the way they live their lives no matter how much guidance and support they get from others (Yalom, 1995). Solution-focused brief therapy
Among the contemporary family and marital therapy approaches, the
SFBT developed by Steve de Shazer (1982, 1985) and his colleagues has been well known for being brief, simple, and efficient. It is brief because it focuses on the solutions, not the problems, and it assumes solutions can be achieved without knowing the causes. Based on SFBT, the discharge planning may begin on admission and avoid going into a lengthy termination process (Vaughn, Young, Webster, & Thomas, 1996; Walter & Peller, 1992). Another reason for its being brief is that it is "atheoretical and client-determined" (Berg & Miller, 1992, p. 8). It implies the client's view is accepted according to what has been said. The therapist will not try to convince the client to accept a certain theory or to deal with resistance/denial when the client disagrees. Further, SFBT therapists state that




only small steps are necessary, through which the clients will find it easy to accomplish any change (de Shazer et al., 1986). The solution-focused model strives for economy in the therapeutic means to achieve desired therapeutic ends (Berg & Miller, 1992). It also assumes the client has the strengths to solve his/her own problems. Utilizing these existing inner resources makes the therapy more efficient (Weiner-Davis, 1992; Weiner-Davis, de Shazer, & Gingerich, 1987). Basic assumptions. Most of the assumptions underlying an SFBT approach are clearly stated in the book, In Search of Solutions (O'Hanlon & Weiner-Davis, 1989). There are several more articulated by others (e.g., Walter & Peller, 1992; Water & Petter, 1996). These assumptions can be grouped into three themes: the change process, the client, and the therapist. I. The change process
1. Change is constant.
2. A change in one part of the system can affect change in another part of the system.
3. A small change is all that is necessary.
4. Rapid changes or resolutions of problems are possible.
5. There is no one "right" way to view things; different views may be just as valid and may fit the facts equally well.
6. Focus is on what is possible and changeable, rather than what is impossible and intractable.
7. Focus on the positive (Walter and Peller, 1992).
8. There is no such thing as "resistance" (de Shazer, 1985). Cooperation is inevitable as patients understand their thinking and act accordingly (Walter




& Peller, 1992).
9. Meaning and experience are interactionally constructed. "We inform meaning onto our experience and it is our experience at the same time"
(Walter & Peller, 1992, p. 24).
10. Meaning is the response (Walter & Peller, 1992). 11. Change may happen if it is presupposed to come true (Gale, 1991). 12. Exceptions suggest solutions (Walter & Peller, 1992). II. The client
1. Clients have resources and strengths to resolve complaints.
2. Clients define the goal because they know what is best for themselves.
3. Clients are the experts (see also Walter & Peller, 1992). Ill. The therapist
1. Curiosity for the therapist is indispensable (Berg & Miller, 1992).
2. The therapist's job is to identify and amplify change.
3. The therapist does not need to know a great deal about the complaint in order to solve it.
A nonpathologic model of treating depression. This model holds that depression is not an illness but a "stuck" situation for the client (Walter & Peller, 1992; WeinerDavis, 1992; Weiner-Davis et al., 1987). A solution-focused approach does not focus on the cause of depressive symptoms since the solution does not necessarily relate to its cause. Depression, rather than being seen as a disease, is viewed by this approach as the way that one person tries to solve his/her personal problems, such as marital discord (e.g., de Shazer, 1991). The goal of treatment for depression, instead of alleviating the depressive symptoms, is to stabilize the




crisis (Vaughn, et al., 1996). The SFBT approach focuses on how to enable a depressed person to recognize the inefficiency and uselessness of the old solutions and help the person try on new methods to solve the problems (Adams, Piercy, & Jurich, 1991).
Extensive application. The SFBT was initially developed as an outpatient treatment. More recently, it has been adopted to deal with a variety of problems. It has been used in residential and inpatient hospital settings (Kok & Leskela, 1996; Vaughn, et al., 1996). Research shows that the SFBT demonstrated positive effects in controlling anger (Schorr, 1977), dealing with chronic mental illness (Booker & Blymyer, 1994; Eakes, Walsh, Markowski, Cain, & Swanson, 1997; Kok & Leskela, 1996), treating substance abuse (Berg & Reuss, 1998), managing issues regarding social work (Sundman, 1997), general family problems (Lee, 1997), general school problems (Littrell, Malia, & Vanderwood, 1995), physical abuse (Corcoran & Franklin, 1998; Lipchik, 1993), making positive changes in life patterns, regression minimization, and preventing unnecessary hospitalization (Vaughn, et al., 1996).
Models of questions. The SFBT is unique with regard to the concrete and clearly identifiable questions asked. In fact, it is referred to as the "model of questions" (Miller, 1995). A variety of ways to ask questions have been utilized by practitioners and researchers, such as the (a) defining questions (for constructing the problem), (b) miracle question (for amplifying client goals), (c) relationship questions (for drawing out alternatives), (d) exception questions (for uncovering client successes and strengths), (e) scaling questions (for measuring client progress and, in general, helping clients render vague perceptions more concrete




and definable), (f) coping questions (for reminding the clients the strengths and resources they have), (g) future-oriented questions (for envisioning life without problems), (h) competence and/or resource questions (for validating client's feelings and providing compliments), and (i) provocative questions (for initiating self-assertive arguments).
Defining questions. The therapist may first ask, "How do you know you are depressed by your argument?" or "What gives you the idea that you are troubled by depression?" (de Shazer, 1991, 1994). The therapist may gain an understanding of the problem in the clients' framework. It also helps to get the other side of the picture that implies potential solutions. The client may answer that she knows because she contrasts the days she was not arguing with her husband and was not depressed. "So, could you talk about what did you do in those days?"
The miracle question. One of the most well-known SFBT questions is the miracle question that helps to envision the goal more concretely. The therapist might say, "Suppose one night, while you were asleep, there was a miracle and you two stopped fighting and you no longer felt depressed. How would you know? What would be different? How would your husband/wife know without your saying a word?" (de Shazer, 1988). The purpose of the miracle question is to activate a mindset and encourage clients to begin doing things they want to do in spite of the problem.
Scaling questions. Scaling questions also can serve well in several ways (Berg & de Shazer, 1993; Berg & Miller, 1992). First, to specify and identify the severity of the problem, the therapist asks the client questions like, "On a scale of 0 to 10, with 0 being how troubled you were when you called me and 10 being how




relieved you feel when you are not arguing with each other, how do you feel right now?" and to monitor progress, "You were at three last week; what would you rate yourself today?" Second, to identify intermediate goals, the therapist asks, "What will you be doing differently when you are at a 4 instead of a 3?" Third, to help a client make plans for improving his/her situation, the therapist asks, "What would you like to do to bring a 3 to a 4?" (see review in McKeel, 1996).
Exceptions questions. The therapists asks, "Can you think of a time when you did not fight with each other and were not depressed?" (de Shazer, 1985, 1988; O'Hanlon & Weiner-Davis, 1989). These kinds of exception questions serve to help the client construct the problem in a way that he/she might find solutions other than past experiences and also serve to create a self-fulfilling prophecy. De Shazer (1985) stated that the therapist need not point out exceptions in the beginning session. He suggested the therapist create an indirect link between past situations and the current complaint situation by giving compliments on a couple's past successful experiences (de Shazer, 1985).
Coping questions. The therapist asks, "With all the terrible things you've been going through, what has kept you from killing yourself?" (Miller, 1995). The way clients cope with their difficulties needs to be acknowledged and validated because suffering may be the nature of life and clients' past successes can increase their trust in themselves to keep working.
Competence and/or resource questions. By asking, "How did you do
that?" or "How did you figure that out?" the therapist supports and validates what clients did for themselves (De Jong & Miller, 1995; Simon, 1996).




Provocative questions. The therapist asks the clients, "Why didn't I see
you change?" and the clients will persuade you that they did create some changes by themselves (Berg & Reuss, 1998).
Constructivism through teamwork
Solution-Focused Brief Therapy relates itself with the idea of
constructivism. More than to say, "Realities are invented rather than discovered," de Shazer (1991) suggested, "Reality arises from consensual linguistic process" (p. 44). This approach first enhances the collaborative relationships between or among the therapist(s) and the client(s) as co-inventors of the realities. It adopts Andersen's (1991) theory of a reflecting team as one of its distinguishing features. Different people may have different ways of constructing stories about their problems and solutions. There is seldom a direct link between a problem and a solution. Therapeutic intervention is achieved by way of integrating the "polyocular view" of both therapists/teams and the clients, and produces a bonus, which is in its higher logical type (de Shazer, 1985, p. 171).
De Shazer and Molnar (1984) described sessions they conducted at the Brief Family Therapy Center as lasting for 1 hour, including the team consultation break. This hour is divided as follows: (a) a 40-minute interview with the family; (b) a 10minute consultation time with the team or a 10-minute break to reflect when working alone; and (c) 10 minutes for delivering the intervention message before ending the session.
Solution-focused brief therapy techniques
According to de Shazer (1985), there are several rules of thumb that help therapists to construct solutions.




Rules of thumb. These rules are (a) to compliment a client's past
successes, (b) to note exceptions to the rules, (c) to substitute "both/and" for an "either/or' way of thinking about the situation, (d) to bring doubts about the certainty of client's facts, and (e) to presuppose things to happen by using "when" instead of "if." During the interview, the therapists pay close attention to the client's words, listening and exploring them in ways that help build the next interview question from the client's last response (Berg & De Jong, 1996).
Process features of solution-focused brief therapy. After SFBT had been used on different occasions, de Shazer and Berg (1997) formulated the process features of the SFBT: (a) At some point in the first interview, the therapist will ask the miracle question; (b) at least once during the first interview and at subsequent ones, the client will be asked the scaling question; (c) at some point during the interview, the therapist will take a break; (d) after this intermission, the therapist will give the client some compliments that sometimes (frequently) will be followed by suggestions or homework tasks.
Identifying Pretreatment changes. Weiner-Davis et al. (1987) suggested asking questions in the first session to identify pretreatment changes for the purpose of maintenance and amplification of what has been done, such as, "Many times people notice in between the time they make the appointment for therapy and the first session that things already seem different. What have you noticed about your change?" If changes were noticed, "Do these changes relate to the reason you came for therapy? Are these the kinds of changes you would like to continue to have happen? What do you need to do to continue these changes?"




39
Getting a head start in the first session. The purpose of the first session is to construct clients' complaints, search for exceptions, and define their goals. The couple may already be able to articulate clear and specific complaints, or they may just describe the complaints in vague terms. However, clients' goals often are vague and/or mutually exclusive and/or indescribable (de Shazer, 1988). In that case, more sessions will be necessary for setting the goals.
Setting goals. According to de Shazer (1988), it is after searching for
exceptions and being able to describe the differences between exceptions and complaints that the therapist together with the client start to set goals. To form a goal, the therapist might ask, "How will you know that the problem has been solved? What further change is needed for you to feel that there is no longer a problem?"
Berg and Miller (1992) present seven qualities of well-formed goals. They are (a) saliency to the client, (b) small, (c) concrete, specific, and behavioral, (d) the presence rather than the absence of something, (e) a beginning rather an end,
(f) realistic and achievable within the context of the client's life, and (g) perceived as involving hard work. The sessions will come to an end when the goals are finally met.
Task assignments. Solution-Focused Brief Therapy uses several task
assignments to help the client. They include (a) observation tasks/formula first session task and (b) all known tasks. If clients have trouble recalling any positive events or successful experiences so that they cannot think about any exceptional details, the therapist can give them a formula first session task or a variation at the end of the first session (de Shazer, 1985). The therapist may say, "Between now and the next time we meet, we (1) want you to observe, so that next time you can




tell us (me) what happens in your marriage that you want to continue to happen." The purpose for giving the task is to build up the expectation of changes and have the clients recognize the difference between what has really happened and their perceived stability of the problem. If things are only partially done, the client will do more of the all-known tasks (de Shazer, 1988). All-known tasks imply those that have the same patterns which can be utilized in different cases that share similar problem variables.
Deconstructing. In some difficult cases the complaints are too global and so the therapist needs to help clients to deconstruct the old frame or complaints. The therapist and the clients have to build hypothetical solutions first, for example, by asking the miracle question (de Shazer, 1988; Walter & Peller, 1992) and exception questions. However, if the clients seem to choose not to use their strengths and exceptions, Lipchik (1993) suggested going to a second phase. This phase involves both clients' and therapists' determining "the right degree of balance between the clients' bad presenting situation and their good stated goals" (Lipchik, 1993, p. 26) and generating solutions that fit for a particular time and situation. In cases of marital conflict, Weiner-Davis (1992) also suggested deconstructing the illusions about intimate relationships between couples in order to generate solutions. Six illusions delineated by Weiner-Davis (1992) are (a) our problems have lasted so long, it's too late to change; (b) my husband can't communicate; (c) my wife nags all the time; (d) we've grown apart; (e) my spouse had an affair, so the marriage cannot work; (f) I don't love him (her) anymore.
Solution talk or change talk. The SFBT features its change process as linguistic. It emphasizes "change talk" (de Shazer, 1988, p. 98) in which the




therapist makes use of several critical questions to facilitate the production of the consensus "bonus." Searching for exceptions and defining how to know when the problem is solved are two of the primary techniques designed to elicit and promote change talk (de Shazer, 1988). Another suggestion is to use "when" instead of "if" to presuppose the goals to happen, e.g., to ask, "What will be different when you no longer have the problem?" (de Shazer, 1985; Gale, 1991; Lipchik, 1993; O'Hanlon, 1993).
Research outcomes of solution-focused brief therapy
The solution-focused approach has been drawing increasing research interest in the past 10 years. New research outcomes have been continually providing new findings in this area. There may not be as much empirical research as with other models in the past several decades, yet researchers have continuously ascertained the positive effects.
The average length of treatment in SFBT is about 5 sessions (de Shazer,
1991; Andreas, 1993). In a recently conducted descriptive study, Lee (1997) used the approach with children in a mental health facility. The findings indicated a 64.9% success rate with an average of 5.5 therapy sessions over an average of
3.9 months. In addition, these findings provided initial support for the applicability of the SFBT to a wide range of families from diverse backgrounds, as well as to the practice of working with whoever comes to therapy.
Sundstorm (1993) examined the effectiveness of a single session of SFBT for the treatment of depression and concluded that one session was not sufficient to treat depression. However, it did bring some positive mood changes. Eakes et al. (1997) used SFBT to work with families and clients diagnosed with




schizophrenia. A control group of clients and their families received traditional outpatient therapy, while an experimental group of clients and their families were treated with a SFBT model. All participants were pretested and then posttested with the Family Environment Scale after five therapy sessions over a 10-week period. Significant differences between the groups were found on the expressiveness, active-recreational orientation, moral-religious emphasis, and family congruence items.
The SFBT model seems to be brief and efficient according to these empirical findings. Nonetheless, McKeel (1996) pointed out that the results should be viewed with caution. The assessments may be too simple and they lack a control sample.
Several authors have suggested integrating this approach with other models or applying it in different modalities (Booker & Blymyer, 1994; Coe & Zimpfer, 1996; Kiser, Piercy, & Lipchik, 1993; Kok & Leskela, 1996; Washburn, 1994; Zimmerman, Prest, & Wetzel, 1997). Washburn (1994) attempted to integrate the solutionfocused principles into home-based family preservation services. After the description of several case studies, Washburn (1994) concluded that in response to specific therapeutic interventions, clients could frequently shift their focus from unattainable goals to effective coping strategies. Kiser et al. (1993) enhanced solution-focused therapy by more overtly incorporating emotions into its theoretical framework and therapeutic strategies. The authors reported a successful case in which depression symptoms were reduced to a minimum. Kok and Leskela (1996) integrated a medical model with the solution-focused approach in an adult inpatient psychiatric hospital setting. They found that many patients expressed




satisfaction with their treatment and reported improvement of the present complaint, but they did not provide empirical evidence.
Booker and Blymer (1994) presented five assumptions formed by SFBT
principles and reported five cases in a crisis/detox program to describe how those assumptions were supported by each case. Only "focus on the present and future" was more helpful in effecting change. A chronically alcoholic client did not support "a focus on the past." The other four, the resources assumption, client-as-expert assumption, worldview consistence assumption, and small change assumption were sustained by their work with four chronically mentally ill clients.
There have been attempts to redesign this approach into a more structured format in order to become more conducive to empirical research. One of the studies worth mentioning is the solution-focused couples therapy group done by Zimmerman et al. (1997). They conducted a project designed to build on the empirical evidence regarding the effectiveness of solution-focused couple therapy with groups. This study utilized pretest comparisons of treatment and comparisons groups, and examined pretest to posttest changes in the scores of the treatment group couples. Twenty-three treatment group couples participated in this project. The Dyadic Adjustment Scale (DAS) compared them with 13 control group couples after a 6-week, solution-focused couple therapy. The outcomes showed a positive effect as a result of treatment.
Jordan and Quinn (1994) evaluated whether there was a difference in
treatment effects in a single session between two brief family therapy approaches:
(a) the problem-focused approach, and (b) the solution-focused approach. The process of problem identification (starting with the formula first session task)




through the process of goal specification was evaluated using three self-report measures and one observational measure. The findings indicated a significant difference between the two approaches when dealing with the client's perceived problem improvement, outcome expectancy, session depth, session smoothness, and session positive effects. Additional findings indicated no significant differences between the two approaches when dealing with personal attachment, goal identification, problem improvement optimism, client's capability of improvement, and session arousal.
Finally, there was a qualitative process study found in the literature. Gale and Newfield (1992) used conversation analysis to study a one-session, solutionfocused marital therapy case conducted by Bill O'Hanlon. Conversation analysis is a method of data analysis that describes how language is used to elicit new constructions of reality. It offers descriptive categories useful to both clinicians and researchers. Through intense examination of the communications of the therapist, wife, and husband, nine categories of linguistic strategies used by O'Hanlon in his pursuit of solution-focused conversation were developed. They are (a) pursuing a response over many turns; (b) clarifying unclear references; (c) modifying his assertion until he receives the response he is seeking; (d) posing questions or possible problems and answering these questions himself; (e) ignoring the recipient's misunderstanding or rejection and continuing as if his assertion were accepted; (f) overlapping his talk with the husband or wife in order to get a turn; (g)
(re)formulation; (h) offering a candidate answer; and (i) using humor to change a topic from a problematic theme to a solution theme.




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A solution-focused brief therapy-group model for depressed clients. Based on the assumptions and techniques of the SFBT model reviewed in this section, an SFBT group for clients with depression may at least have the following features: (a) it is brief, in terms of no more than six sessions; (b) it generates solution talk by using exception questions, the miracle question, scaling questions, coping questions, etc.; (c) it trusts group members' expertise in searching for their solutions because it holds the belief that humans have inner strengths and resources; (d) it places emphases on collaborative relationships between the group leader(s) and the members, so the leader is not the only expert in the group; (e) it gives task assignments; (f) it is operated by team work; (g) it encourages members to think in a way that frees them from being stuck; and finally (h) it values co-constructing a new reality, that is, the group assists every member to construct new solutions.
In order for this model to be effective, Metcalf (1998) presented 10 directions for facilitating a SFBT group. They are (a) keeping the group nonpathological, (b) focusing on exceptions, (c) commenting immediately when competency is noticed,
(d) focusing on the client's ability to survive the problem situation, (e) seeing the client as having complaints, not symptoms, about their lives, (f) assisting the member to think in a simple way, (g) taking the client's view to lessen the resistance, (h) helping the members to see the problems externally, (i) focusing on the possible and changeable, and (j) going slowly, while encouraging members to ease into solutions gradually.
Comparative Effectiveness of Treatments for Depression
Many researchers have reported the comparative effectiveness of
psychological and pharmacological treatments, as well as combinations of the two




treatments, for depression. Most of the findings reviewed here are from three metaanalysis studies conducted by Jarrett (1995), Roth and Fonagy (1996), and Rush and Thase (1999). Evidence of effective treatment may serve to answer the question of what works better for whom. The inquiry was in four domains: active treatment vs. nonactive treatment, psychotherapy vs. nonpsychotherapy, combination treatment vs. single treatment, and psychotherapy vs. pharmacotherapy. Comparisons among different antidepressants were not included in this research.
Active Treatment vs. Nonactive Treatment
Three studies showed that active treatments had a better effect for reducing depression symptoms than nonactive treatments. In the first, Scott and Stradling (1990) revealed cognitive therapy either in an individual or group modal plus treatment as usual (in which half the sample also received pharmachotherapy from their general practitioners) reduced depression symptoms more significantly than the waiting list control. In the second, Weissman et al. (1979) showed that amitriptyline alone, interpersonal therapy alone, or amitriptyline plus interpersonal therapy reduced depression symptoms significantly more than nonscheduled treatment. In the third, Ravindran et al. (1999) reported that the specific antidepressant, sertraline, was more effective than placebo. Three studies, in contrast, showed no better evidence in active treatments than nonactive treatments. One of these studies was the NIMH Treatment of Depression Collaborative Research Program (Elkin et al., 1989). The findings showed no statistical significance between pill placebo plus clinical management, cognitive therapy, interpersonal therapy, and imipramine intervention. In the second, Beutler




47
et al. (1987) compared (a) pill placebo plus support, (b) alprazolam plus support, (c) cognitive therapy plus pill placebo, and (d) cognitive therapy plus alprazolam in treating depressed elderly outpatients. Beutler and colleagues found no statistically significant differences among the conditions using the Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1960) in the reduction of depressive symptoms at the end of treatment or at the followup. Also in the research conducted by Ravindran et al. (1999), cognitive group was no more effective than pill placebo. So far, there is no evidence showing nonactive treatments are better than active treatments or vice versa.
Psychotherapy vs. Pharmacotherapy
According to Jarrett (1995), "No study conducted to date has produced main effects showing that antidepressants used alone reduce depressive symptoms in depressed outpatients significantly more than short-term psychotherapy" (p. 442). Nonetheless, this statement was not supported by the newly conducted study. In the research comparing sertraline and cognitive group therapy for dysthymic patients (Ravindran et al., 1999), medication showed the better treatment effects. In contrast, Rush, Beck, Kovacs and Hollon (1977) reported that individual cognitive therapy (CT) was more efficient in reducing depressive symptoms and creating a higher rate of improvement or complete remission than imipramine. Dropout rates also were lower with CT than pharmocotherapy. The above treatment gains were maintained at the three-month followup. With individual cognitive therapy, mood and view of self/future changed before vegetative and motivational systems (Rush, Kovacs, Beck, Weissenburger, & Hollon, 1981). Individual cognitive therapy was more efficient in improving hopelessness and




48
general self-concept. However, no difference was found at 3-month followup (Rush, Beck, Kovacs, Weissenburger, & Hollon, 1982). Better treatment effect also was reported in a cognitive psychotherapy group than when using medication alone (Blackburn, Bishop, Glen, Whalley, & Christie, 1981). Blackburn and Bishop (1983) also found, for the general-practice group, CT alone had quicker response than drugs alone.
Nine studies found better efficiency in certain psychotherapy approaches as opposed to pharmachotherapy. Weissman et al. (1979) did not find significant differences between IPT and amitriptyline. However, DeMascio et al. (1979) differentiated that amitriptyline affected vegetative symptoms beginning at week one, and IPT affected mood, suicidal ideation, work, and interests beginning at week one and through week four. McLean and Hakstian (1979) also found no difference between behavior therapy (BT), brief dynamic psychotherapy, amitriptyline, and relaxation training in reducing depressive symptoms. In the study of Elkin et al. (1989), no significant difference was found between IPT and imipramine. Further, Hollon et al. (1992) did not find difference between CT and imipramine. Similar results were reported by McKnight, Nelson-Gray, and Barnhill (1992), though antidepressants were not specified. Cognitive therapy was compared with Nortripline in three studies, and it was found that the treatment results did not differ (Murphy, Simons, Wetzel, & Lustman, 1984; Simons, Garfield, & Murphy, 1984; Simons, Levine, Lustman, & Murphy, 1984).
There have been more and more researchers devoting their effort to studying depression generated by relationship issues and the effects of their treatments. In the findings reported by Leff et al. (2000), the dropout rates were




49
5.68% from drug treatments for 77 depressed patients and 15% for couple therapy group. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the BDI, both at the end of the treatment and after a second year off the treatment.
Combination Treatment vs. Psychotherapy or Pharmochotherapy
Combination treatment (a short-term psychotherapy plus pharmachotherapy) showed better efficiency in the following studies. First, in a study by Weissman et al. (1979), combining amitriptyline and IPT created a greater main effect than either single treatment. Combination patients were least likely to refuse treatment or to drop out. Roth, Bielski, Jones, Parker, and Osborn (1982) reported that selfcontrol therapy plus antidepressants resulted in significantly more rapid improvement as measured by the BDI, and gains were maintained for both groups at three-month followup. Blackburn et al. (1981) revealed that the patients referred from a psychiatric outpatient clinic in his study benefited more from the combination treatment than CT alone. Blackburn and Bishop (1983), using the same sample, reported two years later that combination treatment for hospital outpatient group was better than pharmochotherapy alone in altering views of self, world, and future. Combination treatment had a greater and quicker rate of improvement than either treatment alone.
Six research findings, however, showed that combination treatments did not significantly reduce depressive symptoms more than short-term psychotherapy alone in the case of outpatients with unipolar major depressive disorder (Beck, Hollon, Young, Bedrosian, & Budenz, 1985; Blackburn et al., 1981; Covi & Lipman, 1987; Hollon et al., 1992; Murphy et al., 1984; Rush & Watkins, 1981). On the




other hand, when combination therapy was compared to pharmacotherapy alone, the five studies did not find a significant difference either (Beutler et al., 1987; Hersen, Bellack, Himmelhoch, & Thase, 1984; Hollon et al., 1992; Murphy et al., 1984; Weissman et al., 1979;). As this review indicates, combination treatment does not necessarily create better efficiency in treating depressive disorder. Comparisons between Different Combinations.
When a short-term psychotherapy plus pill placebo was compared to shortterm psychotherapy plus pharmacotherapy, three studies did not find differences regarding depression symptom reduction (Hersen et al., 1984; Murphy et al., 1984; Beutler et al., 1987). It could be concluded that the client's response to medication might be psychological.
Comparisons between Different Psychotherapies.
In the study of McLean and Hakstian (1979), behavior therapy (BT) was
proved to be better than brief dynamic psychotherapy at posttreatment and the BT drop out rate was not as high as brief dynamic psychotherapy. However, at 3month followup, there were no differences between BDI treatments. Elkin et al. (1989) found no difference between IRT and CBT.
It is suggested by Prince and Jacobson (1995) that couple therapy for
depression be used clinically. This suggestion was supported by a comparative study among psychotherapies, alone or combined. In her dissertation research conducted by Trapp (1997), Integrated Couple Therapy (ICT) produced the best response percentages to treatment for depressed women across all variables it concerned. It was more effective than CBT in both depression symptoms and marital distress reduction. However, the combined group (CO) was the only group




at posttreatment whose means were indicative of both nondistress and no depression. In summary, we cannot conclude that any one treatment for depressed clients be the first choice, with or without marital problems.
Summary
Depression has a significant impact on marital relationship. Interaction between the couples in which at least one is clinically depressed tends to be featured by hostility, tension, difficulty resolving conflicts and difficulties related to depression. From a temporal and causal perspective, depression and marital discord may be both the cause and consequence of each other. In some circumstances, marital discord precipitates depression; in others, depression is the contributor to marital discord, or they are concomitants in a marital relationship.
Since there is a large body of research showing an association between
marital discord and depression, it is reasonable for us to treat both depression and marital discord in order to achieve positive change for the clients. The treatment of depression has been divided into two categories: biological treatment and psychological treatment. The division was influenced by the underlined assumptions about the etiology of depression: biological model or psychosocial model.
In regard to the endogenous/biological bases of depression, there are five major causes identified to be related to depression: (a) too few of norepinephrine or serotonin neurotransmitter molecules being synthesized and released, (b) reduced cerebrospinal fluid (CSF) concentrations of amine metabolites, (c) hypersecretion of cortisol, (d) the disturbed circadian rhythms in our body, and (e) faulty circuitry failing both in generating positive feelings and inhibiting disruptive




negative ones. The treatment alternatives are those that are based on biology, such as antidepressants.
The psychosocial model addresses the stressful events one has experienced or certain psychological traits in one's personality. This approach has a major interest in the effectiveness of an innovative model, SFBT developed by de Shazer and his colleagues in the Brief Family Therapy Center (BFTC). The assumptions can be grouped into three themes: the change process, the client, and the therapist.
The assumption about change process may include (a) change is constant;
a change in one part of the system can affect change in another part of the system,
(b) focus is on what is possible, changeable and positive, (c) the SFBT also assumes that clients' resistance does not exit. The therapist should comprehend the message derived from the resistance and make changes accordingly, (d) meaning and experience are interactionally constructed, (e) change may happen if it is presupposed to come true, and (f) exceptions suggest solutions. The assumptions about clients are (a) clients have resources and strengths to resolve complaints; (b) clients define the goal because they know what is the best for themselves; and (c) clients are the experts.
The assumptions regarding therapists are (a) curiosity for the therapist is
indispensable; (b) the therapist's job is to identify and amplify change; and (c) the therapist does not need to know a great deal about the complaint in order to solve it.
A group design that conforms to the assumptions and techniques of a SFBT model may feature the following: (a) no more than 6 sessions; (b) it is solution-




53
focused by using exception questions, the miracle question, scaling questions, and coping questions; (c) it is client oriented; (d) it places emphases on collaborative relationships between the group leader(e) and the members; (f) it gives task assignments; (g) it is operated by team work; (h) it encourages members to think in a both/and way; and (i) it values the expertise of the clients'.
Whether a SFBT group has an impact on the problem experienced by a
depressed client with marital problems more than another treatment is a question that will be answered in this study. However, in reviewing the comparative effectiveness of treatments of depression, we only know that active treatments are very likely to be better than nonactive treatments, pharmachotherapy is not likely to be better than psychotherapy, and there is no psychotherapy better than another psychotherapy, nor any combination treatments are better than other combination treatments. It indicates that the conditions for the treatments to be effective, not the kind of treatment itself, may be more worthy of our examining.
Based upon the preceding literature review, the researcher will present the following purpose and hypotheses.
The Purpose
The purpose of this study was to investigate the effectiveness of three
treatments for depressive patients with marital problems. The three treatments were studied to determine (a) whether each of them created a treatment effect, and (b) which was more likely to produce positive changes in the relief of symptoms as measured by the Chinese versions of (a) BDI (Beck, Steer, & Garbin, 1988), (b) MSI (Weiss & Cerreto, 1980), (c) DAS (Spanier, 1976), (d) CTS (Straus and Gelles, 1988), and (e) the scaling questions.




Null Hypotheses
The following null hypotheses were evaluated in this study:
1. There is no difference among the three treatment groups (AM only, SFBT
only, AM+SFBT) in eliminating depression symptoms of depressed
clients with marital problems after 8 weeks of treatment.
2. There is no difference between pretest and posttest for the three treatment
groups (AM only, SFBT only, AM+SFBT) in eliminating depression
symptoms of depressed clients with marital problems after 8 weeks of
treatment.
3. There is no difference among the three treatment groups (AM only, SFBT
only, AM+SFBT) in improving marital adjustment of depressed clients with
marital problems after 8 weeks of treatment.
4. There is no difference between pretest and posttest for the three treatment
groups (AM only, SFBT only, AM+SFBT) in improving marital adjustment
of depressed clients with marital problems after 8 weeks of treatment.
5. There is no difference among the three treatment groups (AM only, SFBT
only, AM+SFBT) in stopping the dissolution of marital status of depressed
clients with marital problems after 8 weeks of treatment.
6. There is no difference between pretest and posttest for the three treatment
groups (AM only, SFBT only, AM+SFBT) in stopping the dissolution of marital status of depressed clients with marital problems after 8 weeks
of treatment.
7. There is no difference among the three treatment groups (AM only, SFBT
only, AM+SFBT) in reducing spousal abuse of depressed clients with




marital problems after 8 weeks of treatment.
8. There is no difference between pretest and posttest for the three treatment
groups (AM only, SFBT only, AM+SFBT) in reducing spousal abuse of
depressed clients with marital problems after 8 weeks of treatment.
9. There is no difference among the three treatment groups (AM only, SFBT
only, AM+SFBT) in scaling scores of depressed clients with marital
problems after 8 weeks of treatment.
10. There is no difference between pretest and posttest for the three treatment
groups (AM only, SFBT only, AM+SFBT) in scaling scores of depressed
clients with marital problems after 8 weeks of treatment.




CHAPTER 3
METHODOLOGY
Introduction
The researcher purposed to measure degree of depression, likelihood of
divorce, relationship satisfaction, spousal abuse, self-evaluation, and the treatment effect in depressed clients with marital difficulties prior to treatments and after two months of therapy. Results for the AM group, the SFBT group, and AM+SFBT group were examined for effects of treatment on (a) decrease in depression symptoms, (b) depression recovery rate of the group, (c) increase in relationship satisfaction, (d) decrease in likelihood of divorce (e) decrease in spousal abuse, and (f) decrease in self-evaluated degree of problem.
Through this study the researcher expected to determine differences among the effects of the three treatments. When differences were found, the next step was to determine which treatment group was consistent with positive change over a two-month period. Results of this study are expected to enhance professionals' knowledge based on the facts found to contribute to the recovery and strengthening of depressed clients with marital problems. This study was conducted according to the protocol of the research (see Appendix F) and what was stated in the Introductory Questionnaire (see Appendix F). Both of these documents as well as the informed consent and the measures used in this study were granted approval by the University of Florida Institutional Review Board (see Appendix F).




Research Design
This study was a q uasi-experi mental design with a pretest and posttest. A
self-report questionnaire was used to gather information from groups of subjects in two intervals. The self-report questionnaire booklet included (a) a demographic questionnaire, (b) the Chinese version of the BIDI, 21 items; (c) the Chinese version of the DAS, 35 items; (d) the Chinese version of the MVSI, 14 items; (e) the Chinese version of the CTS, 20 items; and (f) the Chinese SFBT scaling question. In all, there were a total of 91 items that could be completed in 20 to 30 minutes. The data gathered from these six instruments were used for comparisons among the three groups to determine the differences between pretest and posttest results based on the type of the treatment received.
Participant Recruitment
Recent meta-analyses research regarding the effectiveness of
psychotherapy found an effect size ranging from .26 (Allison & Faith, 1997) to .75 (Fettes & Peters, 1992). An effect size of .60 was used for this study. Results of a power analysis using an effect size of .60, an alpha level of .05, and power of .90 with three levels of intervention determined the appropriate number of participants per cell to be 13 (Portney & Watkins, 1993). This power analysis assisted in optimizing detection of significant differences in treatment effects. Taking into consideration the possible dropout rate, 15 was previously determined to be an appropriate number of members for each treatment group. However, the participant number for this study at the entry stage was 43, and only 39 subjects were actually scored at the end of the study.




Screening of Group Members
The subjects in this study were depressed patients having marital
problems. They met the criteria in the DSM-IV (APA, 1994) regarding affective disorder, exclusively major depression disorder, dysthymic disorder, minor depressive disorder, and recurrent brief depressive disorder. Psychiatrists working with outpatients in the psychiatry department of the Military Kaohsiung General Hospital made the diagnoses. The psychiatrists referred the participants to this study. The researcher received consent (see Appendix F) from all participants. Information about the different treatments was described at intake.
Group members were screened by the psychiatrists or by the researcher under Dr. Lung's supervision. Clients who were assessed as having suicidal or homicidal intentions were excluded and offered immediate services in other programs. In addition, those who suffered from bipolar mood disorder, postpsychotic depressive disorder, depressive mood due to a general medical condition, or substance-induced mood disorder also were excluded from the group and referred to other treatments. Gender, age, status of marriage, education level, and occupation was requested from all participants for demographic purposes. Exclusionary criteria also included current participation in any other therapeutic treatment. If a participant gave a positive answer to this inquiry, he/she was not included in this study. For members of the SFBT group, if medication had been used previously, participation was allowed only if it could be determined that the antidepressant intervention (a) had been discontinued and (b) the medication was no longer having an effect. Depending on the medication, this time period can be anywhere from 2 to 4 weeks. Members also were informed that if they began to




59
use antidepressants again, they should not be in the study. Although psychiatrists referred all participants to the researcher, most of the subjects were solicited by flyers, posters, and advertisement articles in several newspapers. The treatments were covered under Taiwan's national insurance system. After the patients were referred, they received recruitment information that explained the purpose of the treatment groups.
Subjects were assigned to one of the three treatment groups according to
the following procedure. Subjects were given the chance to select one of the three groups by way of selecting a token. If their assigned condition was not agreeable to them, the researcher put them on a waiting list and allowed them to select a token a second time when it was certain that the researcher did not get enough subjects for a certain group. Consequently, the subjects were asked to pick a token until they arrived at the group they were agreeable to participate in (unless they decided to discontinue entirely). Every subject was interviewed to see if they met the criteria for depression. Intake interviews were conducted either by the researcher or the psychiatrists working at the Military Kaohsiung General Hospital. The intake interview was routine for the outpatients' first-visit. People who refused to give their consent to participate in this research project at the end of the interview were not included in the study. Further, consent for recording and disclosing treatment outcomes was obtained before the study began.
Instruments
Beck Depression Invento
The BIDI is the most extensively used self-report instrument for depression screening (Beck, Steer, & Garbin, 1988). It is a well-researched assessment tool




with substantial support for its reliability and validity. The original BDI was developed by Beck, Ward, Mendelson, Mock, and Erbaugh (1961) and was revised by Beck et al. (1979). The BDI consists of 21 items, or sets of statements, answered on a 0 to 3 scale of severity of depressive problems. Each item has four responses ranging from no complaint to severe complaint. The BDI is scored simply by totaling the highest response for all items. Total scores ranged from 0 to 63. Guidelines for interpreting scores were as follows: 0 to 9, no depression; 10 to 19, mild depression; 20 to 29, moderate depression, and 30 or higher, severe depression. There are two subscales in the BDI. Items 1 through 13 are cognitiveaffective subscale, and items 14 through 21 are somatic-performance subscale.
In a review article by Beck et al. (1988), reported factor structures varied from one to seven. When compared with the DSM-IV to obtain the content validity, the BDI investigated six of the nine criteria. The review article presented discriminant validity via 14 studies that touted a fairly strong discriminant validity. In the studies addressing construct validity, the BDI correlated as predicted with biological and somatological issues, suicidal behaviors, alcoholism, adjustment, and life crisis. In reviewing studies about concurrent validity, the BDI was compared using several tools, including the Minnesota Multiple Personality Inventory (MMPI). The mean correlation for the concurrent validity studies ranged from .60 to .76.
The internal consistency rated by Cronbach's coefficient alpha (Beck et al., 1988) for 25 studies ranged from .73 to .95. The test-retest reliability with patients ranged from .48 to .86 and with nonpsychiatric samples from .60 to .90.
The BDI is relatively state-oriented, because the answers are based on the experiences of the past week. Results may not reflect earlier depression episodes




and may change over time (Sundberg, 1992). Zheng, Wei, Lianggue, Guochen, and Chenggue (1988) concluded that the BDI could not be applied effectively in China. However, another report on usage in diverse language was positive with regard to cross-cultural application (Steer, Beck, & Garrison, 1986). Conoley (1992) cautioned that "when used clinically, care should be taken to use it as an indicator of extent of depression, not as a diagnostic tool" (p.79). Accordingly, this study did not use it as a tool for diagnosis of depression.
Huang (1982) originally modified the Chinese version of the BDI used in this study. Huang (1992) reported the internal consistency rated by Cronbach's coefficient alpha was .91. The test-retest reliability was .83. The construct validity study shows that there are six factors identified in this measure. They are low selfesteem, self-blame, lack of happy feelings, social difficulty, anxiety, and somatic complaints. It shows good construct validity and high reliability. Structured Clinical Interview
The structured clinical interview for patients provides diagnoses consistent with the DSM-III-R. The criteria for the diagnosis of major depression have not changed significantly from DSM-III to DSM-IV. The SCID-P requires graduate level interviewers who are trained to utilize it. The Chinese version of SCID-P (C-SCIDP) was used in research on illness behavior of depression in Taiwan (Lee & Wen, 1998). The language has been modified to a more colloquial manner meeting Taiwanese social context as a result of the study. Dyadic Adiustment Scale
The DAS (Spanier, 1976) has become the most frequently used self-report measure in the marriage and family counseling/therapy field (Crane, Allgood,




Larson, & Griffin, 1990; Spanier, 1985, 1988). This instrument contains 32 items that may be scored from 0 to 5. Total scores of 99 or less are classified as nondistressed. There are four dimensions reported in this scale: (a) consensus on matters of importance to marital functioning, (b) dyadic satisfaction, (c) dyadic cohesion, and (d) affectionate expression. Although the DAS can be used as a measure of the separate components of marital adjustment, Spanier (1988) reported that the DAS worked best as a global summary measure by utilizing the total score.
It has been shown that the DAS has high internal consistency and
discriminate efficiency (Spanier, 1988). When compared with other measures of global marital satisfaction, the DAS was shown to be sensitive to treatment effects (Whisman and Jacobson, 1991).
Shek et al. (1993) developed the Chinese version of the DAS. In a research study attempting to validate this version, results showed that the C-DAS scores had high internal consistency. Shek et al. (1993) and Shek (1995) showed that the C-DAS and its subscales were temporally stable (test-retest reliability coefficients with a two-week interval = .54, .85, .83, .73, .72, and .70 for the scale, total scale of the dyadic adjustment, dyadic consensus, dyadic satisfaction, dyadic cohesion, and affectional expression subscales) (Shek, 1998). The C-DAS scores correlated with measures of marital satisfaction and marital expectation. There were significant differences in C-DAS scores between the marital adjusted and maladjusted groups of respondents (Shek, 1994). Marial Status Inventory
The MSI (Weiss & Cerreto, 1980) is used to measure the likelihood that a




couple will get divorced, It measures the behavioral and cognitive styles of both members of the couple. Items are arranged along a continuum, so that a positive answer to each successive question shows increasing commitment to divorce. The items are true or false questions. Each response is keyed according to which answer indicates greater likelihood of divorce. The number of test items is 14.
The coefficient of reproducibility (CR) = .90. The minimum marginal
reproducibility (MMR) = .21. Thus, the percent improvement (PI) = .69. The PI represents the gain in accuracy from use of the total score in each relative to use of model frequencies (Weiss & Cerreto, 1980). The MVSI also has shown good discriminant validity. The researcher in this study collected 723 files of subjects in 1999 and developed the Chinese version of the MVSI. Three Chinese literature teachers revised the written language. A counseling psychologist was asked to ascertain the least difference between the English and Chinese versions in their examination of the contents of the inventory. The reported internal consistency rated by Cronbach's Coefficient Alpha was .7843. Conflict Tactics Scale
The CTS (Gelles & Sraus, 1988; Straus, 1979) is a self-report questionnaire designed to assess individual responses to situations of family conflict. Respondents are presented with a list of 19 behavioral items representing possible responses to conflicts of interests among family members. The variables measured in the 7-point instrument are reasoning, verbal aggression, and physical violence in response to a conflict with, or anger at, other member(s) (Gelles & Sraus, 1988; Straus, 1979). The CTS appears to be fairly effective in avoiding high refusal rates and/or socially desirable responses (Straus, 1979). The Chinese




version of the CTS was developed for detecting early family violence episodes (Joew, 1994). It shows high internal consistency, and results from factor analyses demonstrate good validity. The researcher also translated the same scale and collected data from 723 subjects in 1999. The Cronbach's alpha was .91. Scaling Questions
Scaling questions constitute one of the basic techniques used in SFBT
(Berg & de Shazer, 1993). Subjects were asked, "On a zero to 10 scale, where 0 is when the problem was at its worst, and 10 is when it is solved to your satisfaction, give me the number that best describes where you are now." In this study, subjects first described their goals in written language, and they were rated on the scaling question at pretest and posttest (see Appendix G and Appendix H).
Measurement Procedure
The C-BDI, C-DAS, C-CTS, C-MSI, and scaling questions were completed in the first session of the treatment. The C-SCID-P was used only for screening subjects. Repeated measures with C-BDI, C-DAS, C-CTS, C-MSI, and scaling results were completed at the end of Session 8. Following the 8th week, all participants also completed a scaling question regarding self-report satisfaction.
Treatment Conditions
Before the beginning of the research, each subject received the same
reading materials (see Appendix I) consisting of information explaining depression, its impact on family members, and how the family supports the depressive members and gives them necessary help. The different treatment conditions are described below.




Group Leader
Due to a serious lack of marriage and family therapists in Kaohsiung,
where the research was conducted, the researcher herself co-led the SFBT group with a psychiatrist, Dr. Lieu Chun-Long, on Monday evenings. The researcher also co-led with a psychiatrist, Dr. Yen Yung-Chieh in the SFBT+AM group on Wednesday evenings. There were two supervisors for the groups. Dr. Lung ForWey supervised the SFBT+AM group and Dr. Tzeng Tong-Shun supervised the SFBT group. Their roles as the supervisors of the groups were more as the consultants than the directors of the therapists. The researcher had one hour of supervision with Dr. Lung to discuss the issues found in the groups on Thursday. And she also received an hour of supervision from Dr. Tzeng, who stayed in another room listening to the group process, after each group session. The depressed participants in this study were patients of one of the four doctors mentioned above.
Before the beginning of this study, the researcher had already
accumulated SFBT group leading experience. One experience was in a familyserving center where the group members were all adult females. The second was in a medical college. The group members were senior college students whose major was psychology. The researcher felt that SFBT functioned well when it was utilized to generate some solutions for the members' problems. She also found that some members wanted to hold on to part of their problems and did not really want to solve them completely.
Antidepressant Medication Condition
The participants in this group took antidepressants prescribed by




psychiatrists on a daily basis. They were outpatients at the Military Kaohsiung General Hospital. Although the date for the clients to begin taking medication might not be the same day as they were selected to the AM group, it was not more than a week earlier or later than the assignment of treatment groups. Most of the antidepressants prescribed in this research were SSRIs. Few were TOAs. There were no MAQIs used in this study. Participants were required to come back to the clinic once a week. The compliance was inquired as one of the routine steps when the psychiatrists saw their patients. The participants could stop medication properly under their psychiatrists' advice at any time. However, only those who underwent an eight-week course of medication were investigated. The researcher included 20 participants in this group at the beginning of the study to ensure having enough subjects at the end. Only 13 of these patients actually became subjects in the research.
Solution-Focused Brief Therapy Condition
This treatment program began April 9, 2001, and ended June 11, 2001. Two treatment groups started in the same week. One group met on Monday evenings and the other on Wednesday evenings, starting at 7:00 p.m. and ending at 9:00 p.m. Neither of the groups was delayed for any session during the research period. The participants in the SFBT condition were mixed with those who took medication (AM +SFBT) and those who did not (SFBT alone). The researcher co-led the two groups with different psychiatrists. There were no other members on the treatment team.
In this study, SFBT consisted of eight sessions based on a six-week,
solution-focused couple therapy group designed by Zimmerman et al. (1997). Two




67
sessions were added to increase the time for the group to work on the therapeutic process and to equalize the treatment duration among the three groups. The SFBT group session topics included (a) becoming a group, (b) stepping back and moving on, (c) noticing the track and the pattern, (d) hunting for exceptions, (e) thinking positively, (f) doing something different, (g) keeping the change going, and (h) setting goals for the future. One presession meeting and one postsession meeting were held in addition to the eight group sessions. It took 10 weeks to complete the total participation in this research.
Each member received an SFBT group workbook (see Appendix J) in the presession meeting. The workbook was designed to facilitate group interactions and to generate the change process. There were three pages for each session. The initial page had a color picture of a lotus and words cited from the dialogue of a popular movie. These words were used as supplementary materials for discussion in the group. The second page was a worksheet. It was designed to inform group members about the assumptions and techniques of the SFBT The third page was a homework assignment, which also was based upon SFBT assumptions and techniques. In order to break the ice, the researcher included a sexually oriented joke in every worksheet, which could be easily read in a group comprised of depressed members. This also served to warm up the group and to initiate the major activity for the session.
The procedure for conducting each session began with a warm-up activity. In this treatment program, the researcher led a 20-minute meditation with the sound of waves at the beach in the background. The meditation served to prepare each client's mind and body for the group activities. A 30-minute discussion about




the homework assignment or some of the valuable changes occurring in a member's life followed the meditation. There was a 1 0-minute break before continuing the session. Then, the therapists began one of the 40-minute activities designed for each session. They started by reading the cover page of the workbook, discussing it, and going into the worksheet for that session. During the final 20 minutes, participants received instructions for the next homework assignment, and the group ended.
The group therapists were responsible for facilitating the change process in treating co-occurring marital problems and depression. Although the SFBT therapist can apply many of the questions developed for use in the group sessions, "the best questions will develop spontaneously in the group process as the therapist follows clients in their conversations, noting the exceptions that emerge and translating these into solutions" (Metcalf, 1998, p. 64). Keeping this in mind, the researcher designed the sessions to be as flexible and generative as possible. The mobilization of the underlying mechanism for change was assumed as either from treating marital problems or depression, since they interacted with each other in the client's system.
In the pretreatment meeting, members received an orientation, introduced
themselves briefly, and took a pretest. They wrote down the problems for which they wanted assistance. They also evaluated the severity of the problems using
scaling scores. After the meeting, group members were asked to write about any
presession changes that they noticed in their first homework assignment (Weiner-Davis et al., 1987). The purpose for this was to bring about selfawareness of their strengths. They also were asked to describe what would be




different in themselves, their families, and their marriages when the group was over in order to set up an attitude for focusing on solutions (see Appendix J).
The purpose for the first session was for the group members to build
collaborative relationships to help one another to reach his/her goals. The cover page and the joke (see Appendix J) were used to increase the appreciation of meeting friends in the group. First, the members discussed the group contract and signed it. Then they talked about the problems and goals in their homework assignments. In discussing group process, the therapists gave an illustration of using a more positive tone to describe one's problem and an attitude to look for what had changed before coming to the group. For the rest of the session, the psychiatrist explained how it is good for our well-being if we laugh frequently. A mood of relaxation and humor was encouraged in the group. The therapists explained what was expected to perform a "formula first session task" (de Shazer, 1985) (see Appendix J) as the homework assignment at the end of the first session.
The purpose for the second session was to build awareness of how one used to see things in their lives, especially the marital relationship. After the sharing of the "formula first session task," the researcher led the discussion about the myth of marriage (Weiner-Davis, 1992), as was written on the worksheet of Session One (see Appendix J). The therapists used members' stories to delineate how the myth could have influenced their marriages. The homework assignment, "it happened all the time," was to prepare the members to think about the patterns behind their problems.




The design of Session Three was to enhance participants' understanding regarding the patterns associated with their problems. Through discussion and feedback from other group members and the therapists, they were able to achieve awareness that their old solutions might have become new problems.
In Session Four, the goal for the group was to search for an exception that happened outside of their problematic patterns (de Shazer, 1985, 1988; O'Hanlon & Weiner-Davis, 1989). The homework was the miracle question (de Shazer, 1988). Based on what had been discovered in the previous three sessions, the goal for Session Five was to build participants' self-confidence that they could always make positive changes in their lives. After a discussion of a crying old lady who changed her sad face to a laughing face, group members were encouraged to change their negative perspectives in a positive direction (O'Hanlon & WeinerDavis, 1989; Walter & Peller, 1992). Following this session the members were more prepared to take new actions to change their lives. Therefore, the idea of synchronicity" was introduced in Session Six to support their determination for doing things differently (de Shazer, 1985; Walter & Peller, 1992). In Session Seven the researcher illustrated the idea of "forgive" versus "forget" in order for the members to let go some of their doubts and anger about their relationship problems and be more able to keep the changes going. In this stage of group development, building the habit of looking at things in an appreciative and positive way was the main task of the homework assignment.
After the group had been together for two months, the final session was to close with blessings from members toward one another. The therapists




encouraged them to write down a concrete goal for the future as their last homework assignment.
The AM+SFBT Group.
The combined treatment group required participants to join the SFBT group while taking certain antidepressant medications. The duration of the SFBT group treatment was eight weeks, and the duration of the AM treatment was at least eight weeks.
Data Analysis
To analyze the effects of alleviating symptoms of depression and marital discord for subjects receiving one of the three treatments (AM, SFBT, or AM+SFBT), measures (BDI, DAS, MSI, and CTS) were administered before and after the treatment. The questions of interest were, first, whether there were differences in scores of depression symptoms and marital discord among the three treatments, and, second, whether there were differences between scores of pretreatments and posttreatments of each group. To answer this question, a oneway ANOVA was used to test whether there were significant differences in mean scores of the preintervention measures (BDI, DAS, MSI, and CTS) among the treatment groups. It was found that the assumption of homogeneity of regression slopes was met. Then the researcher used ANCOVA to test overall differences among the three treatment groups by comparing the postintervention measures and the preintervention measure. All possible pairwise comparisons were conducted using simultaneous confidence intervals (Westfall, Tobias, Rom, Wolfinger, & Hochberg, 1999) in the two statistical methods.




Since there were four response variables (BDI, DAS, MSI, and CTS), these were compared for the three treatment groups (AM, SFBT, and AM+SFBT). There were three pairwise comparisons of the score on the BDI, three pairwise comparisons of the score on the DAS, three pairwise comparisons of the score on the MSI, and three pairwise comparisons of the score on the CTS. For this family of inferences, all 12 confidence intervals for the differences in means were computed. When applying ANCOVA, all means were covariate adjusted.
To answer the second question, whether there were differences between
scores of pretreatments and posttreatments in each group, the researcher utilized the t test to examine differences between pretest and posttest scores on the BDI, DAS, MSI, and CTS of each group. The chi-square method was used to detect differences between the scores of pretest and posttest scores for the scaling question.




CHAPTER 4
RESULTS
Descriptive Information
Demographic Information
Descriptions of the participants' demographics regarding their gender, age, marital status, education level, and occupation are presented in Table 4-1. As this table shows, only 9 (23%) subjects were men. More than half of the subjects (54%) were 30-39 years of age. Thirty-four of total participants (87%) were in their first marriage, while all of the subjects in the SFBT group were in their first marriage. Half of the subjects (51%) were college graduates. Their occupations varied.
Among them, 11 (28%) were businesspersons and 7(18%) were teachers. Table 4-1. Demographic Information of the Participants Demographics
Demographics AM SFBT AM+SFBT Total
I___ n(%) n(%
Entire sample 13(100) 13(100) 13(100) 39(100)
Gender
Male 4(31) 3(23) 2(15) 9(23)
Female 9(69) 10(77) 11(85) 30(77)
Age
20-29 1(8) 2(15) 2(15) 5(13)
30-39 6(46) 9 (69) 6(46) 21(54)
40-49 5(39) 2(15) 2(15) 9(23)




Table 4-1--continued

Demographics

50-59 60-69
Marital status
First marriage
Separated
Divorced
Second marriage
Cohabiting Education level
K-6 7-9
10-12
College
Graduate school Occupation
None
Housekeeper Military worker Governmental Officer Teacher Businessperson Industry worker Serviceperson

AM SFBT AM+SFBT Total

AM
n (%)
1(8) 0(0)
9(69) 1(8) 1(8) 1(8) 1(8)
1(8) 2(15) 4(31) 6(46) 0(0)
0(0)
4(31) 0(0) 0(0)
1(8) 5(39)
1(8) 2(15)

SFBT
0(0) 0(0)
13(100)
0(0) 0(0) 0(0) 0(0)
0(0) 0(0)
4(31) 9(69) 0(0)
0(0) 2(15) 1(8) 1(8)
4(31) 3(23) 2(15) 0(0)

AM+SFBT
2(15)
1(8)
12(92)
0(0) 1(8) 0(0) 0(0)
2(15) 2(15)
3(23) 5(39)
1(8)
1(8)
2(15) 0(0) 0(0)

Total
3(8) 1(3)
34(87)
1(3) 2(5) 1(3)
1(3)
3(8) 4(10) 11(28) 20(51) 1(3)
1(3)
8(21) 1(3)
1(3)

2(15) 7(18)
3(23) 11(28) 2(15) 5(13)
3(23) 5(13)




Descriptive Statistics
Descriptive statistics of the dependent variables of the three treatment
groups are presented in Table 4-2. Mean change between pretest and posttest is also shown in Table 4-2. There were two mean changes in the direction against treatment effects. One was the MSI mean scores of the combined group. The scores increased by 0. 96 point after two months of treatment. The other was the CTS of the antidepressants group. The scores increased by 0.23 point. The rest of the mean scores changed in favor of treatment effects. Table 4-2 Means and Standard Deviations for Pretest and Posttest in Each Group
Variables Group Pretest posttest Mean
Mean/SD Mean/SD Change
Depression (BDI)

Antidepressants SFBT group AM+SFBT

28.15 (8.53)
19.62(11.77) 33.62(16.03)

22.69(12.02)
9.31(4.94) 22.23(13.58)

Dyadic Adiustment (DAS)

Antidepressants SFBT group AM+SFBT

135.54(28.94) 125.85(29.80) 117.00(30.71) 114.46(27.98) 134.54(39.89) 122.44(37.16)

Marital Status (MSI)

Antidepressants 8.39(1.39)

4, 5.46 4, 10.61 411.39

A9.69
42.54 4112.10

8.00(3.42) A,.39




Table 4-2-continued
Variables

Group
SFBT group AM+SFBT

Pretest Mean/SD
6.23(3.19)
5.46(3.62)

posttest Mean/SD
6.15(3.16)
6.42(3.58)

Spousal Abuse (CTS)

Antidepressants SFBT group AM+SFBT

28.46(9.50) 23.62(6.40) 28.39(9.22)

28.69(8.69)
23.15(5.98) 27.85 (10.67)

Scaling Scores

Antidepressants SFBT group AM+SFBT

8.15(1.07)
7.31(2.02) 7.00(1.47)

5.39(2.84) 4.08(2.66) 5.54(2.82)

4-2.76 $3.23 11.56

Description of the Change Process
Members of the two SFBT treatment groups put down what they thought to be their goals for coming into the therapy in the pretreatment meeting. Their goals could be categorized into three domains. They were (a) reducing depression symptoms, (b) solving marital problems, and (c) a combination of both goals. The percentage of the three categories of the treatment goals in each group is shown in Table 4-3. Clients reported higher expectation for reducing depression symptoms either alone or combined with solving marital problems than simply expecting to solve the marital problems. Among the three groups, the AM+SFBT group expressed the highest expectation for treating both depression symptoms and marital problems.

Mean Change
A0.08
10.96

10.23 A0.47 A0.54




Table 4-3. The percenta-ge of reported treatment goals in pretreatment
Reducing depression symptoms Solving marital problems Both
n(%) n (%) n (%)
AM 9(69) 2(15) 2(15)
SFBT 6(46) 3(23) 2(15)
AM+SFBT 3 (23) 2 (15) 8 (61)
According to the posttest scores of BDI, there were 2 persons reduced their scores under 9 in the AM group, 7 persons in the SFBT group, and 3 persons in the AM+SFBT group. Therefore, the recovery rate in the three treatment groups were 15% for the AM group, 54% for the SFBT group, and 23% for the AM+SFBT group. Among the three groups, the SFBT group alone achieved the best recovery rate and the AM group alone the least.
The major topics for the two SFBT groups were different. In the Monday
group, the topic discussed most frequently was regarding extramarital relationship. On Wednesday evening, the theme topic was the conflicts between the wife and the mother-in-law. Members in the second group showed better therapy outcomes in that they were able to find a way to keep a safer distance from the other women at the end of the sessions. At the posttreatment meeting, members were invited to talk about the most beneficial treatment experience they had in the past eight weeks and what were the most needed things to be done by the hospital. They could go into the workbook, the therapists, the place, the time, the contract, the group activities, etc. The worksheet in session 7, it is not "for-get"; it is "for-give," and the cover page of session 7, which said, "If you really want something very




badly, set it free," earned the most positive responses. There were few suggestions for the improvement. In one group, they expressed their wish to have more directions from the therapists.
Statistical Results of the Research Hypotheses Test for Pretreatment Difference
A one-way analysis of variance (ANOVA) was used to examine whether there was a significant difference in the mean scores of the preintervention measures (BDI, DAS, MSI, and CTS) among the treatment groups. The results are presented in Table 4-4. It was found that there was no difference in pretest scores of the DAS among groups. The analysis yielded an F (2, 36) = 1.26; p = .30. There also was no difference in the CTS among groups, with F (2, 36) = 1.39; p= .26. However, the pretest scores of the BDI and MSI among the three groups were found to be significantly different before the treatment sessions. The analysis yielded an F (2, 36) = 4.15; 2=. 004 for the BDI and an F (2, 36) = 3.55; p=.04 for the MSI. Then tests for common slope were adopted to test whether the pretest scores of the DAS, CTS, BDI, and MSI among the three groups yielded parallel regression lines. The result is presented in Table 4-5. It was found that slopes of every regression line were parallel. In the BDI, test of common slopes yielded an F (2,36) = 2.32; p=. 37. In the MSI, F (2,36) = .25; p=. 778. In the DAS, F (2,36) = .26; p= .78. In the CTS, F (2,36) = 2.32; p=. 11. The researcher then examined the treatment effects among the three groups utilizing Analysis of Covariate (ANCOVA). The results are presented as they pertain to each of the hypotheses posed.




Table 4-4. Analysis of Variance for the Pre-intervention Scores in the BDI,
DAS, MSI, and CTS for Different Groups

Source df SS M___S
BDI
Group 2 1294.51 647.26
Error term 36 5619.85 156.11
DAS
Group 2 2826.51 1413.26
Error term 36 40462.46 1123.96
MSI
Group 2 59.62 29.85
Error term 36 302.62 8.4
CTS
Group 2 200.36 100.18
Error term 36 2593.39 72.04
Alpha = .05
Table 4-5. Test of Homogeneity of Common Slopes in
CTS

F p

4.15*

1.26

3.55*

1.36

the DAS. BDI. MSI. and

Source df SS MS F p
Group*DAS 2 172.68 86.34 .26 .78
Group*BDI 2 236.68 118.34 1.04 .37
Group*MSI 2 2.61 1.31 .25 .78
Group*CTS 2 123.97 61.69 2.32 .11
Alpha = .05
Test for Depression Symptoms Elimination
Ho: 1 There is no difference among the three treatment groups (AM only,
SFBT only, AM+SFBT) in eliminating depression symptoms of

I I I




depressed clients with marital problems after eight weeks of
treatment.
In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there were significant differences in treatments for depression. As presented in Table 4-6, the analysis produced significant F values for BDI scores, F (2, 36) = 3.87; p= .03. Hypothesis 1 was rejected.
Table 4-6. Analysis of Covariance for the BDI Source df SS MS F p
Pretest 1 246.22 246.22 2.16 .15
Group 2 882.83 441.42 3.87* .03
Alpha = .05
A post hoc test was used to compare the adjusted mean differences between groups. The adjusted means of the three groups were 22.48 for the AM group, 10.88 for the SFBT group, and 20.87 for the AM+SFBT group. It was found that the mean differences, I J =11.60, between the AM group and the SFBT group were significant, p = .04. However, the mean differences between the SFBT group and the AM+SFBT group, I J = -9.99, were not found to be different, p = .12. The mean differences, I J =1.61, between the AM group and the AM+SFBT group were not significant, p = 1.00, either. The adjusted means and the multiple comparisons are presented in Table 4-7 and Table 4-8.




Table 4-7. The Adiusted Means of the Three Treatment Groups
Group Adiusted Means
The AM Group 22.48
The SFBT Group 10.88
The AM+SFBT Group 20.87

Table 4-8. Multiple Comparisons of Mean Differences among Groups in the BDI

(I) Group AM SFBT
AM Alpha = .05

(J) Group
SFBT AM+SFBT AM+SFBT

Adjusted Mean Difference (I J) 11.60*
-9.99
1.61

Ho: 2 There is no difference between pretest and posttest for the three
treatment groups (AM only, SFBT only, AM+SFBT) in eliminating depression symptoms of depressed clients with marital problems
after eight weeks of treatment.
A dependent sample t-test was applied to examine the mean difference
between pretest and posttest in each treatment group. The results are shown in Table 4-9. Two of the comparisons showed significant differences in the BDI. One was in the SFBT group (p = .02; 1-tailed), and the other was in the combined group (p = .03; 1-tailed). Hypothesis 2 was partially rejected.

Std. Error
2.97 3.15 3.10

Std. Error
4.36 4.64 4.26

Sig. .04 .12
1.00




Table 4-9. T test for Pretest and Posttest in Each Group for the BDI Antidepressants group SFBT groups Antidepressants + SFBT
T R T P t p
1.63 .13 2.72* .02 2.40* .03
Alpha = .05
Test for Marital Adjustment
Ho: 3 There is no difference among the three treatment groups (AM only,
SFBT only, AM+SFBT) in improving marital adjustment
of depressed clients with marital problems after eight weeks of
treatment.
In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there was no significant difference in treatments for marital adjustment. As presented in Table 4-10, the analysis did not produce significant F values for marital adjustment, F (2, 36) = .11; p=.90. Hypothesis 3 was regarded as 'fail to reject'. Table 4-10. Analysis of Covariance for the DAS Source Df SS MS F P
Pretest 1 25370.84 25370.84 78.95 .00
Group 2 68.08 34.04 .11 .90
Alpha = .05
Ho: 4 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in improving




marital adjustment of depressed clients with marital problems
after eight weeks of treatment.
A dependent sample t-test was applied to examine the mean difference
between the pretest and posttest in each treatment group. The results are shown in Table 4-11. None of the comparisons for each group showed significant difference in the DAS. Hypothesis 4 was regarded as 'fail to reject'. Table 4-11. T test for Pretest and Posttest in Each Group by the DAS
Antidepressants group SFBT groups Antidepressants + SFBT
t P t P
1.48 .17 .55 .59 1.72 .11
Alpha = .05
Test for Marital Status Dissolution
Ho: 5 There is no difference among the three treatment groups (AM only,
SFBT only, AM+SFBT) in stopping the dissolution of marital status
of depressed clients with marital problems after eight weeks of
treatment.
In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there was no significant difference in treatments for dissolution of marital status. As presented in Table 4-12, the analysis did not produce significant F values for marital adjustment, F (2, 36) = .42; p=.66. Hypothesis 5 was regarded as 'fail to reject'.




Table 4-12. Analysis of Covariance for the MSI
Source df SS MS F
Pretest 1 4.17 2.09 47.27 .0
Group 2 4.17 2.09 .42 .6
Alpha = .05
Ho: 6 There is no difference between pretest and posttest for the three
treatment groups (AM only, SFBT only, AM+SFBT) in stopping
marital status dissolution of depressed clients with marital problems
after eight weeks of treatment.
A dependent sample t-test was applied to examine the mean difference
between the pretest and posttest in each treatment group. The results are shown in Table 4-13. None of the comparisons for each group showed a significant difference in the MSI. The researcher failed to reject hypothesis 6. Table 4-13. T test for Pretest and Posttest in Each Group by the MSI Antidepressants group SFBT groups Antidepressants + SFBT

t P t P t
.41 .69 .43 .67 -1.38 .19
Alpha = .05
Test for Spousal Abuse Reduction
Ho: 7 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in reducing spousal abuse of depressed
clients with marital problems after eight weeks of treatment.
In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results

P
0
6




of an ANCOVA procedure showed that there was no significant difference in treatments for reducing spousal abuse. As presented in Table 4-14, the analysis did not produce significant F values for the CTS, F (2, 36) = .28; p=. 76. Hypothesis 7 was regarded as 'fail to reject'. Table 4-14. Analysis of Covariance for the CTS Source df SS MS F p
Pretest 1 1697.87 1697.87 59.17 .00
Group 2 16.06 8.03 .28 .76
Alpha = .05
Ho: 8 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in reducing
spousal abuse of depressed clients with marital problems
after eight weeks of treatment.
A dependent sample t-test was applied to examine the mean difference
between the pretest and posttest in each treatment group. The results are shown in Table 4-15. None of the comparisons for each group showed a significant difference in the CTS. Hypothesis 8 was regarded as 'fail to reject'. Table 4-15. T-Test for Pretest and Posttest in Each Group for the CTS Antidepressants group SFBT groups Antidepressants + SFBT

1.75 .11 1.48 .17 .39 .70
Alpha = .05




Test for Goal Performance Scaling
Ho: 9 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in scaling scores of depressed clients with marital problems after eight weeks of treatment.
Participants expressed their goals for seeking the treatment in the
pretreatment meeting on the Scaling Question sheet (see Appendix G). They evaluated the severity of the problems that hindered them from achieving their goals on a scale of 1 to 10. Scaling scores between pretreatment and posttreatment were examined. In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there was no significant difference in treatments for scaling scores. As presented in Table 4-16, the analysis did not produce significant F values for scaling scores, F (2, 36) =
1.46; p=.25. Hypothesis 9 was regarded as 'fail to reject'. Table 4-16. Analysis of Covariance for Scaling Scores
Source Df SS MS F P
Pretest 1 52.15 52.15 8.11 .01
Group 2 18.79 9.40 1.46 .25
Alpha = .05
Ho: 10 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in scaling
scores of depressed clients with marital problems after eight weeks
of treatment.




A dependent sample t-test was applied to examine the mean difference
between the pretest and posttest in each treatment group. The results are shown in Table 4-17. All of the comparisons for each group showed significant differences in scaling scores. The mean change showed that posttreatment scaling scores in each group declined significantly when compared with the pretest scaling scores. Hypothesis 10 was rejected.
Table 4-17. T-test for Pretest and Posttest in Each Group by Scaling Scores Antidepressants group SFBT groups Antidepressants + SFBT
T t t p
3.68** .002 4.50** .000 2.33* .02
Alpha = .05
Summary of the Research Findings
When comparing the three treatments, the SFBT group resulted in greater symptom reduction than the AM group significantly. Hypothesis 1 was rejected. However, there were no significant differences between the AM group and the SFBT group, or between the AM group and the AM+SFBT group. Although mean scores of the BDI in the three groups were reduced 9 points on average after treatment, improvement for reducing depression symptoms was statistically significant in the SFBT group and the AM+SFBT group, but not in the AM group. Hypothesis 2 was partially rejected. When Ho 3, Ho 4, Ho 5, Ho 6, Ho 7, and Ho 8 were examined, none of the groups were more effective in treating marital problems than any other, including improving dyadic adjustment, maintaining marital status, or reducing spousal abuse. Results also revealed that in treating marital problems, none of the treatment groups showed statistically significant




improvement when compared with pretest scores. Scaling scores, by which participants in the three groups expressed how they evaluated the severity of their problems, all were significantly reduced, and the improvement was not different among the three groups. The researcher failed to reject hypothesis 9, while Ho 10 was rejected.
Of thelO0 null hypotheses, 7 were accepted, 2 were rejected, and 1 was partially rejected. It can be concluded that on an overall basis during an eightweek period, not all of the participants improved on most of the variables, and no treatment method showed superiority in dealing with marital problems for depressed patients. The only exception was the SFBT group alone or combining with antidepressants when treating depression. The SFBT group was significantly more effective than the AM group.




CHAPTER 5
CONCLUSIONS
The purpose of this study was to investigate the effects of three different approaches to reduce marital problems and symptoms of depression. The following areas were assessed: dyadic adjustment, depression symptoms, marital status, and spousal abuse. This chapter includes a discussion of the data in relation to the hypotheses under investigation, followed by implications, limitations, and recommendations for future study.
Discussion of the Research Results
Treatment Effect for Depression
First, the depression variable will be discussed as presented in the first two null hypotheses. Hypothesis 1 stated that there were no differences among the three treatment groups (AM only, SFBT only, AM+SFBT) in eliminating depression symptoms of depressed clients with marital problems after eight weeks of treatment. The findings indicated that there were significant differences among the three groups. The SFBT group showed better treatment effects than the AM group for depressed patients who also experienced marital problems within eight weeks. The SFBT group was also the group that reached statistically significant improvement in depression symptom reduction both alone and combined with antidepressants in the posttest. This finding resulted in the partial rejection of




Full Text

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A COMPARISON OF THREE APPROACHES TO REDUCE MARITAL PROBLEMS AND SYMPTOMS OF DEPRESSION MEI-KUEI HUANG A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2001

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I dedicate this dissertation to my parents, my sisters, my sons. Dr. Yuen Hon Keung, and Dr. Lung For-Wey, for their love, support, and confidence in me that bring a new yellow rose to this world. ii

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ACKNOWLEDGMENTS I thank my whole family for their support for my fulfilling this dream. I would like to express deep appreciation to Dr. Silvia Echevarria Doan, my doctoral research committee chairperson, for her continual support and encouragement during my doctoral study in the United States and this dissertation research. I would like to acknowledge the other members of my committee for their assistance in completing this study. Both Dr. Ellen Amatea and Dr. James Pitts gave me very valuable feedback and guidance to describe my research findings. Dr. Miller guided me through the data analysis and interpretation. This dissertation would not have been completed without their help. Special thanks are offered to Dr. Yuen Hon Keung, who accompanied me through many difficult moments when I was dealing with statistical problems. His generosity has been limitlessly provided for me both when I was in the United States and when I was back to Taiwan. He also gave me full support and confidence in my abilities to complete my doctoral study throughout the whole process. I would like to acknowledge Dr. Jim Morgan for his unconditional positive regard to an international doctoral student. His expertise in hypnosis and solution-focused model has been demonstrated in his style of doing III

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psychotherapy. I have been very fortunate for the opportunity to model from him and obtain the greatest inspiration from him. Words cannot adequately express the deep gratitude I feel for Dr. Lung For-Wey, the director, and the five treatment teams he leads in the psychiatry department at Military Kaohsiung General Hospital in Taiwan. If not for his permission to conduct this research project in his department, there would not be this dissertation. I also received great mentoring, supervision, and statistical assistance from him. Special thanks are extended to Dr. Tzen Tong-Shun, another supervisor. Dr. Yen Yung-Chien, and Dr. Lieu Chun-Long, whose talents, expertise in psychiatry, and experience in treating patients with depression provided me the strongest support for conducting medical research in this hospital. I would like to thank Dr. Wen Jung-Kuang in the Chang Gung General Hospital, Dr. Chen Cheng-Chung and Dr. Tang Tze-Chun in the Chung-Ho Memorial Hospital, and Dr. Chou Huang-Chih in the Kai-Suan Psychiatry Hospital, who gave their consent to refer depressed patients to the study and provided me a certain amount of assistance to complete this project. I would also like to acknowledge the ex-mayor of Kaohsiung City, Wu Duin-Yee, who granted special approval for my coming to the United States for my doctoral study; Mr. Chen Jung Hua, the former principal secretary of the Education Bureau of Kaohsiung City government, and Mr. Chen Shun Cheng, the chairman of the Social Education Department in the Education Bureau, who iv

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both signed the letter that guaranteed my return to Taiwan to serve the country; and Dr. Chen Yong-Shing, the chief of the IVIental Health Bureau of Kaohsiung City government, who assisted me in locating a site for this study after six months of unproductive effort. I am also deeply grateful for the recommendation letters Dr. Jim Shuh-Ren, the President of Chinese Guidance Association; Dr. Tai Chia-Nan, the President of Kaohsiung Normal University; Dr. Tsai ShungLiang, my adviser for the master's thesis; and Shieh San-Huei, the director of Kaohsiung Family Service Center, wrote for me when I was applying for doctoral study in this department. Finally, I thank all my friends in the United States and Taiwan. Special thanks for all the shared hopes, warmth, caring, and love that I treasure as the light in the dark night go to the staff members in IRB-01, my colleagues in Hoping Junior High School, my clients in several sites, the Statistic Consultation Team led by Dr. Wu Yu-Yee in Kaohsiung Normal University, and everyone whom I met on this academic journey. V

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TABLE OF CONTENTS Page ACKNOWLEDGMENTS iii ABSTRACT x CHAPTERS I INTRODUCTION 1 Depression 4 Treatment for Depression 8 Treatment of Marital Issues for Depressed Clients 10 Definitions of Terms 11 II LITERATURE REVIEW 13 Etiology of Depression 14 The Biological Model of Depression 15 The Psycho-Social Model of Depression 16 The Bio-Psycho-Social Model of Depression 18 Depression and Marital Issues 18 The Relationship between Depression and Marital Discord...19 Marital Discord Model of Depression 21 Spousal Abuse and Depression 21 Treatment for Depression within Marriage 22 Antidepressant Medications 23 The Choice for Psychotherapy 26 Cognitive-behavioral therapy 27 Interpersonal therapy 28 Choosing a therapy group modality 30 Solution-focused brief therapy 31 Comparative Effectiveness of Treatments for Depression 46 Active Treatment vs. Non-active Treatment 46 Psychotherapy vs. Pharmacotharapy 47 Combination Treatment vs. Psychotherapy or Pharmochotherapy 49 Comparisons between Different Combinations 50 Comparisons between Different Psychotherapies 50 Summary 51 vi

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Page The Purpose 53 Null Hypotheses 54 III METHODOLOGY 56 Introduction 56 Research Design 57 Participant Recruitment 57 Screening for group members 58 Instruments 59 Beck Depression Inventory 59 Structured Clinical Interview for DSM-lll-R-Patient Edition 61 Dyadic Adjustment Scale 61 Marital Status Inventory 62 Conflict Tactics Scale 63 Scaling Questions 64 Measurement Procedure 64 Treatment Conditions 64 Group Leader 65 Antidepressants Medication (AM) Group 66 Solution-Focused Brief Therapy (SFBT) Group 66 The AM+SFBT Group 71 Data Analysis 71 IV RESULTS 73 Descriptive Information 73 Demographic Information 73 Descriptive Statistics 75 Description of the Change Process 76 Statistical Results of the Research Hypotheses 78 Test for Pretreatment Difference 78 Test for Depression Symptoms Elimination 79 Test for Marital Adjustment 82 Test for Marital Status Dissolution 83 Test for Spousal Abuse Reduction 84 Test for Goal Performance Scaling 86 Summary of the Research Findings 87 V CONCLUSION 89 Discussion of Research Results 89 Treatment Effect for Depression 89 vii

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Page Treatment Effect for Marital Problems 91 Self-Evaluation of Goal Achievement 92 Implications 92 Limitations 95 Recommendations for Future Research 97 APPENDICES A CRITERIA FOR MAJOR DEPRESSIVE EPISODE 100 B CRITERIA FOR DYSTHYMIA DISORDER 101 C THE COGNITIVE MODEL OF DEPRESSION 102 D THE MARITAL/FAMILY DISCORD MODEL OF DEPRESSION. .103 E CONDITIONS AND INTRVENTIONS OF DEPRESSION 104 F DOCUMENTS FOR INSTITUTIONAL REVIEW BOARD -01 105 G THE SCALING QUESTION IN PRETREATMENT 134 H THE SCALING QUESTION IN POSTTREATMENT 135 I READING MATERIALS: DEPRESSION 136 J GROUP WORKBOOK 138 REFERENCES 166 BIOGRAPHICAL SKETCH 182 viii

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LIST OF TABLES Table Pafle 1 Demographic Information of the Participants Demographics 73 2. Means and Standard Deviations for Pretest and Posttest in Each Group 75 3. The Percentage of Reported Treatment Goals in Pretreatment 77 4. Analysis of Variance for the Pre-intervention Scores in BDI, DAS, MSI, and CTS for Different Groups 79 5. Test of Homogeneity of Common Slop in BDI and MSI in Each Group 79 6. Analysis of Covariance for BDI 80 7. The Adjusted Means of the Three Treatment Groups 81 8. Multiple Comparisons of Mean Differences among Groups in the BDI 81 9. T Test for Pretest and Posttest in Each Group for BDI 82 1 0. Analysis of Covariance for DAS 82 11. T Test for Pretest and Posttest in Each Group for DAS 83 12. Analysis of Covariance for MSI 84 13. T Test for Pretest and Posttest in Each Group for MSI 84 14. Analysis of Covariance for CTS 85 15. T Test for Pretest and Posttest in Each Group for CTS 85 16. Analysis of Covariance for Scaling Scores 86 17. T Test for Pretest and Posttest in Each Group by Scaling Scores 87 ix

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy A COMPARISON OF THREE APPROACHES TO REDUCE MARITAL PROBLEMS AND SYMPTOMS OF DEPRESSION By Mei-Kuel Huang December 2001 Chairperson: Silvia Echevarria-Doan Major Department: Counselor Education This study evaluated the effectiveness of three treatment groups provided for depressed patients in Military Kaohsiung General Hospital (MKGH) in Taiwan. The three treatment groups were (a) antidepressants medication (AM) alone, (b) Solution-Focused Brief Therapy (SFBT) group alone, and (c) the combined treatment of the two (AM+SFBT). Thirty-nine participants composed the sample. Psychiatrists working in MKGH and other psychiatry departments in several general hospitals referred these subjects to the researcher. They had diagnosed these patients as having affective disorder(s) such as minor depression, major depression, and dysthymia. The purpose of this study was to determine whether there were any differences among participants of the three treatment groups (AM only, SFBT only, AM and SFBT) in reducing depression symptoms, stopping the dissolution X

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of marital status, improvement in dyadic adjustment, or reduction of conflict tactics after eight weeks of treatment. This study was a quasi-experimental design with a pretest/posttest. A selfreport questionnaire included (a) a demographic questionnaire, (b) the Chinese version of the Beck Depression Inventory, (c) the Chinese version of the Dyadic Adjustment Scale, (d) the Chinese version of the Conflict Tactics Scale, (e) the Chinese version of the Marital Status Inventory; and (f) the SFBT scaling questions. Analyses of covariance (ANCOVA) were conducted, with posttest scores as the dependent variables and pretest scores as the covariant. Significant differences were found among the three groups in terms of reduced depression symptoms. Results of post hoc analyses indicated that the SFBT group was more effective than the AM group. However, there were no differences either between the AM group and the AM+SFBT group or between the SFBT group and the AM+SFBT group. There were no significant differences among the three groups in terms of stopping the dissolution of marital status, improving dyadic adjustment, or reducing spouse abuse. A dependent sample t-test was used to examine the differences between pretest and posttest scores in each variable for every group. Significant differences indicated treatment effects were found in the BDI of both the SFBT group and the combined group. Scaling scores of each group also decreased significantly in the posttest. xi

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CHAPTER 1 INTRODUCTION Research efforts in the treatment of depression, although extensive, still leave room for more in-depth study that can be addressed in several different ways. These include "the comparative effectiveness of psychological and pharmacological treatments, as well as combination treatments, for treating depression" (Barlow & Hoffmann, 1997, p. 102). In this study, the efficacy of three different approaches in the treatment of depression was tested with clients who were also experiencing marital difficulties. Treatment effects of both standard methods (e.g., medication) and less-tested, more innovative methods of treatment like Solution-Focused Brief Therapy (SFBT) were compared in terms of differences in outcome over an eight-week period. The three comparison groups consisted of subjects treated with antidepressant medication (AM) alone, SFBT alone, and SFBT added to AM. The intent of this study was to collect valid and reliable data to determine which types of treatments for depressed patients made a difference in their wellbeing after a two-month treatment period. The information gained from this study offers mental health providers further information on the efficacy of interventions with depressed patients who also experience marital difficulties. It may be especially useful in the treatment of those patients who reject antidepressants as a standard treatment. The effects of an alternative SFBT approach, a standard 1

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2 treatment, and a combination of SFBT with standard medication were examined in this study. A comparatively brief psychotherapy (SFBT), which involves fewer than six sessions, is said to be enough to bring positive change by therapists who use this approach (de Shazer, 1991; Lee, 1997). This treatment period is shorter than what is believed to be the natural threeto six-month course of depression (Eaton et al., 1997; Fennell, 1991; Leonard, 1997). A brief form of therapy that could benefit depressed clients in less time is worthy of study. The results of this study have implications for mental health providers, researchers, and policymakers. The results also may be helpful for purposes of treatment planning, program development, and service delivery in Taiwan. Depression, known historically as melancholia, was noted in Hippocratic writing as early as the fifth and fourth centuries B.C. (Jackson, 1986). It is now the most common psychiatric disorder seen by mental health professionals in the United States (Dobson & Jackman-Cram, 1996). Depression has been referred to as the "common cold of mental illness" (Gelman, 1987; Shorter, 1999). It is the second most disabling ailment (after heart disease) in Western countries (Marano, 1999) and the world's fourth most disabling disease according to Murray and Lopez (1997). Epidemiological studies indicate that the prevalence of depression is increasing in many countries (Cross-National Collaborative Group, 1992). The effects of depression can devastate the lives of individuals, particularly their work, family and marital relationships. There is a great need for effective treatments of serious mental health problems such as depression in order to prevent the massive personal and societal costs they present.

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3 In the United States, 26% of adult women and 12% of adult men experience a major depressive episode sometime during their lives (National Institutes of Health, 1991). The American Psychiatric Association (APA, 1994) reported that the lifetime risk for a major depressive disorder in community samples varies from 10 to 25% for adult women and 5 to 12% for adult men. According to these data, women are prone to experience depression at least twice as frequently as men. Among women in Western countries, major depression is the most common illness (Shorter, 1999). It also is one of the five psychiatric causes of the top 10 chronic diseases in women (Harvard's New School of Public Health Global Burden of Disease study, cited in Shorter, 1999). However, it is necessary to note that the ratios may be a methodological artifact because women are more willing to acknowledge difficulty and they express more help-seeking behaviors than men. Further, people express depression in many ways. Men may have different diagnosed behaviors associated with depression than those seen in women. They may turn to substance abuse or alcohol, or they may become aggressive. These are not behaviors generally associated with depression in women (Aneshensel, Rutter, & Lachenbruch, 1991). One of the epidemiological studies conducted in Taiwan from 1981 to 1986 revealed that the lifetime prevalence rate for major depression was significantly lower than that in most of the United States (Hwu, Yeh, & Chang, 1989). Nonetheless, these findings could reflect cultural differences in that people in Taiwan may not be as likely to seek professional help for psychological problems unless they are causing some kind of physical pain. In studies of

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4 persons living in Taiwan, somatization of mental problems has been found to be a normative behavior of illness (Wen, 1998). Beach et al. (1990) reported that experiencing marital distress and having interpersonal disputes were two of the six vulnerability factors found in depressed patients. In a meta-analysis, Meichenbaum (1996) concluded that there was a relationship between depression and marital distress based on the work of Beck, Rush, Shaw, and Emery (1979), Beach et al. (1990), and Hollon and Beck (1993). Meichenbaum (1996) noted that 20% of all married couples were distressed in the marriage, 50% of the patients who requested psychotherapy did so because of marital discord, 30% of marital problems involved at least one spouse who was clinically depressed, 50% of those who requested treatment for depression also evidenced marital discord, and 50% of discordant couples had a depressed spouse. Coyne, Kahn, and Gotlib (1987) also reported that 40% of the spouses were sufficiently distressed by their depressed partners to warrant treatment themselves. As more individuals seek treatment for depression, these studies indicate that there are growing concerns about the effects of depression on marital relationships as well. This research was based on the study of effective methods of intervention in the treatment of depressed patients who are experiencing marital problems. Depression Clinical descriptions of depression have been consistent despite some shifts and changes (Jackson, 1986). From observations of Hippocrates to present research findings, the most salient features of depression are described as

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5 exhibiting depressed mood and loss of interest, dysfunctional negative cognition (including pessimism and dejection), and reduced behavioral activation (including withdrawal, silence, and irritability) (Dobson & Jackman-Cram, 1996; Hammen, 1997; Stefanis & Stefanis, 1999). A depressed mood generally is viewed as normal or common after one experiences a loss. In contrast, symptoms of major clinical depression are characterized by a persistent depressed mood or loss of interest and pleasure in activities, accompanied by changes in appetite, weight, sleep, and psychomotor agitation or retardation, decreased energy, tiredness, and fatigue, feelings of worthlessness or guilt, difficulty in thinking, concentration, and decision making, and recurrent thoughts of death or suicidal thoughts, plans, or attempts (APA, 1994) (see Appendix A). According to the fourth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (APA, 1994), before making the diagnosis of major depression, it should be determined that five or more of the symptoms described above have been present during the same two-week period. The symptoms also should present a change from previous functioning. Brady (1999) reported that after administering a screening questionnaire for depression, a core subset of four symptoms should be used to effectively diagnose depression. These four symptoms, sleep disturbance, anhedonia, low self-esteem, and decreased appetite, accounted for virtually all of the symptomrelated variance in functional status and well-being of depressed patients. The associated features found in individuals with a major depressive episode frequently are presented as tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of pain

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6 (e.g., headaches or joint, abdominal, or other pain) (APA, 1994). The degree of impairment associated with depression varies. The individuals may experience some interference in social, occupational, or other important areas of functioning even in mild cases. If the impairment is severe, the person may lose social or occupational functions. In more extreme cases, the person may not be able to maintain or perform minimal self-care or self-hygiene (APA, 1994). A Taiwanese study of the illness behavior of depressed patients achieved similar findings with insomnia being the most frequently reported symptom, followed by depressed mood, low self-confidence, decreased appetite, and thoughts of death (Lee & Wen, 1998). In contrast to studies of Western subjects, depressed mood mixed with psychological and somatic terms, such as "discomfort inside heart and liver," were more likely to be expressed (Lee & Wen, 1998). Recent research efforts have investigated the effects of depression on both partners in a marital relationship. If neither partner shows evidence of depression, both experience more satisfaction in their marital life (McLeod & Eckberg, 1993). Premarital dysphoria was associated with later marital dissatisfaction (Beach & O'Leary, 1993). Heim and Snyder (1991) found that disaffection accounted for one-third of the variance of depressive symptoms in couples. Whisman and Jacobson (1989) noted that depressed wives showed greater inequality in decision making. Halloran (1998) supported this finding and delineated the interrelationship of inequity of marital power with depression and marital distress. Stress in marital interactions may change depressive symptoms and result in unfavorable reflected appraisals, low competency, low self-efficacy,

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7 and low self-esteem. Both depression and self-efficacy may negatively mediate self-concept disconfirmation with marital happiness, and therefore individuals with lower levels of self-efficacy are more depressed (Schafer, Wickrama, & Keith, 1998). In a study of the relationships between major depression and marital satisfaction, Cascardi, O'Leary, Lawrence, and Schlee (1995) reported that for both abused and nonabused women seeking treatment for marital discordant problems, there was a tendency for abused women to have higher lifetime rates of depression prior to their current marriages than those found in maritally satisfied and nonabused women. Further, Aseltine and Kessler (1993) identified the association between marital disruption and depression. Finally, Weissman (1987) stated that a spouse of either sex in a discordant marriage is 25 times more likely to be depressed than one from a nondiscordant marriage. Results from a study testing the Stress Generation Model highlighted the cyclical course of dysphoria and stress among wives in 154 newlywed couples (Bradbury, Davila, Tochluk, & Cohan, 1997). The presence of an extended family was related to depression in both men and women (Gerstel & Gallagher, 1993). It was found that depression rates increased because of interference from members in the extended family. In summary, the literature suggests that effects of depression, including dysfunctional cognition, retardation of physical activities, negative affect, somatic disturbance or pain, and impaired relationships with others, can significantly impact marital relationships (e.g., in terms of marital satisfaction or disaffection, power issues, self-appraisal, marital conflicts, and marital disruption).

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8 Treatment for Depression Interventions for solving human problems such as depression vary in accordance with how people conceptualize the problems. For decades, treatment for depression has been divided into two fundamental models (Shorter, 1999). The biological model stresses neuroscience and an emphasis on brain chemistry and medication. According to this model, symptoms of depression arise from a biologically influenced imbalance in one's neurotransmitters. The psychosocial model attributes the symptoms of depression to a psychological process, which may be activated when a person has difficulty in adjusting to social problems or personal stressors. To date, training in psychiatry favors pharmacological treatment for depression. Shorter (1999) noted that there is growing confidence in seeing psychiatry as a specialty of medicine. Antidepressant medication is the most commonly administered treatment (Fava & Rosenbaum, 1995; Williams, 1997). Although the vast majority of major depression episodes subside eventually, they tend to recur whether treated or not (Hammen, 1997). Recent findings suggest that the lowest recurrence rates require patients to continue at the dosage levels used to achieve remission (Kupfer et al., 1992). On the other hand, using psychotherapies to treat depression also has been proven to be effective (Barlow & Hoffmann, 1997; Dobson, 1989; Hammen, 1997; Rush & Thase, 1999). Among them, the most dominant orientation in depression research and theory has been the cognitive approach led by Aaron Beck and his colleagues (Beck, 1967, 1976, 1993; Beck et al., 1979; Beck & Weishaar, 1989). This is a time-limited, structured approach based on the

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9 assumption that an individual's thoughts and ideas determine his/her affect (Papolos & Papolos, 1987). Therefore, by modifying the activities of the mind, mood and emotion are modified. There are two other models that also are predominant in treating depression. First is the psychodynamic approach of therapy. This approach emphasizes the impact that past experiences have on current life, and how one's unconscious conflicts may result in difficulties as well. The second is the interpersonal approach of therapy. This approach focuses on the relationship between depression and interpersonal difficulties. It is also a time-limited, shortterm psychotherapy. The psychodynamic treatment for depression has been regarded as difficult and unhelpful (Hammen, 1997). However, two other approaches, cognitive and interpersonal therapies, are commonly reported as efficient and useful. Despite the large number of treatment approaches available utilizing these more traditional methods, this study will examine the effectiveness of a relatively new model of psychotherapy known as SFBT (Berg, 1994; de Shazer, 1986; de Shazer & Berg, 1997; de Shazer & Molner, 1984). The SFBT focuses on generating solutions instead of attempting to delineate how problems evolve from pathological cognitive functioning. In contrast to pathology-focused models, SFBT emphasizes the client's competence and resources (e.g., O'Hanlon & WeinerDavis, 1989; Walter & Peller, 1992) and tries to capitalize on these elements to improve clients' lives. The SFBT therapist listens very carefully to what the client reveals in interviews, and views the client as the expert in his/her life (e.g.. Berg & De Jong, 1996). Therefore, therapy is "a mutual search for new options and

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10 understanding" (Nichols & Schwartz, 1995, p. 452). The main reason for the present researcher to study this model is because SFBT utilizes what has been identified as the most important factors of "what works" in therapy (Lambert, 1992). These factors are personal strength, talent, beliefs, resources, and social support. According to Lambert (1992), client factors contribute to 40% of successful therapeutic outcomes. The other three factors are therapist factors, such as a therapist's empathy, acceptance, and warmth (contributing 30% of outcomes); expectancy factors such as hope and expectations for change (contributing 15% of outcomes); and, finally, model/technique factors employed by therapists (contributing 15% of outcomes). Treatment of Marital Issues for Depressed Clients Since marital issues fall into a psychosocial area, it is not surprising that there is no agreement as to what kind of antidepressant medication is better for treating marital problems. However, from a biological perspective, depression is an illness that causes the depressed person's "demoralization" (Klein & Wender, 1993). In cases where marital problems are associated with depression, medication may offer an alternative. In other words medication can improve one's physical, cognitive, affective, and behavioral state in ways that can help one deal with marital problems more effectively (Mays & Croake, 1997). Psychotherapy may be seen as a way of accelerating the healing process (Klein & Wender, 1993). Psychotherapy deals with psychosocial issues directly with the hope that depression eventually will disappear. Marital issues have been emphasized in the treatment of depression. Beach, Jouriles, and O'Leary (1985) suggested that in 50% of couples experiencing marital problems, one spouse is clinically depressed.

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11 In more than 50% of unhappy marriages, at least one spouse is depressed (O'Leary & Beach, 1990). O'Leary and Beach (1990) developed the marital discord model of depression and a cognitive-behavioral marital therapy designed to deal with both the marital issues and the problems associated with depression at the same time. Those using interpersonal psychotherapy suggest that by working through marital issues, the client will both resolve the marital dilemma and treat the depression (Swartz & Markowitz, 1995). A group form of therapy is also suggested for the treatment of depressed clients with mild or moderate depression as they deal with interpersonal difficulties (Luby, 1995). As for the SFBT approach, there are still very few empirical research findings concerning its effectiveness for both marital difficulties and depression. Definition of Terms Depression in this study is defined as described in the DSM-IV (APA, 1994): sessions of major depressive disorder, with mild and moderate specifiers (see Appendix A) and dysthymic disorder (see Appendix B). Depression with psychotic features, depression with suicide or homicide attempts, and depression with clinical bipolar recursive episodes were excluded from this study. Additionally, a score on the Beck Depression Inventory (BDI) (Beck et al., 1979) of 10 or greater was used as an inclusion criterion. Depressed clients are defined as those who were interviewed by a psychiatrist utilizing the Chinese version of the Structured Clinical Interview for DSM-lll-R-Patient Edition (Spitzer, Williams, Gibbon & First, 1990) and who were found to meet the DSM-IV criteria.

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12 Marital status is defined by scores on the Chinese version of the Marital Status Inventory (MSI) (Weiss & Cerreto, 1980). Higher scores on the inventory indicate a greater potential for disruption of the marital relationship. Dvadic adiustment is defined by the total scores on the Chinese Dyadic Adjustment Scale (C-DAS) (Shek, Lam, Tsoi, & Lam, 1993; Spanier, 1976). Higher scores on the scale represent better dyadic adjustment. Spousal abuse is defined by scores on the Chinese version of the Conflict Tactics Scale (C-DAS) (Straus and Gelles, 1988). Higher scores on the scale reflect more serious conflict between partners/spouses. Antidepressants in this study fall within three categories: tricyclic antidepressants, monoamine oxidase inhibitors, and serotonin reuptake inhibitors (SSRIs), such as Trazodone (Desyrel), Amoxapine (Asendin), and Fluoxetine (Prozac). Solution-Focused Brief Therapy is a treatment model created by Steve de Shazer and Insoo Kim Berg in 1980 (de Shazer & Berg, 1997). They suggest that when SFBT is used in a research context, it is important to include the four characteristic features of asking the miracle question, scaling questions, breaking from sessions to consult with the team, and concluding sessions with compliments and homework tasks (frequently called experiments) (de Shazer & Berg, 1997).

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CHAPTER 2 LITERATURE REVIEW Hippocrates first described depression clinically in the fourth century B.C. as melancholia (Beck, 1967). Since then, philosophers and physicians have placed great effort in the search for the cause and treatment of this disorder, and an extensive body of knowledge about depression has emerged. In this chapter a review of the epistemology regarding depression will be presented, followed by theories and research findings regarding the relationships between depression and marital issues. Several treatment models for depression will then be reviewed by describing the basic concepts, techniques, and research findings as related to each spousal relationship area. The discussion regarding treatment will first address the use of antidepressant medications, followed by a description of several types of therapeutic interventions. Greater emphasis will be placed on SFBT. Other descriptions will include Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT). The reasons SFBT was chosen as the focused treatment model will be delineated. The modality of group therapy as part of any psychotherapy approach also will be described. Comparisons of the effectiveness of various treatment modalities for depression will be discussed. Finally, a summary of the literature review will be presented, and the purpose as well as the research hypotheses will be stated in the end of this chapter. 13

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14 Etiology of Depression There is no single theory in the etiology of depression (Kendell, 1999). The occurrence of depression may result from interactions among many factors. The onset and course have been shown to relate to a variety of biological, historical, environmental, and psychosocial variables. These variables include disturbances in neurotransmitter functioning, atrophy of the left side of the prefrontal cortex (PFC), a greater flow in amygdala, a family history of depression or alcoholism, early parental loss or neglect, recent negative life events, a critical or hostile spouse, lack of a close confiding relationship, lack of adequate social support, and long-term lack of self-esteem (e.g., Hammen, 1999; Marano, 1999; Shorter, 1999). Over the past 30 years, depression gradually has ceased to be regarded as a purely psychological disorder. Instead, it has been well accepted that depression may be associated with important biological abnormalities (DeBattista & Schatzberg, 1995). Depression has been divided by practitioners into the endogenous type (i.e., no apparent external cause) and the reactive type (i.e., an identifiable external cause), or the biological versus the psychosocial model (e. g., Leonard, 1997; Kendell, 1999; Shorter, 1999). The first model stresses neuroscience, placing a greater interest in brain chemistry, brain anatomy, and medication. The origin of psychic distress is associated with the biology of the cerebral cortex. The psychosocial model focuses on the events in people's lives. In this model the origins of depression are associated with adjustment related social problems or other psychosocial issues.

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15 Biological Model of Depression Research regarding the endogenous/biological bases of depression has concentrated mainly on four major areas (DeBattista & Schatzberg, 1995; Glass, 1999; Kendell, 1999; Leonard, 1997; Papolos & Papolos, 1987; Short, 1999; Thase & Howland, 1995). Recently, research findings in neurodegenerative disorders also have contributed new theories about how depression occurs. The first area constitutes changes in biogenic amine neurotransmitters. Two neurotransmitters have most often been implicated in depression: norepinephrine and serotonin. In a depressive state there are too few norepinephrine or serotonin neurotransmitter molecules being synthesized and released, and therefore not enough molecules to ferry the impulse across the synaptic cleft (Papolos & Papolos, 1987). The neurotransmitters act on specific sites called receptors. The level of receptor sensitivity to these neurotransmitters has been reported to be a dynamic interaction with neurotransmitters. Consequently, it is not just the quantity of neurotransmitters that matters in mood disorders but also the low level of receptor sensitivity (Thase & Howland, 1995). Second, there are changes in cerebrospinal fluid (CSF) concentrations of amine metabolites (Leonard, 1997). These changes have been reported to occur in the CSF of untreated depressed patients. The rate of accumulation of these metabolites is reduced with untreated depression and can return to normal following clinical treatments. Third, hypersecretion of Cortisol that is not readily amenable to suppression has been widely advocated as a biological marker of depression (Leonard, 1997). The hypothalamic-pituitary release of Cortisol adrenal (HPA) axis controls the

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' ^ 16 release of Cortisol. Cortisol readies the body for "fight or flight." Depressed patients secrete more Cortisol than nondepressed people, and an oversupply of Cortisol is maintained in the bloodstream. The fourth factor concerns the circadian rhythms in our body. Mood disorders, including those of depressed patients, are temporal disorders in which the timing of biological rhythms is temporarily and pathologically altered. This is observed in a number of behavioral, automatic, and neuroendocrine aspects, including temperature, blood pressure, hormonal secretions, blood sugar, and many other bodily activities. Many of the circadian rhythms are molded by the daily light-dark cycle. It has been suggested that depressed persons may have conflicting body pacemakers, lack the capacity to process time and light cues, or have a disturbance in the melatonin circadian secretion pattern (Papolos & Papolos, 1987). The newest evidence presented by neuroscientists shows that a disorder in nerve circuits may cause depressive symptoms (Marano, 1999). Depression is seen as a neurodegenerative disorder. Emotions take shape in a neural circuit. Faulty circuitry fails both in generating positive feelings and Inhibiting disruptive negative ones (Marano, 1999). Psychosocial Model of Depression The psychosocial model addresses the stress events one has experienced or certain psychological traits in one's personality. A psychoanalyst may stress the pathological influence of early childhood events, which are a predisposition to later depression. For instance, an adult depressed person may have repressed childhood sexual memories and fantasies that caused the neurosis. In this case.

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17 depression arose from unconscious conflicts over long-past events. The depressive episodes may be seen as repetitions of childhood experiences with significant others (Karasu, 1990). The interpersonal model of psychotherapy postulates that depression is essentially relational in nature (Joiner, Coyne, & Blalock, 1999). Interpersonal psychotherapy holds the assumption that depression evolves from a person's current interpersonal issues (e.g., marital conflict, loss of a job, loss of a spouse) (Swartz & Markowitz, 1995). The crucial factor in depression is the social network or interpersonal relationships of the patient. It assumes that disturbed social roles and unsatisfactory interpersonal relationships can be antecedents to and/or consequences of a depressive disorder (Karasu, 1990). Cognitive behavior therapy, led by the work of Aaron T. Beck and his associates (Beck, 1967, 1976, 1993; Beck et al., 1979; Beck & Weishaar, 1989), provides a very well-structured conceptualization about both the cognitive and behavioral models of depression. In the cognitive model, an individual has disturbances of thought content and thought process. The thought content of depressed people is characterized by automatic negative thoughts (ANTs) and feelings about the self, the world, and the future (Beck's cognitive triad). In states of acute depression, ANTs fall into two thematic domains, reflecting issues of competence or lovability. These two themes reflect an unconscious level of cognition referred to as depressogenic schemata. The problematic schemata are shaped by the interaction of aptitude, temperament, and experience. An intermediate level between ANTs and depressogenic schemata is referred to as dysfunctional attitudes or beliefs. Dysfunctional attitudes may be most relevant for chronically depressed patients (Thase, 1995). Another intermediate cognition

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18 construct is attributional style. Depressed persons are prone to attribute events to Internal factors instead of external ones, global factors instead of specific causality, and enduring factors instead of transient situations. This process is illustrated in the figure of the cognitive model of depression (see Appendix C). The informationprocessing distortions in a depressed person's cognition may include an overestimation of losses or limitations, undervaluation of one's strengths and resources, and increased recall of negative experiences. Bio-Psvchosocial Model of Depression In a living system such as a human being, it is difficult to separate mind and brain. Efforts have been made to unite the biological and psychosocial models of depression. In those physical parts of the system such as the brain, we see that nerve circuits, including the prefrontal cortex, amygdala, and hypothalamus, color psychosociological events positively and negatively (Marano, 1999). Conversely, the brain reacts to stress-related events. For instance, ongoing research in animals and humans demonstrates that early stress can alter the nerve circuits that control emotion, exaggerating the neurochemical and behavioral changes that occur later in depression. In other words, it leads to chronic overactivation of the system (Marano, 1999). With respect to the causes of depression, the biopsychosocial model would address the multiple factors already described in both the biological and psychosocial models. It does not hold a single cause theory for depression. Depression and Marital Issues Marital discord plays an important role in the etiology and course of depression (Anderson, Beach, & Kaslow, 1999; Beach, 2000; Jacobson & Gurman,

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19 1995) There is a consistent association between marital distress and depression (Rounsaville, Weissman, Prusoff, & Herceg-Baron, 1979; Whisman, 2000). Related research findings in marital satisfaction, marital dissolution, and marital conflict may give a clearer idea with regard to the intertwined relationship among them. Relationship Between Depression and Marital Discord From a temporal and causal perspective, there are four hypotheses about the relationship between marital distress and depression. First, marital discord causes later depression. Marital disruption is frequently observed just prior to incidents of depression. Marital distress may be implicated directly in the development of a depressive episode, or it may interact with stressful life events and lead to a depressive episode, either by increasing the total level of stress experienced or by failing to provide an adequate buffer against the impact of the events (Hobfoll & Lieberman, 1987). Marital satisfaction was found to have a significant effect on depression in a study on women working full time (Beach et al., 1996) Women who experienced low levels of marital satisfaction showed greater depressive symptoms after one year. Results from a study conducted by Fincham, Beach, Harold, and Osborne (1997) also showed that the flow of causality from marital dissatisfaction to depression in the wife was different than the husband when compared in cases where depression occurs before marital dissatisfaction. Brown and Harris (1978) found that married women who lacked close, confiding relationships with their partners were four times more likely to develop major depression when faced with a major stressor than stressed women who had such a relationship. Marital status also had an impact on a person's well-being

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20 (Whisman, 2000). It was not just being in an unhappy marriage that puts a person at high risk. Those who divorced also had significantly higher levels of depression than those who were either continuously married or never married (Smith & Weissman, 1992). Second, depression may cause marital discord and even marital dissolution. Merikangas (1984) found the divorce rate in depressed patients two years after discharge to be nine times that of the general population. Another research finding concerned the effect of premarital dysphoria on marital discord (Beach & O'Leary, 1993). Relationship satisfaction and level of dysphoria were assessed in both spouses prior to marriage, 6 months after marriage, and 18 months after marriage. Results suggested that premarital dysphoria was associated with the subsequent deterioration of marital relationships. When studying the perception and affective responses to depressed partners, Sacco, Dumont, and Dow (1993) suggested that spouses of depressed wives had a generalized negative view of their wives. This negative view may include dispositional attributions, seeing the partner as a burden (Coyne et al., 1987), and viewing the depressed partner's behavior as putting the spouse in an unpleasant bind (BIglan, Rothlind, Hopes, & Sherman, 1989). A different relationship causal path for men was found to be quite opposite from the path for women in that the association emerged from depression to marital satisfaction. Third, marital discord may be concomitant with depression (Prince & Jacobson, 1995). Beach et al. (1985) suggested that in 50% of couples experiencing marital problems, one spouse is clinically depressed. In more than 50% of unhappy marriages, at least one spouse is depressed (O'Leary & Beach,

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21 1990). Studies indicate that depressive symptomatology and marital conflict can, and frequently do, occur simultaneously (Prince & Jacobson, 1995). Finally, it is proposed that depression and marital discord may be mutually connected. It is not just a linear relationship; both can be the cause and effect of each other (Bradbury, Davila, Tochluk, & Cohan, 1997). Unresolved marital conflicts are predictive of rapid relapse (Rounsaville & Chevron, 1982). A vicious cycle may develop in which marital difficulties expand or prolong depression, and depression makes the difficulties even worse. Prince and Jacobson (1995) suggested that couple therapy for depression be used clinically. Marital Discord Model of Depression The Marital Discord Model presented by Gotlib and Beach (1995) delineates a reciprocal relationship between marital discord and depression (see Appendix D). There are six support provisions in a marital system: (a) cohesion, (b) acceptance of emotional expression, (c) coping assistance, (d) self-esteem support, (e) spousal dependability, and (f) intimacy. Marital discord decreases these provisions and increases five hostility and stress-produced areas: (a) aggressive behavior, (b) threats of separation, (c) denigration and criticism, (d) disruption of routines, and (e) other marital stressors. These nine factors could precipitate depression, and depression leads to poorer social skills, increased avoidance of conflict issues, and increased interpersonal friction. After these occur, one is expected to experience marital discord (Gotlib & Beach, 1995). Spousal Abuse and Depression Severe marital conflict including verbal abuse and physical abuse has been associated with depression (Arias, Lyons, & Street, 1997; Fischbach &

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22 Herbert, 1997; Gilbert, Bassel, Schilling, & Friedman, 1997; Orava, McLeod, & Sharpe, 1996). In 1981 a national survey in the United States showed that 26% of respondents admitted to being involved in violence during the previous year, and up to 60% of couples reported being exposed to violence from their spouses at some time (Randall, 1990). Randall (1990) also estimated that approximately 33% of abused women suffer from depression. Tang (1998) found that psychological abuse of Chinese wives correlated with depression, anxiety, marital dissatisfaction and negative mental health measures of general psychological symptoms. When examining the relationship between a woman's history of experiencing violence and current psychological health, Orava et al. (1996) found that 21 abused subjects had lower beliefs in self-efficacy, were more depressed, and had lower self-esteem than 18 comparison subjects. Depression, stress-related syndromes, chemical dependency, and suicide are consequences observed in the context of violence in women's lives (Fischbach, & Herbert, 1997). Whether depressed women are prone to be abused by their husbands or partners is a topic still to be investigated. However, correlations among depression, spousal abuse and longlasting psychological impacts such as the depressed symptomology in children who have witnessed parental abuse (Cummings, DeArth-Pendley, Schudlich, & Smith, 2000; Jaffe & Sudermann, 1995; O'Leary & Cano, 2000) suggest that treatment for depressed clients who suffer from severe marital problems is critical. Treatment for Depression Within Marriaoe Differences in the treatment of depression can be attributed to the choices made by practitioners based on assumptions about depression. Until the mid-70s, conceptualizations of depression emphasized disturbance in mood and was not as

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23 an illness (Fennel!, 1991). To date, the biological model of depression has gained roots in this area after many scientific researchers achieved substantial new findings from biochemical technology. Shorter (1999) reported that the average psychiatrist in America now prescribes psychoactive drugs. The general outpatient psychiatry practice in Taiwan provides only 10 minutes per session. However, a great many Taiwanese psychotherapists prefer a nonpathological point of view with this disorder. Different forms of psychotherapy may be their preferred forms of treatment. In line with the bio-psychosocial model of depression, it has been possible to establish a rationale for the use of combined physical and psychotherapeutic methods for the treatment of depression over the past two decades. Mays and Croake (1997) presented a multimodel intervention diagram to illustrate the continuum of biological dimensions involved in the conditions of depressive mood disorder, and they suggested interventions (see Appendix E). Mays and Croake suggested that more severe cases of depression are best treated with a psychotropic approach, while psychosocially based problems should be treated using psychotherapy. This review of treatment modalities will begin with antidepressant medications, move to a review of psychotherapy approaches, and end with combined methods. Antidepressant Medications The biological theory upon which somatic therapy is based proposes that depression may be seen as caused by (a) lower levels of specific neurochemicals, such as a deficiency of norepinephrine or serotonin, (b) reduced rates in cerebrospinal fluid concentrations of amine metabolites, (c) hyperactivity of the endocrine system and the hormone Cortisol, (d) disregulated circadian rhythms, in

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24 which the timing of biological rhythms is temporarily altered (Papolos & Papolos, 1987), and (e) atrophy and retraction of nerve dendrites (Marano, 1999). In this regard, somatic therapy will serve to adjust or regulate those factors that cause the physical dysfunction. Somatic therapy for treating depression may include medication and electroconvulsive therapy. This review addressed only the first type of therapy because electroconvulsive therapy is only used for severely depressed patients with strong suicidal intention, and these symptoms are beyond the scope of this study. Three types of antidepressants have been described by many to be used in the treatment of depression (e.g., Bech, 1999). Initially, monoamine oxidase inhibitors were used to counteract the depletion of certain neurotransmitters, particularly norepinephrine (NE), serotonin (5HT), and dopamine (DA). Monoamine oxidase inhibitors were proved to be effective. However, the side effects and the risk of toxicity create problems for some users (Mays & Croake, 1997). The second type drugs often used are tricyclic antidepressants. Used for 40 years, these were until recently the first drugs that a psychiatrist would try with a newly diagnosed depressed patient. Tricyclic antidepressants are thought to work by preventing the secreting cells from reabsorbing such neurotransmitters as serotonin and norepinephrine (Klein, & Wender, 1993). They also have side effects (Mays & Croake, 1997), including cardiotoxicity, anticholinergic effects, such as blurred vision, dry mouth, constipation, sexual dysfunction, and urinary retention; antiadrenergic effects, such as dizziness, certain forms of tachycardia, and

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25 effects on blood pressure; and antihistaminic effects, such as weight gain, sedation, and a lowering of blood pressure. Tricyclic antidepressants can also interact with other drugs" ( p. 106). A new generation of antidepressants began to appear in the 1980s. Among them were Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine). These drugs are generally called selective serotonin reuptake inhibitors, or SSRIs. These medicines produced both therapeutic benefits and better side-effect profiles. They have been found to be effective in treatment of depression, especially in the less severe and nonpsychotic varieties (e.g.. May & Croake, 1997). However, this group of antidepressents can cause a "serotonin syndrome" referred to by Lejoyeau, Ades, and Rouillon (1994). This condition includes diarrhea, confusion, restlessness, hypomania, myoclonus, and sometimes lack of coordination and fever (cited in May & Croake, 1997). Klein and Wender (1993) made the following additional comments about antidepressants: 1. Antidepressant drugs have little effect on normal mood. When taken by normal persons, they do not produce a "high." 2. Antidepressant drugs are "normalizing" in contrast to other drugs affecting moods. They do not have the antidepression effect on normal persons. 3. The three major antidepressants mentioned above have not been abused because they do not produce high, elated feelings in normal people. 4. Most patients with depression can stop taking the medication and remain without symptoms and do not become dependent on the

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26 drug. 5. When antidepressants are effective, patients usually continue to Derive benefit from them and do not become tolerant to their effects. 6. The major effects of antidepressants rarely begin before two to four weeks of treatment. Maximum benefits may take two to three months to develop. 7. Side effects often begin when medication is started, before the positive effects begin. 8. No laboratory or chemical tests can predict which drug will be best for a particular individual. 9. At times, various drugs must be combined. 10. The most effective dose for each individual varies considerably. 1 1 Antidepressants do not affect the natural history — the life span — of the depressive illness. They just control the symptoms while nature is taking its healing course. There is no theory that presents a direct relationship between treatment with antidepressants and their effect on marital discord. However, they are assumed to relieve an individual's suffering by treating the underlying disease and offering improvement in physical condition as well as increasing courage, morale, and cognitive functioning to deal with his/her marital problems. The Choice for Psychotherapy According to Rush and Thase (1999), psychotherapy may have several objectives, including improved adherence to medication (or other disease

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27 management procedures), symptom reduction or attainment of symptom remission, reduction of disability (e.g., improved marital/occupational/social functioning), prevention of relapses/recurrences, or prevention or delay of the onset/progression of depression conditions. The choice of psychotherapy is to attain any of these goals. Many studies indicate that patients with severe depression are less likely to respond to psychological therapies (e.g.. Roth & Fonagy, 1996). In this section, three models of psychotherapy will be reviewed. They are CBT, IPT, and SFBT. The group therapy modality also will be reviewed. Cognitive-behavioral therapy Cognitive-behavioral psychotherapy has been considered as one of the standard treatments for unipolar depression. The basic assumptions for conducting CBT are: (a) a depressive individual's affect and behavior are largely determined by the way in which he/she views the world; (b) cognition (thoughts, beliefs, fantasies, images, etc.) can be self-monitored by the client and communicated; and (c) the modification of cognition will lead to changes in affect and behavior (Beck et al., 1979). Cognitive-behavioral psychotherapy is designed to be a time-limited, short-term treatment. General guidelines suggest 15 to 25 (50-minute) sessions at weekly intervals. A series of highly specific learning experiences is incorporated into treatment. Each session consists of a review of reactions to and results of the previous session, planning, specific tasks, and assignment of homework. Before each session the client is assigned reading matehals on coping with depression and is asked to report on a weekly activity schedule (Karasu, 1990). Sacco and Beck (1995) recommended that clients' level of depression be

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assessed throughout treatment to monitor their progress. There are six frequently used techniques in CBT (Williams, 1997), including thought catching, task assignment, reality testing, cognitive rehearsal, and alternative therapy, dealing with underlying fears and assumptions. Specifically, Beck et al. (1979) described five steps for CBT: Step 1: Identify and monitor dysfunctional automatic thoughts. Step 2: Recognize the connections among thoughts, emotions, and behaviors. Step 3: Evaluate the reasonableness of the automatic thoughts. Step 4: Substitute more reasonable interpretations for the dysfunctional automatic inference. Step 5: Identify and alter dysfunctional silent assumptions. It suggested that all clients receive a thorough diagnostic evaluation and case formulation prior to the beginning of treatment (Beck et al., 1979). The research findings show that nonbipolar, nonpsychotic depressed clients are well suited for CBT (Sacco & Beck, 1995). In cases of severe marital discord, O'Leary and Beach (1990) suggested that marital therapy be used in addition to CBT. Interpersonal psychotherapy Interpersonal psychotherapy, developed by Klerman, Weissman, Rounsaville, and Chevron (1984), attempts to alleviate depressive symptoms and to improve interpersonal functioning by improving such as clarifying, refocusing, and renegotiating the interpersonal context associated with the onset of depression (Joiner,1994; Joiner & Metalsky, 1995; Weissman & Klerman, 1990). Interpersonal psychotherapy also is a time-limited, short-term therapy,

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29 generally taking 12 to 16 weeks. There are three phases in IPT. In the first phase, the therapist works on assessment and forming treatment goals in the first few sessions. During this phase the patient is taught the "sick role," learning about depression as an illness and receiving encouragement to continue regular activities, but without the expectation of performing normally. The second phase identifies and targets interpersonal problems thought to contribute to the depression. The third phase focuses on consolidating what has been learned and anticipating the use of the skills during future times of difficulty. According to the assumptions of IPT (Klerman, Weissman, Rounsaville, & Chevron, 1984), there are four areas associated with the onset of depression. They are (a) abnormal grief reaction (i.e. severe or unusual bereavement in response to the death of a significant other), (b) interpersonal role disputes, (i.e. unreasonable, nonreciprocal expectations of or by significant others, especially disagreements about sex roles), (c) difficult role transition or unsuccessful attempts to cope with developmental landmarks or significant life events (positive or negative), such as getting married or divorced, having a child, graduating from school, changing careers, or retiring, and (d) interpersonal deficits, including inadequate social skills and a history of social isolation or transient relationships. Information is gathered concerning the patient's functioning in the four areas. Interpersonal psychotherapy helps the persons identify their problems and their consequences and acquire new behaviors. In general, IPT therapists make use of nondirective exploration, encourage expression of affect, teach the patient more effective methods of interpersonal communication, and they attempt to alter depressive behaviors through insight, providing information, and role playing

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30 (Hammen, 1997). Choosing a therapy group modality According to Lewin (1970), groups have an impact on individual behaviors, feelings, and perceptions. Decisions made in a group setting have more power than do individual decisions (Bloom, 1992). Yalom (1995) further identified 11 therapeutic forces that characterize the healing process in group therapy. Several of them seem to particularly "fit" the treatment of depression patients. The 11 therapeutic factors include (a) instillation of hope, (b) universality, (c) altruism, (d) development of socializing techniques, (e) catharsis, (f) interpersonal learning, (g) corrective recapitulation if the primary family group, (h) imitative behavior, (i) imparting of information, (j) group cohesiveness, and (k) existential factors. These factors will be discussed in terms of their therapeutic force in dealing with the fundamental psychological characteristics of depression: pessimism, hopelessness, withdrawal, and lack of motivation (Luby, 1995). Hope vs. hopelessness. Hopelessness is one of the salient emotions for depressive patients. It may riot be easy to deal with in an individual therapy session. The clients often claim that no one is able to understand their feelings of hopelessness unless this person is another victim. In a group setting, a member has an opportunity to witness the progress of peers. Confidence that the depressive state is changeable is built, and hope is instilled. Members are encouraged if they see the group help others with problems similar to theirs. Universality vs. shame and ouilt. The awareness of the similarity of other's emotional experiences, a sense of universality that "we are in the same boat," also may have a liberating impact on depressed patients (Luby, 1995). Group members

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31 can free themselves from the feelings of shame and guilt once they have heard other members talk about their similar difficulties. Altruism vs. self-disrespect. Depressed patients often suffer from doubts about their self-worth and competence. It is through the encouragement of the group leader that members discover their ability to contribute positively to others' lives and reestablish their self-esteem. Experiential acceptance vs. victimization. When sharing each other's life stories, members learn to accept an imperfect life by experiential factors in group. They understand that life is at times unfair and unjust. They can recognize that there is no escape from some of life's pain. Consequently, they may learn that they must take ultimate responsibility for the way they live their lives no matter how much guidance and support they get from others (Yalom, 1995). Solution-focused brief therapy Among the contemporary family and marital therapy approaches, the SFBT developed by Steve de Shazer (1982, 1985) and his colleagues has been well known for being brief, simple, and efficient. It is brief because it focuses on the solutions, not the problems, and it assumes solutions can be achieved without knowing the causes. Based on SFBT, the discharge planning may begin on admission and avoid going into a lengthy termination process (Vaughn, Young, Webster, & Thomas, 1996; Walter & Peller, 1992). Another reason for its being brief is that it is "atheoretical and client-determined" (Berg & Miller, 1992, p. 8). It implies the client's view Is accepted according to what has been said. The therapist will not try to convince the client to accept a certain theory or to deal with resistance/denial when the client disagrees. Further, SFBT therapists state that

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32 only small steps are necessary, through which the clients will find it easy to accomplish any change (de Shazer et al., 1986). The solution-focused model strives for economy in the therapeutic means to achieve desired therapeutic ends (Berg & Miller, 1992). It also assumes the client has the strengths to solve his/her own problems. Utilizing these existing inner resources makes the therapy more efficient (Weiner-Davis, 1992; Weiner-Davis, de Shazer, & Gingerich, 1987). Basic assumptions. Most of the assumptions underlying an SFBT approach are clearly stated in the book, In Search of Solutions (O'Hanlon & Weiner-Davis, 1989). There are several more articulated by others (e.g., Walter & Peller, 1992; Water & Petter, 1996). These assumptions can be grouped into three themes: the change process, the client, and the therapist. I. The change process 1 Change is constant. 2. A change in one part of the system can affect change in another part of the system. 3. A small change is all that is necessary. 4. Rapid changes or resolutions of problems are possible. 5. There is no one "right" way to view things; different views may be just as valid and may fit the facts equally well. 6. Focus is on what is possible and changeable, rather than what is impossible and intractable. 7. Focus on the positive (Walter and Peller, 1992). 8. There is no such thing as "resistance" (de Shazer, 1985). Cooperation is inevitable as patients understand their thinking and act accordingly (Walter

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33 & Peller, 1992). 9. Meaning and experience are interactionally constructed. "We inform meaning onto our experience and it is our experience at the same time (Walter & Peller, 1992, p. 24). 10. Meaning is the response (Walter & Peller, 1992). 11. Change may happen if it is presupposed to come true (Gale, 1991). 12. Exceptions suggest solutions (Walter & Peller, 1992). II. The client 1 Clients have resources and strengths to resolve complaints. 2. Clients define the goal because they know what is best for themselves. 3. Clients are the experts (see also Walter & Peller, 1992). III. The therapist 1 Curiosity for the therapist is indispensable (Berg & Miller, 1992). 2. The therapist's job is to identify and amplify change. 3. The therapist does not need to know a great deal about the complaint in order to solve it. A nonpathologic model of treating depression. This model holds that depression is not an illness but a "stuck" situation for the client (Walter & Peller, 1992; WeinerDavis, 1992; Weiner-Davis et al., 1987). A solution-focused approach does not focus on the cause of depressive symptoms since the solution does not necessarily relate to its cause. Depression, rather than being seen as a disease, is viewed by this approach as the way that one person tries to solve his/her personal problems, such as marital discord (e.g., de Shazer, 1991). The goal of treatment for depression, instead of alleviating the depressive symptoms, is to stabilize the

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34 crisis (Vaughn, et al., 1996). The SFBT approach focuses on how to enable a depressed person to recognize the inefficiency and uselessness of the old solutions and help the person try on new methods to solve the problenns (Adams, Piercy, & Jurich, 1991). Extensive application. The SFBT was initially developed as an outpatient treatment. More recently, it has been adopted to deal with a variety of problems. It has been used in residential and inpatient hospital settings (Kok & Leskela, 1996; Vaughn, et al., 1996). Research shows that the SFBT demonstrated positive effects in controlling anger (Schorr, 1977), dealing with chronic mental illness (Booker & BIymyer, 1994; Eakes, Walsh, Markowski, Cain, & Swanson, 1997; Kok & Leskela, 1996), treating substance abuse (Berg & Reuss, 1998), managing issues regarding social work (Sundman, 1997), general family problems (Lee, 1997), general school problems (Littrell, Malia, & Vanderwood, 1995), physical abuse (Corcoran & Franklin, 1998; Lipchik, 1993), making positive changes in life patterns, regression minimization, and preventing unnecessary hospitalization (Vaughn, et al., 1996). Models of questions. The SFBT is unique with regard to the concrete and clearly identifiable questions asked. In fact, it is referred to as the "model of questions" (Miller, 1995). A variety of ways to ask questions have been utilized by practitioners and researchers, such as the (a) defining questions (for constructing the problem), (b) miracle question (for amplifying client goals), (c) relationship questions (for drawing out alternatives), (d) exception questions (for uncovering client successes and strengths), (e) scaling questions (for measuring client progress and, in general, helping clients render vague perceptions more concrete

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35 and definable), (f) coping questions (for reminding the clients the strengths and resources they have), (g) future-oriented questions (for envisioning life without problems), (h) competence and/or resource questions (for validating client's feelings and providing compliments), and (i) provocative questions (for initiating self-assertive arguments). Defining questions. The therapist may first ask, "How do you know you are depressed by your argument?" or "What gives you the idea that you are troubled by depression?" (de Shazer, 1991, 1994). The therapist may gain an understanding of the problem in the clients' framework. It also helps to get the other side of the picture that implies potential solutions. The client may answer that she knows because she contrasts the days she was not arguing with her husband and was not depressed. "So, could you talk about what did you do in those days?" The miracle question. One of the most well-known SFBT questions is the miracle question that helps to envision the goal more concretely. The therapist might say, "Suppose one night, while you were asleep, there was a miracle and you two stopped fighting and you no longer felt depressed. How would you know? What would be different? How would your husband/wife know without your saying a word?" (de Shazer, 1988). The purpose of the miracle question is to activate a mindset and encourage clients to begin doing things they want to do in spite of the problem. Scaling questions. Scaling questions also can serve well in several ways (Berg & de Shazer, 1993; Berg & Miller, 1992/ First, to specify and identify the severity of the problem, the therapist asks the client questions like, "On a scale of 0 to 10, with 0 being how troubled you were when you called me and 10 being how

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36 relieved you feel when you are not arguing with each other, how do you feel right now?" and to monitor progress, "You were at three last week; what would you rate yourself today?" Second, to identify intermediate goals, the therapist asks, "What will you be doing differently when you are at a 4 instead of a 3?" Third, to help a client make plans for improving his/her situation, the therapist asks, "What would you like to do to bring a 3 to a 4?" (see review in McKeel, 1996). Exceptions questions. The therapists asks, "Can you think of a time when you did not fight with each other and were not depressed?" (de Shazer, 1985, 1988; O'Hanlon & Weiner-Davis, 1989). These kinds of exception questions serve to help the client construct the problem in a way that he/she might find solutions other than past experiences and also serve to create a self-fulfilling prophecy. De Shazer (1985) stated that the therapist need not point out exceptions in the beginning session. He suggested the therapist create an indirect link between past situations and the current complaint situation by giving compliments on a couple's past successful experiences (de Shazer, 1985). Coping questions. The therapist asks, "With all the terrible things you've been going through, what has kept you from killing yourself?" (Miller, 1995). The way clients cope with their difficulties needs to be acknowledged and validated because suffering may be the nature of life and clients' past successes can increase their trust in themselves to keep working. Competence and/or resource questions. By asking, "How did you do that?" or "How did you figure that out?" the therapist supports and validates what clients did for themselves (De Jong & Miller, 1995; Simon, 1996).

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37 Provocative questions. The therapist asks the clients, "Why didn't I see you change?" and the clients will persuade you that they did create some changes by themselves (Berg & Reuss, 1998). Constructivism through teamwork Solution-Focused Brief Therapy relates itself with the idea of constructivism. More than to say, "Realities are invented rather than discovered," de Shazer (1991) suggested, "Reality arises from consensual linguistic process" (p. 44). This approach first enhances the collaborative relationships between or among the therapist(s) and the client(s) as co-inventors of the realities. It adopts Andersen's (1991) theory of a reflecting team as one of its distinguishing features. Different people may have different ways of constructing stories about their problems and solutions. There is seldom a direct link between a problem and a solution. Therapeutic intervention is achieved by way of integrating the "polyocular view" of both therapists/teams and the clients, and produces a bonus, which is in its higher logical type (de Shazer, 1985, p. 171). De Shazer and Molnar (1984) described sessions they conducted at the Brief Family Therapy Center as lasting for 1 hour, including the team consultation break. This hour is divided as follows: (a) a 40-minute interview with the family; (b) a 10minute consultation time with the team or a 10-minute break to reflect when working alone; and (c) 10 minutes for delivering the intervention message before ending the session. Solution-focused brief therapy techniques According to de Shazer (1985), there are several rules of thumb that help therapists to construct solutions.

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38 Rules of thumb. These rules are (a) to compliment a client's past successes, (b) to note exceptions to the rules, (c) to substitute "both/and" for an "either/or" way of thinking about the situation, (d) to bring doubts about the certainty of client's facts, and (e) to presuppose things to happen by using "when" instead of "if." During the interview, the therapists pay close attention to the client's words, listening and exploring them in ways that help build the next interview question from the client's last response (Berg & De Jong, 1996). Process features of solution-focused brief therapy. After SFBT had been used on different occasions, de Shazer and Berg (1997) formulated the process features of the SFBT: (a) At some point in the first interview, the therapist will ask the miracle question; (b) at least once during the first interview and at subsequent ones, the client will be asked the scaling question; (c) at some point during the interview, the therapist will take a break; (d) after this intermission, the therapist will give the client some compliments that sometimes (frequently) will be followed by suggestions or homework tasks. Identifying pretreatment changes. Weiner-Davis et al. (1987) suggested asking questions in the first session to identify pretreatment changes for the purpose of maintenance and amplification of what has been done, such as, "Many times people notice in between the time they make the appointment for therapy and the first session that things already seem different. What have you noticed about your change?" If changes were noticed, "Do these changes relate to the reason you came for therapy? Are these the kinds of changes you would like to continue to have happen? What do you need to do to continue these changes?"

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39 Getting a head start in the first session. The purpose of the first session is to construct clients' complaints, search for exceptions, and define their goals. The couple may already be able to articulate clear and specific complaints, or they may just describe the complaints in vague terms. However, clients' goals often are vague and/or mutually exclusive and/or indescribable (de Shazer, 1988). In that case, more sessions will be necessary for setting the goals. Setting goals. According to de Shazer (1988), it is after searching for exceptions and being able to describe the differences between exceptions and complaints that the therapist together with the client start to set goals. To form a goal, the therapist might ask, "How will you know that the problem has been solved? What further change is needed for you to feel that there is no longer a problem?" Berg and Miller (1992) present seven gualities of well-formed goals. They are (a) saliency to the client, (b) small, (c) concrete, specific, and behavioral, (d) the presence rather than the absence of something, (e) a beginning rather an end, (f) realistic and achievable within the context of the client's life, and (g) perceived as involving hard work. The sessions will come to an end when the goals are finally met. Task assignments. Solution-Focused Brief Therapy uses several task assignments to help the client. They include (a) observation tasks/formula first session task and (b) all known tasks. If clients have trouble recalling any positive events or successful experiences so that they cannot think about any exceptional details, the therapist can give them a formula first session task or a variation at the end of the first session (de Shazer, 1985). The therapist may say, "Between now and the next time we meet, we (I) want you to observe, so that next time you can

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40 tell us (me) what happens in your marriage that you want to continue to happen." The purpose for giving the task is to build up the expectation of changes and have the clients recognize the difference between what has really happened and their perceived stability of the problem. If things are only partially done, the client will do more of the all-known tasks (de Shazer, 1988). All-known tasks imply those that have the same patterns which can be utilized in different cases that share similar problem variables. Deconstructing. In some difficult cases the complaints are too global and so the therapist needs to help clients to deconstruct the old frame or complaints. The therapist and the clients have to build hypothetical solutions first, for example, by asking the miracle question (de Shazer, 1988; Walter & Peller, 1992) and exception questions. However, if the clients seem to choose not to use their strengths and exceptions, Lipchik (1993) suggested going to a second phase. This phase involves both clients' and therapists' determining "the right degree of balance between the clients' bad presenting situation and their gfood stated goals" (Lipchik, 1993, p. 26) and generating solutions that fit for a particular time and situation. In cases of marital conflict, Weiner-Davis (1992) also suggested deconstructing the illusions about intimate relationships between couples in order to generate solutions. Six illusions delineated by Weiner-Davis (1992) are (a) our problems have lasted so long, it's too late to change; (b) my husband can't communicate; (c) my wife nags all the time; (d) we've grown apart; (e) my spouse had an affair, so the marriage cannot work; (f) I don't love him (her) anymore. Solution talk or change talk The SFBT features its change process as linguistic. It emphasizes "change talk" (de Shazer, 1988, p. 98) in which the

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41 therapist makes use of several critical questions to facilitate the production of the consensus "bonus." Searching for exceptions and defining how to know when the problem is solved are two of the primary techniques designed to elicit and promote change talk (de Shazer, 1988). Another suggestion is to use "when" instead of "if to presuppose the goals to happen, e.g., to ask, "What will be different when you no longer have the problem?" (de Shazer, 1985; Gale, 1991; Lipchik, 1993; O'Hanlon, 1993). Research outcomes of solution-focused brief therapy The solution-focused approach has been drawing increasing research interest in the past 10 years. New research outcomes have been continually providing new findings in this area. There may not be as much empirical research as with other models in the past several decades, yet researchers have continuously ascertained the positive effects. The average length of treatment in SFBT is about 5 sessions (de Shazer, 1991; Andreas, 1993). In a recently conducted descriptive study, Lee (1997) used the approach with children in a mental health facility. The findings indicated a 64.9% success rate with an average of 5.5 therapy sessions over an average of 3.9 months. In addition, these findings provided initial support for the applicability of the SFBT to a wide range of families from diverse backgrounds, as well as to the practice of working with whoever comes to therapy. Sundstorm (1993) examined the effectiveness of a single session of SFBT for the treatment of depression and concluded that one session was not sufficient to treat depression. However, it did bring some positive mood changes. Eakes et al. (1997) used SFBT to work with families and clients diagnosed with

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42 schizophrenia. A control group of clients and their families received traditional outpatient therapy, while an experimental group of clients and their families were treated with a SFBT model. All participants were pretested and then posttested with the Family Environment Scale after five therapy sessions over a 10-week period. Significant differences between the groups were found on the expressiveness, active-recreational orientation, moral-religious emphasis, and family congruence items. The SFBT model seems to be brief and efficient according to these empirical findings. Nonetheless, McKeel (1996) pointed out that the results should be viewed with caution. The assessments may be too simple and they lack a control sample. Several authors have suggested integrating this approach with other models or applying it in different modalities (Booker & BIymyer, 1994; Coe & Zimpfer, 1996; Kiser, Piercy, & Lipchik, 1993; Kok & Leskela, 1996; Washburn, 1994; Zimmerman, Prest, & Wetzel, 1997). Washburn (1994) attempted to integrate the solutionfocused principles into home-based family preservation services. After the description of several case studies, Washburn (1994) concluded that in response to specific therapeutic interventions, clients could frequently shift their focus from unattainable goals to effective coping strategies. Kiser et al. (1993) enhanced solution-focused therapy by more overtly incorporating emotions into its theoretical framework and therapeutic strategies. The authors reported a successful case in which depression symptoms were reduced to a minimum. Kok and Leskela (1996) integrated a medical model with the solution-focused approach in an adult inpatient psychiatric hospital setting. They found that many patients expressed

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43 satisfaction with their treatment and reported improvement of the present complaint, but they did not provide empirical evidence. Booker and BIymer (1994) presented five assumptions formed by SFBT principles and reported five cases in a crisis/detox program to describe how those assumptions were supported by each case. Only "focus on the present and future was more helpful in effecting change. A chronically alcoholic client did not support "a focus on the past." The other four, the resources assumption, client-as-expert assumption, worldview consistence assumption, and small change assumption were sustained by their work with four chronically mentally ill clients. There have been attempts to redesign this approach into a more structured format in order to become more conducive to empirical research. One of the studies worth mentioning is the solution-focused couples therapy group done by Zimmerman et al. (1997). They conducted a project designed to build on the empirical evidence regarding the effectiveness of solution-focused couple therapy with groups. This study utilized pretest comparisons of treatment and comparisons groups, and examined pretest to posttest changes in the scores of the treatment group couples. Twenty-three treatment group couples participated in this project. The Dyadic Adjustment Scale (DAS) compared them with 13 control group couples after a 6-week, solution-focused couple therapy. The outcomes showed a positive effect as a result of treatment. Jordan and Quinn (1994) evaluated whether there was a difference in treatment effects in a single session between two brief family therapy approaches: (a) the problem-focused approach, and (b) the solution-focused approach. The process of problem identification (starting with the formula first session task)

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44 through the process of goal specification was evaluated using three self-report measures and one observational measure. The findings indicated a significant difference between the two approaches when dealing with the client's perceived problem improvement, outcome expectancy, session depth, session smoothness, and session positive effects. Additional findings indicated no significant differences between the two approaches when dealing with personal attachment, goal identification, problem improvement optimism, client's capability of improvement, and session arousal. Finally, there was a qualitative process study found in the literature. Gale and Newfield (1992) used conversation analysis to study a one-session, solutionfocused marital therapy case conducted by Bill O'Hanlon. Conversation analysis is a method of data analysis that describes how language is used to elicit new constructions of reality. It offers descriptive categories useful to both clinicians and researchers. Through intense examination of the communications of the therapist, wife, and husband, nine categories of linguistic strategies used by O'Hanlon in his pursuit of solution-focused conversation were developed. They are (a) pursuing a response over many turns; (b) clarifying unclear references; (c) modifying his assertion until he receives the response he is seeking; (d) posing questions or possible problems and answering these questions himself; (e) ignoring the recipient's misunderstanding or rejection and continuing as if his assertion were accepted; (f) overlapping his talk with the husband or wife in order to get a turn; (g) (re)formulation; (h) offering a candidate answer; and (i) using humor to change a topic from a problematic theme to a solution theme.

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45 A solution-focused brief therapy group model for depressed clients. Based on the assumptions and techniques of the SFBT model reviewed in this section, an SFBT group for clients with depression may at least have the following features: (a) it is brief, in terms of no more than six sessions; (b) it generates solution talk by using exception questions, the miracle question, scaling questions, coping questions, etc.; (c) it trusts group members' expertise in searching for their solutions because it holds the belief that humans have inner strengths and resources; (d) it places emphases on collaborative relationships between the group leader(s) and the members, so the leader is not the only expert in the group; (e) it gives task assignments; (f) it is operated by team work; (g) it encourages members to think in a way that frees them from being stuck; and finally (h) it values co-constructing a new reality, that is, the group assists every member to construct new solutions. In order for this model to be effective, Metcalf (1998) presented 10 directions for facilitating a SFBT group. They are (a) keeping the group nonpathological, (b) focusing on exceptions, (c) commenting immediately when competency is noticed, (d) focusing on the client's ability to survive the problem situation, (e) seeing the client as having complaints, not symptoms, about their lives, (f) assisting the member to think in a simple way, (g) taking the client's view to lessen the resistance, (h) helping the members to see the problems externally, (i) focusing on the possible and changeable, and (j) going slowly, while encouraging members to ease into solutions gradually. Comparative Effectiveness of Treatments for Depression Many researchers have reported the comparative effectiveness of psychological and pharmacological treatments, as well as combinations of the two

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46 treatments, for depression. Most of the findings reviewed here are from three metaanalysis studies conducted by Jarrett (1995), Roth and Fonagy (1996), and Rush and Thase (1999). Evidence of effective treatment may serve to answer the question of what works better for whom. The inquiry was in four domains: active treatment vs. nonactive treatment, psychotherapy vs. nonpsychotherapy, combination treatment vs. single treatment, and psychotherapy vs. pharmacotherapy. Comparisons among different antidepressants were not included in this research. Active Treatment vs. Nonactive Treatment Three studies showed that active treatments had a better effect for reducing depression symptoms than nonactive treatments. In the first, Scott and Stradling (1990) revealed cognitive therapy either in an individual or group modal plus treatment as usual (in which half the sample also received pharmachotherapy from their general practitioners) reduced depression symptoms more significantly than the waiting list control. In the second, Weissman et al. (1979) showed that amitriptyline alone, interpersonal therapy alone, or amitriptyline plus interpersonal therapy reduced depression symptoms significantly more than nonscheduled treatment. In the third, Ravindran et al. (1999) reported that the specific antidepressant, sertraline, was more effective than placebo. Three studies, in contrast, showed no better evidence in active treatments than nonactive treatments. One of these studies was the NIMH Treatment of Depression Collaborative Research Program (Elkin et al., 1989). The findings showed no statistical significance between pill placebo plus clinical management, cognitive therapy, interpersonal therapy, and imipramine intervention. In the second, Beutler

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47 et al. (1987) compared (a) pill placebo plus support, (b) alprazolam plus support, (c) cognitive therapy plus pill placebo, and (d) cognitive therapy plus alprazolam in treating depressed elderly outpatients. Beutler and colleagues found no statistically significant differences among the conditions using the Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1960) in the reduction of depressive symptoms at the end of treatment or at the followup. Also in the research conducted by Ravindran et al. (1999), cognitive group was no more effective than pill placebo. So far, there is no evidence showing nonactive treatments are better than active treatments or vice versa. Psychotherapy vs. Pharmacotherapy According to Jarrett (1995), "No study conducted to date has produced main effects showing that antidepressants used alone reduce depressive symptoms in depressed outpatients significantly more than short-term psychotherapy" (p. 442). Nonetheless, this statement was not supported by the newly conducted study. In the research comparing sertraline and cognitive group therapy for dysthymic patients (Ravindran et al., 1999), medication showed the better treatment effects. In contrast. Rush, Beck, Kovacs and Hollon (1977) reported that individual cognitive therapy (CT) was more efficient in reducing depressive symptoms and creating a higher rate of improvement or complete remission than imipramine. Dropout rates also were lower with CT than pharmocotherapy. The above treatment gains were maintained at the three-month followup. With individual cognitive therapy, mood and view of self/future changed before vegetative and motivational systems (Rush, Kovacs, Beck, Weissenburger, & Hollon, 1981). Individual cognitive therapy was more efficient in improving hopelessness and

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48 general self-concept. However, no difference was found at 3-month followup (Rush, Beck, Kovacs, Weissenburger, & Hollon, 1982). Better treatment effect also was reported In a cognitive psychotherapy group than when using medication alone (Blackburn, Bishop, Glen, Whalley, & Christie, 1981). Blackburn and Bishop (1983) also found, for the general-practice group, CT alone had quicker response than drugs alone. Nine studies found better efficiency in certain psychotherapy approaches as opposed to pharmachotherapy. Weissman et al. (1979) did not find significant differences between IPT and amitriptyline. However, DeMascio et al. (1979) differentiated that amitriptyline affected vegetative symptoms beginning at week one, and IPT affected mood, suicidal ideation, work, and interests beginning at week one and through week four. McLean and Hakstian (1979) also found no difference between behavior therapy (BT), brief dynamic psychotherapy, amitriptyline, and relaxation training in reducing depressive symptoms. In the study of Elkin et al. (1989), no significant difference was found between IPT and imipramine. Further, Hollon et al. (1992) did not find difference between CT and imipramine. Similar results were reported by McKnight, Nelson-Gray, and Barnhill (1992), though antidepressants were not specified. Cognitive therapy was compared with Nortripline in three studies, and it was found that the treatment results did not differ (Murphy, Simons, Wetzel, & Lustman, 1984; Simons, Garfield, & Murphy, 1984; Simons, Levine, Lustman, & Murphy, 1984). There have been more and more researchers devoting their effort to studying depression generated by relationship issues and the effects of their treatments. In the findings reported by Leff et al. (2000), the dropout rates were

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49 5.68% from drug treatments for 77 depressed patients and 15% for couple therapy group. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the BDI, both at the end of the treatment and after a second year off the treatment. Combination Treatment vs. Psvchotheraov or Pharmochotherapv Combination treatment (a short-term psychotherapy plus pharmachotherapy) showed better efficiency in the following studies. First, in a study by Weissman et al. (1979), combining amitriptyline and IPT created a greater main effect than either single treatment. Combination patients were least likely to refuse treatment or to drop out. Roth, Bielski, Jones, Parker, and Osborn (1982) reported that selfcontrol therapy plus antidepressants resulted in significantly more rapid improvement as measured by the BDI, and gains were maintained for both groups at three-month followup. Blackburn et al. (1981) revealed that the patients referred from a psychiatric outpatient clinic in his study benefited more from the combination treatment than CT alone. Blackburn and Bishop (1983), using the same sample, reported two years later that combination treatment for hospital outpatient group was better than pharmochotherapy alone in altering views of self, world, and future. Combination treatment had a greater and quicker rate of improvement than either treatment alone. Six research findings, however, showed that combination treatments did not significantly reduce depressive symptoms more than short-term psychotherapy alone in the case of outpatients with unipolar major depressive disorder (Beck Hollon, Young, Bedrosian, & Budenz, 1985; Blackburn et al., 1981; Covi & Lipman, 1987; Hollon et al., 1992; Murphy et al., 1984; Rush & Watkins, 1981). On the

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50 other hand, when combination therapy was compared to pharmacotherapy alone, the five studies did not find a significant difference either (Beutler et a!., 1987; Hersen, Bellack, Himmelhoch, & Thase, 1984; Hollon et al., 1992; IVIurphy et al., 1984; Weissman et al., 1979;). As this review indicates, combination treatment does not necessarily create better efficiency in treating depressive disorder. Comoarisons between Different Combinations When a short-term psychotherapy plus pill placebo was compared to shortterm psychotherapy plus pharmacotherapy, three studies did not find differences regarding depression symptom reduction (Hersen et al., 1984; Murphy et al., 1984; Beutler et al., 1987). It could be concluded that the client's response to medication might be psychological. Comparisons between Different Psvchotherapies In the study of McLean and Hakstian (1979), behavior therapy (BT) was proved to be better than brief dynamic psychotherapy at posttreatment and the BT drop out rate was not as high as brief dynamic psychotherapy. However, at 3month followup, there were no differences between BDI treatments. Elkin et al. (1989) found no difference between IRT and CBT. It is suggested by Prince and Jacobson (1995) that couple therapy for depression be used clinically. This suggestion was supported by a comparative study among psychotherapies, alone or combined. In her dissertation research conducted by Trapp (1997), Integrated Couple Therapy (ICT) produced the best response percentages to treatment for depressed women across all variables it concerned. It was more effective than CBT in both depression symptoms and marital distress reduction. However, the combined group (CO) was the only group

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51 at posttreatment whose means were indicative of both nondistress and no depression. In summary, we cannot conclude that any one treatment for depressed clients be the first choice, with or without marital problems. Summary Depression has a significant impact on marital relationship. Interaction between the couples in which at least one is clinically depressed tends to be featured by hostility, tension, difficulty resolving conflicts and difficulties related to depression. From a temporal and causal perspective, depression and marital discord may be both the cause and consequence of each other. In some circumstances, marital discord precipitates depression; in others, depression is the contributor to marital discord, or they are concomitants in a marital relationship. Since there is a large body of research showing an association between marital discord and depression, it is reasonable for us to treat both depression and marital discord in order to achieve positive change for the clients. The treatment of depression has been divided into two categories: biological treatment and psychological treatment. The division was influenced by the underlined assumptions about the etiology of depression: biological model or psychosocial model. In regard to the endogenous/biological bases of depression, there are five major causes identified to be related to depression: (a) too few of norepinephrine or serotonin neurotransmitter molecules being synthesized and released, (b) reduced cerebrospinal fluid (CSF) concentrations of amine metabolites, (c) hypersecretion of Cortisol, (d) the disturbed circadian rhythms in our body, and (e) faulty circuitry failing both in generating positive feelings and inhibiting disruptive

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52 negative ones. The treatment alternatives are those that are based on biology, such as antidepressants. The psychosocial model addresses the stressful events one has experienced or certain psychological traits in one's personality. This approach has a major interest in the effectiveness of an innovative model, SFBT developed by de Shazer and his colleagues in the Brief Family Therapy Center (BFTC). The assumptions can be grouped into three themes: the change process, the client, and the therapist. The assumption about change process may include (a) change is constant; a change in one part of the system can affect change in another part of the system, (b) focus is on what is possible, changeable and positive, (c) the SFBT also assumes that clients' resistance does not exit. The therapist should comprehend the message derived from the resistance and make changes accordingly, (d) meaning and experience are interactionally constructed, (e) change may happen if it is presupposed to come true, and (f) exceptions suggest solutions. The assumptions about clients are (a) clients have resources and strengths to resolve complaints; (b) clients define the goal because they know what is the best for themselves; and (c) clients are the experts. The assumptions regarding therapists are (a) curiosity for the therapist is indispensable; (b) the therapist's job is to identify and amplify change; and (c) the therapist does not need to know a great deal about the complaint in order to solve it. A group design that conforms to the assumptions and techniques of a SFBT model may feature the following: (a) no more than 6 sessions; (b) it is solution-

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53 focused by using exception questions, the miracle question, scaling questions, and coping questions; (c) it is client oriented; (d) it places emphases on collaborative relationships between the group leader(e) and the members; (f) it gives task assignments; (g) it is operated by team work; (h) it encourages members to think in a both/and way; and (i) it values the expertise of the clients'. Whether a SFBT group has an impact on the problem experienced by a depressed client with marital problems more than another treatment is a question that will be answered in this study. However, in reviewing the comparative effectiveness of treatments of depression, we only know that active treatments are very likely to be better than nonactive treatments, pharmachotherapy is not likely to be better than psychotherapy, and there is no psychotherapy better than another psychotherapy, nor any combination treatments are better than other combination treatments. It indicates that the conditions for the treatments to be effective, not the kind of treatment itself, may be more worthy of our examining. Based upon the preceding literature review, the researcher will present the following purpose and hypotheses. The Purpose The purpose of this study was to investigate the effectiveness of three treatments for depressive patients with marital problems. The three treatments were studied to determine (a) whether each of them created a treatment effect, and (b) which was more likely to produce positive changes in the relief of symptoms as measured by the Chinese versions of (a) BDI (Beck, Steer, & Garbin, 1988), (b) MSI (Weiss & Cerreto, 1980), (c) DAS (Spanier, 1976), (d) CTS (Straus and Gelles, 1988), and (e) the scaling questions.

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54 Null Hypotheses The following null hypotheses were evaluated in this study: 1 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in eliminating depression symptoms of depressed clients with marital problems after 8 weeks of treatment. 2. There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in eliminating depression symptoms of depressed clients with marital problems after 8 weeks of treatment. 3. There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in improving marital adjustment of depressed clients with marital problems after 8 weeks of treatment. 4. There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in improving marital adjustment of depressed clients with marital problems after 8 weeks of treatment. 5. There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in stopping the dissolution of marital status of depressed clients with marital problems after 8 weeks of treatment. 6. There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in stopping the dissolution of marital status of depressed clients with marital problems after 8 weeks of treatment. 7. There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in reducing spousal abuse of depressed clients with

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marital problems after 8 weeks of treatment. 8. There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in reducing spousal abuse of depressed clients with marital problems after 8 weeks of treatment. 9. There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in scaling scores of depressed clients with marital problems after 8 weeks of treatment. 10. There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in scaling scores of depressed clients with marital problems after 8 weeks of treatment.

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CHAPTER 3 METHODOLOGY Introduction The researcher purposed to measure degree of depression, likelihood of divorce, relationship satisfaction, spousal abuse, self-evaluation, and the treatment effect in depressed clients with marital difficulties prior to treatments and after two months of therapy. Results for the AM group, the SFBT group, and AM+SFBT group were examined for effects of treatment on (a) decrease in depression symptoms, (b) depression recovery rate of the group, (c) increase in relationship satisfaction, (d) decrease in likelihood of divorce (e) decrease in spousal abuse, and (f) decrease in self-evaluated degree of problem. Through this study the researcher expected to determine differences among the effects of the three treatments. When differences were found, the next step was to determine which treatment group was consistent with positive change over a two-month period. Results of this study are expected to enhance professionals' knowledge based on the facts found to contribute to the recovery and strengthening of depressed clients with marital problems. This study was conducted according to the protocol of the research (see Appendix F) and what was stated in the Introductory Questionnaire (see Appendix F). Both of these documents as well as the informed consent and the measures used in this study were granted approval by the University of Florida Institutional Review Board (see Appendix F). 56

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57 Research Design This study was a quasi-experimental design with a pretest and posttest. A self-report questionnaire was used to gather information from groups of subjects in two intervals. The self-report questionnaire booklet included (a) a demographic questionnaire, (b) the Chinese version of the BDI, 21 items; (c) the Chinese version of the DAS, 35 items; (d) the Chinese version of the MSI, 14 items; (e) the Chinese version of the CTS, 20 items; and (f) the Chinese SFBT scaling question. In all, there were a total of 91 items that could be completed in 20 to 30 minutes. The data gathered from these six instruments were used for comparisons among the three groups to determine the differences between pretest and posttest results based on the type of the treatment received. Participant Recruitment Recent meta-analyses research regarding the effectiveness of psychotherapy found an effect size ranging from .26 (Allison & Faith, 1997) to .75 (Fettes & Peters, 1992). An effect size of .60 was used for this study. Results of a power analysis using an effect size of .60, an alpha level of .05, and power of .90 with three levels of Intervention determined the appropriate number of participants per cell to be 13 (Portney & Watkins, 1993). This power analysis assisted in optimizing detection of significant differences In treatment effects. Taking into consideration the possible dropout rate, 15 was previously determined to be an appropriate number of members for each treatment group. However, the participant number for this study at the entry stage was 43, and only 39 subjects were actually scored at the end of the study.

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58 Screening of Group Members The subjects in this study were depressed patients having marital problems. They met the criteria in the DSM-IV (APA, 1994) regarding affective disorder, exclusively major depression disorder, dysthymic disorder, minor depressive disorder, and recurrent brief depressive disorder. Psychiatrists working with outpatients in the psychiatry department of the Military Kaohsiung General Hospital made the diagnoses. The psychiatrists referred the participants to this study. The researcher received consent (see Appendix F) from all participants. Information about the different treatments was described at intake. Group members were screened by the psychiatrists or by the researcher under Dr. Lung's supervision. Clients who were assessed as having suicidal or homicidal intentions were excluded and offered immediate services in other programs. In addition, those who suffered from bipolar mood disorder, postpsychotic depressive disorder, depressive mood due to a general medical condition, or substance-induced mood disorder also were excluded from the group and referred to other treatments. Gender, age, status of marriage, education level, and occupation was requested from all participants for demographic purposes. Exclusionary criteria also included current participation in any other therapeutic treatment. If a participant gave a positive answer to this inquiry, he/she was not included in this study. For members of the SFBT group, if medication had been used previously, participation was allowed only if it could be determined that the antidepressant intervention (a) had been discontinued and (b) the medication was no longer having an effect. Depending on the medication, this time period can be anywhere from 2 to 4 weeks. Members also were informed that if they began to

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59 use antidepressants again, they should not be in the study. Although psychiatrists referred all participants to the researcher, most of the subjects were solicited by flyers, posters, and advertisement articles in several newspapers. The treatments were covered under Taiwan's national insurance system. After the patients were referred, they received recruitment information that explained the purpose of the treatment groups. Subjects were assigned to one of the three treatment groups according to the following procedure. Subjects were given the chance to select one of the three groups by way of selecting a token. If their assigned condition was not agreeable to them, the researcher put them on a waiting list and allowed them to select a token a second time when it was certain that the researcher did not get enough subjects for a certain group. Consequently, the subjects were asked to pick a token until they arrived at the group they were agreeable to participate in (unless they decided to discontinue entirely). Every subject was interviewed to see if they met the criteria for depression. Intake interviews were conducted either by the researcher or the psychiatrists working at the Military Kaohsiung General Hospital. The intake interview was routine for the outpatients' first-visit. People who refused to give their consent to participate in this research project at the end of the interview were not included in the study. Further, consent for recording and disclosing treatment outcomes was obtained before the study began. Instruments Beck Depression Inventory The BDI is the most extensively used self-report instrument for depression screening (Beck, Steer, & Garbin, 1988). It is a well-researched assessment tool

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60 with substantial support for its reliability and validity. The original BDI was developed by Beck, Ward, Mendelson, Mock, and Erbaugh (1961) and was revised by Beck et al. (1979). The BDI consists of 21 items, or sets of statements, answered on a 0 to 3 scale of severity of depressive problems. Each item has four responses ranging from no complaint to severe complaint. The BDI is scored simply by totaling the highest response for all items. Total scores ranged from 0 to 63. Guidelines for interpreting scores were as follows: 0 to 9, no depression; 10 to 19, mild depression; 20 to 29, moderate depression, and 30 or higher, severe depression. There are two subscales in the BDI. Items 1 through 13 are cognitiveaffective subscale, and items 14 through 21 are somatic-performance subscale. In a review article by Beck et al. (1988), reported factor structures varied from one to seven. When compared with the DSM-IV to obtain the content validity, the BDI investigated six of the nine criteria. The review article presented discriminant validity via 14 studies that touted a fairly strong discriminant validity. In the studies addressing construct validity, the BDI correlated as predicted with biological and somatological issues, suicidal behaviors, alcoholism, adjustment, and life crisis. In reviewing studies about concurrent validity, the BDI was compared using several tools, including the Minnesota Multiple Personality Inventory (MMPI). The mean correlation for the concurrent validity studies ranged from .60 to .76. The internal consistency rated by Cronbach's coefficient alpha (Beck et al., 1988) for 25 studies ranged from .73 to .95. The test-retest reliability with patients ranged from .48 to .86 and with nonpsychiatric samples from .60 to .90. The BDI is relatively state-oriented, because the answers are based on the experiences of the past week. Results may not reflect earlier depression episodes

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61 and may change over time (Sundberg, 1992). Zheng, Wei, Lianggue, Guochen, and Chenggue (1988) concluded that the BDI could not be applied effectively in China. However, another report on usage in diverse language was positive with regard to cross-cultural application (Steer, Beck, & Garrison, 1986). Conoley (1992) cautioned that "when used clinically, care should be taken to use it as an indicator of extent of depression, not as a diagnostic tool" (p.79). Accordingly, this study did not use it as a tool for diagnosis of depression. Huang (1982) originally modified the Chinese version of the BDI used in this study. Huang (1992) reported the internal consistency rated by Cronbach's coefficient alpha was .91 The test-retest reliability was .83. The construct validity study shows that there are six factors identified in this measure. They are low selfesteem, self-blame, lack of happy feelings, social difficulty, anxiety, and somatic complaints. It shows good construct validity and high reliability. Structured Clinical Interview The structured clinical interview for patients provides diagnoses consistent with the DSM-III-R. The criteria for the diagnosis of major depression have not changed significantly from DSM-III to DSM-IV. The SCID-P requires graduate level interviewers who are trained to utilize it. The Chinese version of SCID-P (C-SCIDP) was used in research on illness behavior of depression in Taiwan (Lee & Wen, 1998). The language has been modified to a more colloquial manner meeting Taiwanese social context as a result of the study. Dyadic Adjustment Scale The DAS (Spanier, 1976) has become the most frequently used self-report measure in the marriage and family counseling/therapy field (Crane, Allgood,

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62 Larson, & Griffin, 1990; Spanier, 1985, 1988). This instrument contains 32 items that may be scored from 0 to 5. Total scores of 99 or less are classified as nondistressed. There are four dimensions reported in this scale: (a) consensus on matters of importance to marital functioning, (b) dyadic satisfaction, (c) dyadic cohesion, and (d) affectionate expression. Although the DAS can be used as a measure of the separate components of marital adjustment, Spanier (1988) reported that the DAS worked best as a global summary measure by utilizing the total score. It has been shown that the DAS has high internal consistency and discriminate efficiency (Spanier, 1988). When compared with other measures of global marital satisfaction, the DAS was shown to be sensitive to treatment effects (Whisman and Jacobson, 1991). Shek et al. (1993) developed the Chinese version of the DAS. In a research study attempting to validate this version, results showed that the C-DAS scores had high internal consistency. Shek et al. (1993) and Shek (1995) showed that the C-DAS and its subscales were temporally stable (test-retest reliability coefficients with a two-week interval = .54, .85, .83, .73, .72, and .70 for the scale, total scale of the dyadic adjustment, dyadic consensus, dyadic satisfaction, dyadic cohesion, and affectional expression subscales) (Shek, 1998). The C-DAS scores correlated with measures of marital satisfaction and marital expectation. There were significant differences in C-DAS scores between the marital adjusted and maladjusted groups of respondents (Shek, 1994). Marial Status Inventory The MSI (Weiss & Cerreto, 1980) is used to measure the likelihood that a

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63 couple will get divorced. It measures the behavioral and cognitive styles of both members of the couple. Items are arranged along a continuum, so that a positive answer to each successive question shows increasing commitment to divorce. The items are true or false questions. Each response is keyed according to which answer indicates greater likelihood of divorce. The number of test items is 14. The coefficient of reproducibility (CR) = .90. The minimum marginal reproducibility (MMR) = .21. Thus, the percent improvement (PI) = .69. The PI represents the gain in accuracy from use of the total score in each relative to use of model frequencies (Weiss & Cerreto, 1980). The MSI also has shown good discriminant validity. The researcher in this study collected 723 files of subjects in 1999 and developed the Chinese version of the MSI. Three Chinese literature teachers revised the written language. A counseling psychologist was asked to ascertain the least difference between the English and Chinese versions in their examination of the contents of the inventory. The reported internal consistency rated by Cronbach's Coefficient Alpha was .7843. Conflict Tactics Scale The CTS (Gelles & Sraus, 1988; Straus, 1979) is a self-report questionnaire designed to assess individual responses to situations of family conflict. Respondents are presented with a list of 19 behavioral items representing possible responses to conflicts of interests among family members. The variables measured in the 7-point instrument are reasoning, verbal aggression, and physical violence in response to a conflict with, or anger at, other member(s) (Gelles & Sraus, 1988; Straus, 1979). The CTS appears to be fairly effective in avoiding high refusal rates and/or socially desirable responses (Straus, 1979). The Chinese

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64 version of the CTS was developed for detecting early family violence episodes (Joew, 1994). It shows high internal consistency, and results from factor analyses demonstrate good validity. The researcher also translated the same scale and collected data from 723 subjects in 1999. The Cronbach's alpha was .91. Scaling Questions Scaling questions constitute one of the basic techniques used in SFBT (Berg & de Shazer, 1993). Subjects were asked, "On a zero to 10 scale, where 0 is when the problem was at its worst, and 10 is when it is solved to your satisfaction, give me the number that best describes where you are now." In this study, subjects first described their goals in written language, and they were rated on the scaling question at pretest and posttest (see Appendix G and Appendix H). Measurement Procedure The C-BDI, C-DAS, C-CTS, C-MSI, and scaling questions were completed in the first session of the treatment. The C-SCID-P was used only for screening subjects. Repeated measures with C-BDI, C-DAS, C-CTS, C-MSI, and scaling results were completed at the end of Session 8. Following the 8th week, all participants also completed a scaling question regarding self-report satisfaction. Treatment Conditions Before the beginning of the research, each subject received the same reading materials (see Appendix I) consisting of information explaining depression, its impact on family members, and how the family supports the depressive members and gives them necessary help. The different treatment conditions are described below.

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65 Group Leader Due to a serious lack of marriage and family therapists in Kaohsiung, where the research was conducted, the researcher herself co-led the SFBT group with a psychiatrist, Dr. Lieu Chun-Long, on Monday evenings. The researcher also co-led with a psychiatrist, Dr. Yen Yung-Chieh in the SFBT+AM group on Wednesday evenings. There were two supervisors for the groups. Dr. Lung ForWey supervised the SFBT+AM group and Dr. Tzeng Tong-Shun supervised the SFBT group. Their roles as the supervisors of the groups were more as the consultants than the directors of the therapists. The researcher had one hour of supervision with Dr. Lung to discuss the issues found in the groups on Thursday. And she also received an hour of supervision from Dr. Tzeng, who stayed in another room listening to the group process, after each group session. The depressed participants in this study were patients of one of the four doctors mentioned above. Before the beginning of this study, the researcher had already accumulated SFBT group leading experience. One experience was in a familyserving center where the group members were all adult females. The second was in a medical college. The group members were senior college students whose major was psychology. The researcher felt that SFBT functioned well when it was utilized to generate some solutions for the members' problems. She also found that some members wanted to hold on to part of their problems and did not really want to solve them completely. Antidepressant Medication Condition The participants in this group took antidepressants prescribed by

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66 psychiatrists on a daily basis. They were outpatients at the Military Kaohsiung General Hospital. Although the date for the clients to begin taking medication might not be the same day as they were selected to the AM group, it was not more than a week earlier or later than the assignment of treatment groups. Most of the antidepressants prescribed in this research were SSRIs. Few were TCAs. There were no MAOIs used in this study. Participants were required to come back to the clinic once a week. The compliance was inquired as one of the routine steps when the psychiatrists saw their patients. The participants could stop medication properly under their psychiatrists' advice at any time. However, only those who undenwent an eight-week course of medication were investigated. The researcher included 20 participants in this group at the beginning of the study to ensure having enough subjects at the end. Only 13 of these patients actually became subjects in the research. Solution-Focused Brief Therapy Condition This treatment program began April 9, 2001, and ended June 11, 2001. Two treatment groups started in the same week. One group met on Monday evenings and the other on Wednesday evenings, starting at 7.00 p.m. and ending at 9:00 p.m. Neither of the groups was delayed for any session during the research period. The participants in the SFBT condition were mixed with those who took medication (AM +SFBT) and those who did not (SFBT alone). The researcher co-led the two groups with different psychiatrists. There were no other members on the treatment team. In this study, SFBT consisted of eight sessions based on a six-week, solution-focused couple therapy group designed by Zimmerman et al. (1997). Two

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67 sessions were added to increase the time for the group to work on the therapeutic process and to equalize the treatment duration among the three groups. The SFBT group session topics included (a) becoming a group, (b) stepping back and moving on, (c) noticing the track and the pattern, (d) hunting for exceptions, (e) thinking positively, (f) doing something different, (g) keeping the change going, and (h) setting goals for the future. One presession meeting and one postsession meeting were held in addition to the eight group sessions. It took 10 weeks to complete the total participation in this research. Each member received an SFBT group workbook (see Appendix J) in the presession meeting. The workbook was designed to facilitate group interactions and to generate the change process. There were three pages for each session. The initial page had a color picture of a lotus and words cited from the dialogue of a popular movie. These words were used as supplementary materials for discussion in the group. The second page was a worksheet. It was designed to inform group members about the assumptions and techniques of the SFBT. The third page was a homework assignment, which also was based upon SFBT assumptions and techniques. In order to break the ice, the researcher included a sexually oriented joke in every worksheet, which could be easily read in a group comprised of depressed members. This also served to warm up the group and to initiate the major activity for the session. The procedure for conducting each session began with a warm-up activity. In this treatment program, the researcher led a 20-minute meditation with the sound of waves at the beach in the background. The meditation served to prepare each client's mind and body for the group activities. A 30-minute discussion about

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the homework assignment or some of the valuable changes occurring in a member's life followed the meditation. There was a 10-minute break before continuing the session. Then, the therapists began one of the 40-minute activities I t designed for each session. They started by reading the cover page of the workbook, discussing it, and going into the worksheet for that session. During the final 20 minutes, participants received instructions for the next homework assignment, and the group ended. The group therapists were responsible for facilitating the change process in treating co-occurring marital problems and depression. Although the SFBT therapist can apply many of the questions developed for use in the group sessions, "the best questions will develop spontaneously in the group process as the therapist follows clients in their conversations, noting the exceptions that emerge and translating these into solutions" (Metcalf, 1998, p. 64). Keeping this in mind, the researcher designed the sessions to be as flexible and generative as possible. The mobilization of the underlying mechanism for change was assumed as either from treating marital problems or depression, since they interacted with each other in the client's system. In the pretreatment meeting, members received an orientation, introduced themselves briefly, and took a pretest. They wrote down the problems for which they wanted assistance. They also evaluated the severity of the problems using scaling scores. After the meeting, group members were asked to write about any presession changes that they noticed in their first homework assignment (Weiner-Davis et al., 1987). The purpose for this was to bring about selfawareness of their strengths. They also were asked to describe what would be

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69 different in themselves, tfieir families, and their marriages when the group was over in order to set up an attitude for focusing on solutions (see Appendix J). The purpose for the first session was for the group members to build collaborative relationships to help one another to reach his/her goals. The cover page and the joke (see Appendix J) were used to increase the appreciation of meeting friends in the group. First, the members discussed the group contract and signed it. Then they talked about the problems and goals in their homework assignments. In discussing group process, the therapists gave an illustration of using a more positive tone to describe one's problem and an attitude to look for what had changed before coming to the group. For the rest of the session, the psychiatrist explained how it is good for our well-being if we laugh frequently. A mood of relaxation and humor was encouraged in the group. The therapists explained what was expected to perform a "formula first session task" (de Shazer, 1985) (see Appendix J) as the homework assignment at the end of the first session. The purpose for the second session was to build awareness of how one used to see things in their lives, especially the marital relationship. After the sharing of the "formula first session task," the researcher led the discussion about the myth of marriage (Weiner-Davis, 1992), as was written on the worksheet of Session One (see Appendix J). The therapists used members' stories to delineate how the myth could have influenced their marriages. The homework assignment, "It happened all the time," was to prepare the members to think about the patterns behind their problems.

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70 The design of Session Three was to enhance participants' understanding regarding the patterns associated with their problems. Through discussion and feedback from other group members and the therapists, they were able to achieve awareness that their old solutions might have become new problems. In Session Four, the goal for the group was to search for an exception that happened outside of their problematic patterns (de Shazer, 1985, 1988; O'Hanlon & Weiner-Davis, 1989). The homework was the miracle question (de Shazer, 1988). Based on what had been discovered in the previous three sessions, the goal for Session Five was to build participants' self-confidence that they could always make positive changes in their lives. After a discussion of a crying old lady who changed her sad face to a laughing face, group members were encouraged to change their negative perspectives in a positive direction (O'Hanlon & WeinerDavis, 1989; Walter & Peller, 1992). Following this session the members were more prepared to take new actions to change their lives. Therefore, the idea of "synchronicity" was introduced in Session Six to support their determination for doing things differently (de Shazer, 1985; Walter & Peller, 1992). In Session Seven the researcher illustrated the idea of "forgive" versus "forget" in order for the members to let go some of their doubts and anger about their relationship problems and be more able to keep the changes going. In this stage of group development, building the habit of looking at things in an appreciative and positive way was the main task of the homework assignment. After the group had been together for two months, the final session was to close with blessings from members toward one another. The therapists

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71 encouraged them to write down a concrete goal for the future as their last homework assignment. The AM+SFBT Group The combined treatment group required participants to join the SFBT group while taking certain antidepressant medications. The duration of the SFBT group treatment was eight weeks, and the duration of the AM treatment was at least eight weeks. Data Analysis To analyze the effects of alleviating symptoms of depression and marital discord for subjects receiving one of the three treatments (AM, SFBT, or AM+SFBT), measures (BDI, DAS, MSI, and CTS) were administered before and after the treatment. The questions of interest were, first, whether there were differences in scores of depression symptoms and marital discord among the three treatments, and, second, whether there were differences between scores of pretreatments and posttreatments of each group. To answer this question, a oneway ANOVA was used to test whether there were significant differences in mean scores of the preintervention measures (BDI, DAS, MSI, and CTS) among the treatment groups. It was found that the assumption of homogeneity of regression slopes was met. Then the researcher used ANCOVA to test overall differences among the three treatment groups by comparing the postintervention measures and the preintervention measure. All possible pairwise comparisons were conducted using simultaneous confidence intervals (Westfall, Tobias, Rom, Wolfinger, & Hochberg, 1999) in the two statistical methods.

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72 Since there were four response variables (BDI, DAS, MSI, and CTS), these were compared for the three treatment groups (AM, SFBT, and AM+SFBT). There were three painwise comparisons of the score on the BDI, three pairwise comparisons of the score on the DAS, three painwise comparisons of the score on the MSI, and three painwise comparisons of the score on the CTS. For this family of inferences, all 12 confidence intervals for the differences in means were computed. When applying ANCOVA, all means were covariate adjusted. To answer the second question, whether there were differences between scores of pretreatments and posttreatments in each group, the researcher utilized the t test to examine differences between pretest and posttest scores on the BDI, DAS, MSI, and CTS of each group. The chi-square method was used to detect differences between the scores of pretest and posttest scores for the scaling question.

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CHAPTER 4 RESULTS Descriptive Information Demographic Information Descriptions of the participants' demographics regarding their gender, age, marital status, education level, and occupation are presented in Table 4-1. As this table shows, only 9 (23%) subjects were men. More than half of the subjects (54%) were 30-39 years of age. Thirty-four of total participants (87%) were in their first marriage, while all of the subjects in the SFBT group were in their first marriage. Half of the subjects (51%) were college graduates. Their occupations varied. Among them, 1 1 (28%) were businesspersons and 7(18%) were teachers. Table 4-1. Demographic Information of the Participants Demographics Demographics AM SFBT AM+SFBT Total ni%l ni%l ni%l n (%) Entire sample 13 (100) 13 (100) 13 (100) 39 (100) Gender Male 4(31) 3(23) 2(15) 9(23) Female 9(69) 10(77) 11(85) 30(77) Age 20-29 1(8) 2(15) 2(15) 5(13) 30-39 6(46) 9(69) 6(46) 21(54) 40-49 5(39) 2(15) 2(15) 9(23) 73

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74 Table 4-1 — continued Demographics AM ni%l SFBT ni%) AiVI+SFBT ni%l Total nX%l 50-59 60-69 Marital status First marriage Separated Divorced Second marriage Cohabiting Education level K-6 7-9 10-12 College Graduate school Occupation None Housekeeper Military worker Governmental Officer Teacher Businessperson Industry worker Serviceperson 1(8) 0(0) 9(69) 1(8) 1(8) 1(8) 1(8) 1(8) 2(15) 4(31) 6(46) 0(0) 0(0) 4(31) 0(0) 0(0) 1(8) 5(39) 1(8) 2(15) 0(0) 0(0) 13(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 4(31) 9(69) 0(0) 0(0) 2(15) 1(8) 1(8) 4(31) 3(23) 2(15) 0(0) 2(15) 1(8) 12(92) 0(0) 1(8) 0(0) 0(0) 2(15) 2(15) 3(23) 5(39) 1(8) 1(8) 2(15) 0(0) 0(0) 2(15) 3(23) 2(15) 3(23) 3(8) 1(3) 34(87) 1(3) 2(5) 1(3) 1(3) 3(8) 4(10) 11(28) 20(51) 1(3) 1(3) 8(21) 1(3) 1(3) 7(18) 11(28) 5(13) 5(13)

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75 Descriptive Statistics Descriptive statistics of the dependent variables of the three treatment groups are presented in Table 4-2. Mean change between pretest and posttest is also shown in Table 4-2. There were two mean changes in the direction against treatment effects. One was the MSI mean scores of the combined group. The scores increased by 0. 96 point after two months of treatment. The other was the CTS of the antidepressants group. The scores increased by 0.23 point. The rest of the mean scores changed in favor of treatment effects. Table 4-2 Means and Standard Deviations for Pretest and Posttest in Each Group Variables Group Pretest Mean/SD posttest Mean/SD Depression (BDI) Dyadic Adjustment (DAS) Marital Status (MSh Antidepressants 28.15(8.53) 22.69(12.02) SFBT group 19.62(11.77) 9.31(4.94) AM+SFBT 33.62(16.03) 22.23(13.58) Antidepressants 135.54(28.94) 125.85(29.80) SFBT group 117.00(30.71) 114.46(27.98) AM+SFBT 1 34.54(39.89) 1 22.44(37. 1 6) Mean Change i 5.46 i 10.61 i 11.39 19.69 12.54 112.10 Antidepressants 8.39(1.39) 8.00(3.42) 40.39

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76 Table 4-2 — continued Variables Group Pretest Mean/SD posttest Mean/SD Mean Change SFBT group 6.23(3.19) 6.15(3.16) i0.08 AM+SFBT 5.46(3.62) 6.42(3.58) tO.96 Soousal Abuse (CTS) Antidepressants 28.46(9.50) 28.69(8.69) tO.23 SFBT group 23.62(6.40) 23.15(5.98) iO.47 AM+SFBT 28.39(9.22) 27.85(10.67) iO.54 Scalina Scores Antidepressants 8.15(1.07) 5.39(2.84) 12.76 SFBT group 7.31(2.02) 4.08(2.66) i3.23 AM+SFBT 7.00(1.47) 5.54(2.82) 11.56 Description of the Change Process Members of the two SFBT treatment groups put down what they thought to be their goals for coming into the therapy in the pretreatment meeting. Their goals could be categorized into three domains. They were (a) reducing depression symptoms, (b) solving marital problems, and (c) a combination of both goals. The percentage of the three categories of the treatment goals in each group is shown in Table 4-3. Clients reported higher expectation for reducing depression symptoms either alone or combined with solving marital problems than simply expecting to solve the marital problems. Among the three groups, the AM+SFBT group expressed the highest expectation for treating both depression symptoms and marital problems.

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77 Table 4-3. The percentage of reported treatment goals in pretreatment Reducing depression symptoms n (%) Solving marital problems n (%) Both n (%) AM 9(69) 2(15) 2(15) SFBT 6(46) 3(23) 2(15) AM+SFBT 3 (23) 2(15) 8(61) According to the posttest scores of BDI, there were 2 persons reduced their scores under 9 in the AM group, 7 persons in the SFBT group, and 3 persons in the AM+SFBT group. Therefore, the recovery rate in the three treatment groups were 15% for the AM group, 54% for the SFBT group, and 23% for the AM+SFBT group. Among the three groups, the SFBT group alone achieved the best recovery rate and the AM group alone the least. The major topics for the two SFBT groups were different. In the Monday group, the topic discussed most frequently was regarding extramarital relationship. On Wednesday evening, the theme topic was the conflicts between the wife and the mother-in-law. Members in the second group showed better therapy outcomes in that they were able to find a way to keep a safer distance from the other women at the end of the sessions. At the posttreatment meeting, members were invited to talk about the most beneficial treatment experience they had in the past eight weeks and what were the most needed things to be done by the hospital. They could go into the workbook, the therapists, the place, the time, the contract, the group activities, etc. The worksheet in session 7, it is not "for-get"; it is "for-give," and the cover page of session 7, which said, "If you really want something very

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78 badly, set it free," earned the most positive responses. There were few suggestions for the improvement. In one group, they expressed their wish to have more directions from the therapists. Statistical Results of the Research Hypotheses Test for Pretreatment Difference A one-way analysis of variance (ANOVA) was used to examine whether there was a significant difference in the mean scores of the preintervention measures (BDI, DAS, MSI, and CTS) among the treatment groups. The results are presented in Table 4-4. It was found that there was no difference in pretest scores of the DAS among groups. The analysis yielded an F (2, 36) = 1.26; p = .30. There also was no difference in the CTS among groups, with F (2, 36) = 1 .39; e_= .26. However, the pretest scores of the BDI and MSI among the three groups were found to be significantly different before the treatment sessions. The analysis yielded an F (2, 36) = 4.15; e=. 004 for the BDI and an F (2, 36) = 3.55; e=.04 for the MSI. Then tests for common slope were adopted to test whether the pretest scores of the DAS, CTS, BDI, and MSI among the three groups yielded parallel regression lines. The result is presented in Table 4-5. It was found that slopes of every regression line were parallel. In the BDI, test of common slopes yielded an F (2,36) = 2.32; b=. 37. In the MSI, F (2,36) = .25; e=. 778. In the DAS. F (2,36) = .26; E= .78. In the CTS, F (2.36) = 2.32; e=. 11. The researcher then examined the treatment effects among the three groups utilizing Analysis of Covariate (ANCOVA). The results are presented as they pertain to each of the hypotheses posed.

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79 Table 4-4. Analysis of Variance for the Pre-intervention Scores in the BDI. DAS. MSI, and CTS for Different Groups csource Hf OT oo IVIO F 1 u BDI Group 2 1294.51 647.26 4.15* .02 Error term 36 5619.85 156.11 DAS Group 2 2826.51 1413.26 1.26 .30 Error term 36 40462.46 1123.96 MSI Group 2 59.62 29.85 3.55* .04 Error term 36 302.62 8.4 CTS Group 2 200.36 100.18 1.36 .26 Error term 36 2593.39 72.04 Alpha = .05 Table 4-5. Test of Homoqeneitv of Common Slopes in the DAS. BDI. MSI. and CTS Source df SS MS F £ Group*DAS 2 172.68 86.34 .26 .78 Group*BDI 2 236.68 118.34 1.04 .37 Group*MSI 2 2.61 1.31 .25 .78 Group*CTS 2 123.97 61.69 2.32 .11 Alpha = .05 Test for Depression Symptoms Elimination Ho: 1 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in eliminating depression symptoms of

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80 depressed clients with marital problems after eight weeks of treatment. In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there were significant differences in treatments for depression. As presented in Table 4-6, the analysis produced significant F values for BDI scores, F (2, 36) = 3.87; q= .03. Hypothesis 1 was rejected. Table 4-6. Analysis of Covariance for the BDI Source df SS MS F P Pretest 1 246.22 246.22 2.16 .15 Group 2 882.83 441.42 3.87* .03 Alpha = .05 A post hoc test was used to compare the adjusted mean differences between groups. The adjusted means of the three groups were 22.48 for the AM group, 10.88 for the SFBT group, and 20.87 for the AM+SFBT group. It was found that the mean differences, I J =11 .60, between the AM group and the SFBT group were significant, p_ = .04. However, the mean differences between the SFBT group and the AM+SFBT group, I J = -9.99, were not found to be different, g = .12. The mean differences, I J =1 .61 between the AM group and the AM+SFBT group were not significant, g = 1.00, either. The adjusted means and the multiple comparisons are presented in Table 4-7 and Table 4-8.

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Table 4-7. The Adjusted Means of the Three Treatment Groups Group Adjusted Means Std. Error The AM Group 22.48 2.97 The SFBT Group 10.88 3.15 The AM+SFBT Group 20.87 3.10 Table 4-8. Multiple Comparisons of Mean Differences among Groups in the BDI (I) Group (J) Group Adjusted Mean Difference (I J) Std. Error Sig. AM SFBT 11.60* 4^36 ^4 SFBT AM+SFBT -9.99 4.64 .12 AM AM+SFBT 1.61 4.26 1.00 Alpha = .05 Ho: 2 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in eliminating depression symptoms of depressed clients with marital problems after eight weeks of treatment. A dependent sample t-test was applied to examine the mean difference between pretest and posttest in each treatment group. The results are shown in Table 4-9. Two of the comparisons showed significant differences in the BDI. One was in the SFBT group (p = .02; 1 -tailed), and the other was in the combined group (p = .03; 1 -tailed). Hypothesis 2 was partially rejected.

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82 Table 4-9. T test for Pretest and Posttest in Each Group for the BDI Antidepressants group SFBT groups Antidepressants + SFBT I E I E t S 1.63 .13 2.72* .02 2.40* .03 Alpha = .05 Test for Marital Adjustment Ho: 3 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in improving marital adjustment of depressed clients with marital problems after eight weeks of treatment. In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there was no significant difference in treatments for marital adjustment. As presented in Table 4-10, the analysis did not produce significant F values for marital adjustment, F (2, 36) = .11; p=.90. Hypothesis 3 was regarded as 'fail to reject'. Table 4-10. Analysis of Covariance for the DAS SouTce Df SS MS F g Pretest 1 25370.84 25370.84 78.95 W Group 2 68.08 34.04 .11 .90 Alpha = .05 Ho: 4 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in improving

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83 marital adjustment of depressed clients with marital problems after eight weeks of treatment. A dependent sample t-test was applied to examine the mean difference between the pretest and posttest in each treatment group. The results are shown in Table 4-11 None of the comparisons for each group showed significant difference in the DAS. Hypothesis 4 was regarded as 'fail to reject'. Table 4-1 1 T test for Pretest and Posttest in Each Group by the DAS Antidepressants group SFBT groups Antidepressants + SFBT t E t fi t B 1.48 .17 .55 .59 1.72 .11 Alpha = .05 Test for Marital Status Dissolution Ho: 5 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in stopping the dissolution of marital status of depressed clients with marital problems after eight weeks of treatment. In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there was no significant difference in treatments for dissolution of marital status. As presented in Table 4-12, the analysis did not produce significant F values for marital adjustment, F (2, 36) = .42; e=.66. Hypothesis 5 was regarded as 'fail to reject'.

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84 Table 4-12. Analysis of Covariance for the MSI Source df SS MS F P Pretest 1 4.17 2.09 47.27 .00 Group 2 4.17 2.09 .42 .66 Alpha = .05 Ho: 6 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in stopping marital status dissolution of depressed clients with marital problems after eight weeks of treatment. A dependent sample t-test was applied to examine the mean difference between the pretest and posttest in each treatment group. The results are shown in Table 4-13. None of the comparisons for each group showed a significant difference in the MSI. The researcher failed to reject hypothesis 6. Table 4-13. T test for Pretest and Posttest in Each Group by the MSI Antidepressants group SFBT groups Antidepressants + SFBT t B t £ t E .41 .69 .43 .67 -1.38 .19 Alpha = .05 Test for Spousal Abuse Reduction Ho: 7 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in reducing spousal abuse of depressed clients with marital problems after eight weeks of treatment. In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results

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85 of an ANCOVA procedure showed that there was no significant difference in treatments for reducing spousal abuse. As presented in Table 4-14, the analysis did not produce significant F values for the CTS, F (2, 36) = .28; q=. 76. Hypothesis 7 was regarded as 'fail to reject'. Table 4-14. Analysis of Covariance for the CTS Source df SS MS F Q. Pretest 1 1697.87 1697.87 59.17 .00 Group 2 16.06 8.03 .28 .76 Alpha = .05 Ho: 8 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in reducing spousal abuse of depressed clients with marital problems after eight weeks of treatment. A dependent sample t-test was applied to examine the mean difference between the pretest and posttest in each treatment group. The results are shown in Table 4-15. None of the comparisons for each group showed a significant difference in the CTS. Hypothesis 8 was regarded as 'fail to reject'. Table 4-15. T-Test for Pretest and Posttest in Each Group for the CTS Antidepressants group SFBT groups Antidepressants + SFBT i B. I E t E 1^75 a] 148 A7 ^9 JO Alpha = .05

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86 Test for Goal Performance Scaling Ho: 9 There is no difference among the three treatment groups (AM only, SFBT only, AM+SFBT) in scaling scores of depressed clients with marital problems after eight weeks of treatment. Participants expressed their goals for seeking the treatment in the pretreatment meeting on the Scaling Question sheet (see Appendix G). They evaluated the severity of the problems that hindered them from achieving their goals on a scale of 1 to 10. Scaling scores between pretreatment and posttreatment were examined. In order to control for pretest variability, analyses of covariance (ANCOVA) were used to test this hypothesis, with the pretest serving as a covariate. Results of an ANCOVA procedure showed that there was no significant difference in treatments for scaling scores. As presented in Table 4-16, the analysis did not produce significant F values for scaling scores, F (2, 36) = 1.46; E=.25. Hypothesis 9 was regarded as 'fail to reject'. Table 4-16. Analysis of Covariance for Scaling Scores Source Df SS MS F U Pretest 1 52.15 52.15 8.11 .01 Group 2 18.79 9.40 1.46 .25 Alpha = .05 Ho: 10 There is no difference between pretest and posttest for the three treatment groups (AM only, SFBT only, AM+SFBT) in scaling scores of depressed clients with marital problems after eight weeks of treatment.

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A dependent sample t-test was applied to examine the mean difference between the pretest and posttest in each treatment group. The results are shown in Table 4-17. All of the comparisons for each group showed significant differences in scaling scores. The mean change showed that posttreatment scaling scores in each group declined significantly when compared with the pretest scaling scores. Hypothesis 10 was rejected. Table 4-17. T-test for Pretest and Posttest in Each Group bv Scaling Scores Antidepressants group SFBT groups Antidepressants + SFBT I B t B t B 3.68** .002 4.50** .000 2.33* .02 Alpha = .05 Summary of the Research Findings When comparing the three treatments, the SFBT group resulted in greater symptom reduction than the AM group significantly. Hypothesis 1 was rejected. However, there were no significant differences between the AM group and the SFBT group, or between the AM group and the AM+SFBT group. Although mean scores of the BDI in the three groups were reduced 9 points on average after treatment, improvement for reducing depression symptoms was statistically significant in the SFBT group and the AM+SFBT group, but not in the AM group. Hypothesis 2 was partially rejected. When Ho 3, Ho 4, Ho 5, Ho 6, Ho 7, and Ho 8 were examined, none of the groups were more effective in treating marital problems than any other, including improving dyadic adjustment, maintaining marital status, or reducing spousal abuse. Results also revealed that in treating marital problems, none of the treatment groups showed statistically significant

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88 improvement when compared with pretest scores. Scaling scores, by which participants in the three groups expressed how they evaluated the severity of their problems, all were significantly reduced, and the improvement was not different among the three groups. The researcher failed to reject hypothesis 9, while Ho 10 was rejected. Of the10 null hypotheses, 7 were accepted, 2 were rejected, and 1 was partially rejected. It can be concluded that on an overall basis during an eightweek period, not all of the participants improved on most of the variables, and no treatment method showed superiority in dealing with marital problems for depressed patients. The only exception was the SFBT group alone or combining with antidepressants when treating depression. The SFBT group was significantly more effective than the AM group.

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CHAPTER 5 CONCLUSIONS The purpose of this study was to investigate the effects of three different approaches to reduce nfiarital problems and symptoms of depression. The following areas were assessed: dyadic adjustment, depression symptoms, marital status, and spousal abuse. This chapter includes a discussion of the data in relation to the hypotheses under investigation, followed by implications, limitations, and recommendations for future study. Discussion of the Research Results Treatment Effect for Depression First, the depression variable will be discussed as presented in the first two null hypotheses. Hypothesis 1 stated that there were no differences among the three treatment groups (AM only, SFBT only, AM+SFBT) in eliminating depression symptoms of depressed clients with marital problems after eight weeks of treatment. The findings indicated that there were significant differences among the three groups. The SFBT group showed better treatment effects than the AM group for depressed patients who also experienced marital problems within eight weeks. The SFBT group was also the group that reached statistically significant improvement in depression symptom reduction both alone and combined with antidepressants in the posttest. This finding resulted in the partial rejection of 89

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90 Hypothesis 2, which stated that there was no difference between the pretest and posttest in each group. These findings were consistent with other studies that reported similar results. A psychotherapy approach such as SFBT alone can be a more effective therapy alternative for treating depression than using antidepressants alone. This finding adds to the literature that supports the positive effects of psychotherapies (Elkin et al., 1989; Hollon et al., 1992; Rush et al., 1977). It also supported what was found in research studies conducted with a solution-focused couple group, that a positive treatment effect could be generated in a brief treatment period (Zimmerman et al., 1997). These results also support findings in a hospital setting. In a study conducted in the Alternatives Program at Colorado Psychiatric Hospital, the average length of stay after implementing a brief, solution-focused continuum-ofcare model declined from 18.1 to 6.9 days for the depressive disorder (Vaughn et a!., 1996). According to the results, even though the mean score in preintervention of the combined group was 33.62, indicating serious depression, there were significant differences between the pretest and posttest. This can be attributed to the SFBT group effects. Participants in the AM group had no statistically significant reduction In symptoms of depression. The possible explanation for these results may be an indication of self-verification (Katz, 2000). Taking medication and being taken care of in a psychiatry department placed the client in a sick role, which might not have supported the concepts that they could recover in a short amount of time nor could they reinforce themselves by any progress evolving in the sessions. In contrast, not taking medication or taking the medication only for supplemental reasons might have implied to the subjects in the SFBT group

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condition that they were not weak and could improve their well-being with their own power. They were empowered to put more effort into the healing process. Treatment Effect for Marital Problems Null hypotheses 3 and 4 examined the difference in treatment effects in improving dyadic adjustments among three groups. Both were accepted. Hypotheses 5 and 6 concerning the reduction of spousal abuse were also accepted. The same results were found when Ho 7 and Ho 8 were examined. In conclusion, no treatment was more effective in treating marital problems than any other. It also was found that in treating marital problems, none of the treatment groups showed statistically significant improvement when compared with pretest scores. Results in this study were consistent with findings presented by Trapp (1997), who studied the comparative effectiveness among three treatment groups (cognitive-behavioral therapy, integrated couple therapy, and a control group) designed to treat both depression and marital discord. No significant improvement was demonstrated until sessions 8 through 12. This maybe related to the researcher's findings of no treatment effect given that sessions were limited to 8 total. In contrast, the results in this study were inconsistent with Zimmerman et al. 's (1997) findings wherein the solution-focused approach helped participants solve their marital problems in six sessions. There were several possible explanations for these research findings. First, the psychiatry department was more focused on treating depression than on treating marital problems. A medical model has been the mainstream in the hospital. Improving a couple's relationship in order to treat depression or vise

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92 versa was not addressed clinically. It also was beyond the training of the two psychiatrists who were co-leaders. Thus, the benefit of participating in treatment in a psychiatric setting might be limited to direct medical response rather than interpersonal relationship change. Second, the design of the SFBT group might not have been intense enough to bring about changes in participants' discordant marital relationships. The group emphasized personal empowerment more than coaching couple communication techniques. It attempted to generate a collaborative team instead of the leaders' mobilizing the activities. This study allowed for the partner who was depressed to participate in the group. It was not a couple therapy that treated relationships directly. This might not have been a strong enough mechanism to produce a relationship change in this short period of time. Thus, it was possible that the treatment ended before the positive effects could take place. Third, it is possible that these results may be attributed to the assessment measures that were utilized in this study. The researcher found that some of the items might not represent the underlying constructs of the measure of Taiwanese society. For example, not many families in Kaohsiung have pets. In this case, "My spouse never gets angry at the animal kept at home or threatens the animal" does not necessarily mean that the spouse was a benign person. Self-Evaluation of Goal Achievement Participants reported positive response to all treatments regardless of which group they were in. However, this might due to the fact that in Chinese culture people will reserve their negative response when asked directly. Implications The present study provided some evidence that SFBT is effective in reducing

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93 depression in clients with marital problems. The primary implication of this study is that the results supported a nonpathological model in the treatment of depression, either alone or combined with antidepressants, may reach the therapeutic power inherent in a person. The assumptions of SFBT-that the clients are their own experts and that they have the resources and strengths to resolve their complaints-were supported. Further, the insignificant results found in the treatment groups for marital problems indicated that co-occurring marital problems and depression required clinicians and researchers to eliminate, modify, expand, that is, to improve the treatments in individual, couple, or group modalities. They may indicate that relationship problems occurred in those subjects' lives require more time than reduction of depressive symptoms for changes to occur. The positive side of this is that regardless of the adversity that one may encounter, it is possible to reduce the negative impact upon oneself to the greatest degree possible. It is possible that if each partner in a discordant relationship work together, the problems in their relationship can be resolved more easily than if just one of them struggles for changes. This would support what Prince and Jacobson (1995) suggested-that couple therapy for depression be used clinically. The results added some answers to the question, "What works best for whom?" They also could be used for purposes of treatment planning, program development, and service delivery in Taiwan. Since only one dependent variable, the BDI, was found to be significantly different among three groups, it is possible that the other measures such as the DAS, MSI, and CTS are not sensitive enough to change based on the treatment

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94 they received. One of the reasons for this outcome might be that different subjects were evaluated when reliability was determined. The Cronbach Alphas of the Chinese versions of these three measures were built on a community sample. There is a need for building scales for clinical use that will be sensitive enough to detect the differences. Although the SFBT group was found to be more effective than the AM group, it is important to note that the subjects were unipolar, nonpsychotic, mildly depressed, in a first marriage, mostly college graduates, and in stable occupations. It is possible that they could have recovered in a positive way regardless of being treated or not. According to Klein and Wender (1993), the life span of the depressive illness is not affected by the antidepressants. It is possible that it is not affected by psychotherapies either. A control group design might help us achieve more knowledge about the effects of the treatment. In addition, Chinese patients often request that psychiatrists avoid prescribing medication for the treatment of depression due to concerns of drug dependence and side effects. Many Chinese look for alternative methods for dealing with emotional problems, such as Chinese medications, Tai-Tze, ChieKaon, Buddhism, and meditation, since many believe more in the natural methods of healing themselves. Chinese patients tend to believe that, while Western medicine may be more efficient, it also deprives a person's ability to heal oneself. It should be noted that, at this time, there is no standard of care for depressed individuals who suffer marital problems in Taiwan. The results of this study will have implications for the mental health profession, for research, and for social policy. Supported by the research findings in this study, SFBT groups also may be

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particularly useful as a treatment option for patients who reject antidepressant medication as a standard treatment. Limitations This study was intended to be a true experimental design. However, due to some of the patients' strong rejection of medication or psychotherapy, the participants in each group in fact were those who voluntarily accepted their treatment. The design for this research was not a true experimental study in that all extraneous variables were not controlled for and subjects were not truly randomly assigned to three treatment groups. Therefore, there are several limitations inherent in this study. 1 When the tools are translated into a foreign language, the original claims of the test may vary due to certain cultural, social, and political differences. 2. The generalizability of these research findings from an Asian urban context may not be possible to replicate in Western countries. 3. Because many Chinese still do not seek help for their spousal relationship problems, the participants in this study may not be a good sample of the overall population of depressed persons with marital problems. 4. There were concerns about socially desirable responses from Chinese respondents, especially when they were answering questions in the MSI and CTS. Bias may occur when a person has difficulty in reporting the conflicting episodes in the family. 5. The composition of the sample was limited to generally well-educated and fairly well-functioning clients in a psychiatry department; validity of the results remains restricted until broader populations are assessed.

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96 6. The exclusive use of self-report measures may not be able to assess depressed clients that often underreport their marital problems and depressive difficulties. 7. In certain clinical cases, depression intertwines with marital problems so profoundly; divorce may be a better way to alleviate depression. Therefore, the effects of treatment were difficult to determine. 8. There was no interrater reliability built among the psychiatrists who diagnosed for the subjects. It was not certain whether exclusion criteria were correctly applied. 9. This was not a uniblind or double blind design. The influence from the awareness of both clients and therapists might have biased the outcomes. 10. There was no reliability test between the two co-leading psychiatrists. Therefore, variance in approaches of the leaders might have been significant. 1 1 There was no control of medication compliance or homework completion. Some clients might not have completed all of the treatment activities. 12. The researcher was also one of the SFBT group therapists. The presence of the researcher as a group leader may have introduced bias into the study. 13. There was no control group for comparison among different treatments. The mean changes might be meaningless if compared with a nonactive control group. 14. There was no further control for the heterogeneity of group members. Source of variance was mostly unknown for the researcher.

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Recommendations for Future Study As a result of this study a number of recommendations for future research emerge. Better Control for the Source of Variance Psychiatrists could monitor medication compliance by titration of urine or blood sample to ensure the patients took the medication. Just the presence of this test might have resulted in better cooperation from the clients. The group therapists should have developed more expertise in leading an SFBT group, especially to assist the client in performing the assignments. Targeting variables such as gender, diagnoses, medications, previous illness history, previous history of taking medication, marital status, years of marriage/cohabitation, and initial severity of depression would generate a more homogeneous sample and would be a good way to control for the source of variance. If a multivariate approach were used, these variables could be tested simultaneously. This research also indicated the need for a nontherapist researcher to ensure the reliability of all the different therapists, and also for the need for a meeting for consultation. Developing New Assessment Instruments There is a great need to develop new assessment tools by which researchers would be able to achieve valuable data to increase our understanding in both the brief psychotherapy group and the marital process in depression. We need instruments that have more sensitivity to cultural background and are able to investigate a wider range of issues in the field of interest. There is also much research need to improve the validity and reliability of the tools.

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98 Applying Qualitative Study Alone or Combining it with Qualitative Methods For a psychotherapy modality such as an SFBT group that is informed by constructivism, the instruments used in this study, which have set items, may not depict the clear scope of what really happened in the treatments. A qualitative method may serve us better in determining what has been constructed in every participant's life by the treatment, while at the same time the researcher may also apply quantitative methods to test the outcomes. Examining Time Factors in the Treatment Process In order to determine at what point in time the treatment is effective in changing participant responses, further study may examine the effect of the time frame on each of the treatments by collecting data at a regular intervals of every 4 sessions across a 12-session psychotherapy. Continuing a longitudinal study is also recommended. Investigating Sub-areas of Each Variable This study examined only the effect of the treatments using the total score of the scales of the BDI, DAS, and CTS. Since each of the these tests has its own subscale and measures different construct, further study may examine the effects of a treatment through analysis of the sub-area rather than the total score. Diagnostic Interview for Discharge Purpose At the end of the study, a diagnostic interview should be conducted to evaluate the status of the participants. Conducting a diagnostic interview may reflect a more accurate measure of outcomes of treatment than using the standardized measures.

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99 Repeating the Research Study The group format and content used in this treatment process need refinement. It is also suggested that attrition rate, response rate, and the interactions between certain medications and psychotherapy should be further investigated. Parts of the workbook that contribute to members' satisfaction, and whether the scaling question should be used for measurement or only as a treatment technique are some of the questions left to be answered in future studies.

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APPENDIX A CRITERIA FOR MAJOR DEPRESSIVE EPISODE A. Five (or more of the following symptoms have been present during the same 2week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., appears tearful). (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (4) insomnia or hypersomnia nearly every day. (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). (6) fatigue or loss of energy nearly every day. (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick. (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (hypothyroidism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. (Adopted from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (4 ed.). Washington, D. C. By American Psychiatric Association.) 100

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APPENDIX B CRITERIA FOR DYSTHYMIC DISORDER A. Depressed mood for most of the day, for more day than not, as indicated either by subjective account or observation by others, for at least 2 years. B. Presence, while depressed, of two (or more) of the following: (1 ) poor appetite or overeating (2) insomnia or hypersomnia (3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty making decisions (6) feelings of hopelessness C. During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time. Note: There may have been a previous Major Depressive Episode provided here was a full remission (no significant signs or symptoms for 2 months) oefore development of Dysthymic Disorder. In addition, after the initial 2 /ears of Dysthymic Disorder, there may be superimposed episodes of Major Depresive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode. D. No Major Depressive Episode has been present during the first 2 years of the disturbance; i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission. E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder. F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder. G. The symptoms are not due to they direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition(e.g., hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (Adopted from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (4" ed.). Washington, D. C. By American Psychiatric Association. 101

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APPENDIX C THE COGNITIVE MODEL OF DEPRESSION (Early) Experience I Formation of Schemata : Self, World, Future Dysfunctional attitudes/ negative attribution styles I Negative automatic thoughts i Compensatory strategies Stressful events: Internal or external I Symptoms of depression Somatic Cognitive Behavioral' Motivational Affective (Adopted from M. E. Thase. (1995). Cognitive behavior therapy. In I. D. Glick. & I. D. Yalom (Eds.), Treating depression. CA: Jossey-Bass.) 102

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APPENDIX D THE MARITAL/FAMILY DISCORD MODEL OF DEPRESSION 1 Decreased cohesion 2. Decreased acceptance of emotional expression 3. Decreased coping assistance 4. Decreased self-esteem support 5. Decreased spousal dependability 6. Decreased intimacy Marital and Family Discord Depression 1. Increased aggressive benavior 2. Increased threats of separation 3. Increased denigration and criticism 4. Increased disruption of routines 5. Increased other family stressors Poorer social skills, increased avoidance of conflictual material, increased interpersonal friction I. H. Gotlib. & S. R. H. Beach. (1995). A marital/family discord model of depression: Implications for therapeutic intervention. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical handbook of couple therapy. New York. Guilford. 103

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APPENDIX E CONDITION AND INTERVENTION FOR DEPRESSION MEDICINES MULTIMODAL INTERVENTION PSYCHOTHERAPY BIPOLAR DISORDERS CYCLOTHYMIA ADJUSTMENT REACTIONS MAJOR DEPRESSIONS DYSTHYMIA RELATIONSHIP ISSUES Cited from M. Mays & J. W. Croake (1997). Treatment of depression in managed care. New York: Brunner/Mazel. 104

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APPENDIX F DOCUMENTS FOR INSTITUTIONAL REVIEW BOARD-1 1 Project Cover Sheet 1 06 2. Introductory Questionnaire 107 3. Protocol 118 4. Informed Consent 123 5. Memorandum for Approval 1 33 105

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106 Institutional Review Board 01 Protocol # 172-2 001 University oti'lorida Health Science Center (lor IRB use onlv) Project Cover Sheet Project Title: A Comparison Of Three Approaches to Reduce Marital Problems and Symptoms oF Depression Key words (3-5): _depression, marital problems. Solution-Focused Brief Group Therapy. antidepressants Name of Investigator: Mei-kuei Huang Department: Counselor Education College: Education Box#: Phone: 01 1-886-7-368-1002 Fax: 011-886-7-368-1002 Email: rosehuang98@hotmail.com Chair: Dr. Harry Daniels. Dept Chair: Dr. Silvia E. Doan. Dissertation Chair Phone: 352-392-0731 Please check type of review required. Important: Refer to the IRB-Ol's Investigators' Manual for definitions of the type of project and for complete instructions : X Full Board. Submit a Project Cover Sheet, an introductory Questionnaire, a Protocol, and an Informed Consent Form. Expedited. Submit a Project Cover Sheet, an Introductory Questionnaire including question U23. a Protocol, and an Informed Consent Form. Exempt. Submit a Project Cover Sheet and an Introductory Questionnaire including question U24. Training Grant. Submit a Project Cover Sheet and an Introductory Questionnaire. Date(s) of deadline(s) for grants or funding related to this project: The undersigned accepts the responsibility to comply with Federal, State and Health Center policies relative to the protection of the rights and welfare of human subjects. Signature of Principal Investigator (P.I.) Date I approve this protocol for submission to the institutional Review Board. Chairperson or Director of Department Date

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107 Introductory Questionnaire All questions must be completed; use "N A" if a question is not applicable. 1. Please ckcck oaly tbose thai apply to Qucsiioa I a. Type of study: If none of the categories below apply, check other and brielly describe the study. Drug study Investigational new drug: IND it IND e.xempt or FDA-approved drug Non-approved indication or dose for approved drug If data will be submitted to (he Food and Drug Administration, provide the IND# Pharmacokinetic/ pharmacodynamic research Device study Investigational device Significant risk-IDE # Non-significant risk:-IDt c.\cmpi For sponsored studies: Sponsor's form indicating whether the device is considered significam or nonsignificant risk. Submit I copy. Marketed device Sponsored project Sponsor's Protocol. Submit 1 copy. Investigator's Brochure. Submit I copy. Multi-center study E.xperimental surgical procedure Radiation or radioactive materials. See question ^2 below. Approval from the UF Human Use of Radiation and Radioactive Materials Committee may also be required. Gene therapy. See #4 below. Approval from the UF Institutionai Biosafety Committee must also be obtained. Genetic testing. See fiS below. JJ. Behavioral/psychological research Observation of disease progression Non-therapeutic research E.xercise or nutrition research Other, please specify: b. Special considerations Request for waiver of consent, waiver of documentation of consent, or modillcation of Informed Consent Form Only allowed under specific circvimstances: contact the IRB Office for more information (846-1494). Deception of subjects Use of placebo Research involving fetuses Research involving pregnant women Research involving subjects younger than 18 years of age Research involving prisoners Use of impaired subjects

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108 For the rcnainder of the qucstkuiaaire, all qocstioos must be completed: ase '*N A** if a qucstioa is aot applicable. 2. Hmomb aac of ndiatioa tad radioactive matcriab a. Will any diagnostic x-ray procedures be performed during this study? No X Yes Ifyes, list the tcsB and the nuinl)eroftim€s they will be pertomied: TEST # of Times Pcrfomicd b. Docs this study involve the use of therapeutic radiation? No X Yes c. Does this study involve the use of radioactive materials? No X Yes .If yes. describe the material and how it will be used: 3. Does tkis study iavolve tlie storage of tissue or body fluids for future studies? a. No X Yes. If yes. complete 3b and 3c: b. Where will it be stored? c. Will any information be kept that will allow the specimen to be linked to the subject? No Yes If yes, list information here; be very specific: 4. Docs tkis study iavolve gene therapy? a. No X Yes If yes. complete b. b. Have you submitted the project to the Institutional Biosafety Committee? No Yes 5. Docs this study iavolve geactic testiBg? No X Yes Ifyes. please complete a-: X Will you conduct tests for specific diseases? No Yes If >es. please list which ones: b. Will the research involve germline cells (cells that produce gametes)? No_ Yes c. Will the research involve somatic cell mutations that can lead to cancer*? No_ Yes d. Does your work involve inheritance patterns in families? No_ Yes e. Will you ask the subjects' family members to panicipate? No_ Yes 6. Origia of the protocol*:

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109 Sponsoring company/institution/agency *Pkase Holr Protocoband Grant proposal lafonacd CoBscat Form kave to be adapted to the staadardf and fonwat X. Principal Investigator Other, please specify: of the lastitatioaal Review Board (IRB) of the Uaivcraily of Florida Health ScieaceCealer. 7. Is there finaactal or material support for the study? No J(_ Yes 1 f yes. indicate wiiha check below whether the support is Pending or has been Obtained: Private sponsor; company name below: National Institutes of Health National Cancer Institute Clinical Research Center Depanment or University Other, name or describe below: 8. Expected daratioa of the study: Two years 9. Expected daratioa of the stady for each sabject: Two months 10. Sabject iaforaiatioa a. Type of subject to be studied, for example, healthy volunteers or patients with specific Patienu who come to Kaohsiuny Military General Hospital For treatment of depression If patients are to be included, please explain how the study treatment differs from the standard of care: Antidepressant medication along, or no antidepressant medication, at the psychiatrists' discretion, is the standard of care for depression for the patients needed in the study (that both are viable treatment options for the subject are inclusion criteria. What is different in this study is that two-thirds of the subjects will be in Solution-Focused Therapy Groups. There is no standard care for marital problems in Taiwan. b. Estimated number of subjects you plan to enroll: 4^ Pending Obtained diseases:

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1 10 if a multi-center trial, estimate the total number of subjects to be studied at all sites: c. Age range of subjects: 18 to 65 years old d. Gender of subjects: Males Females Both X_ If only one gender is to be included, check one of the following: Only the gender selected has the condition. Other, please specify: e. If women of child-bearing potential are to be included in the study, will a pregnancy test be required? Not Applicable No; please state why is it not required: X Yes; please state who will pay: Women of child-bearing potential who are randomized to groups that include the use of antidepressants will take a pregnancy test and are advised in the Informed Consent Form that they must practice birth control while taking antidepressants. f Will subjects of a specific race/ethnicity be recruited? No Yes X If yes. specify: Caucasian African-American Hispanic Asian X Other Reason for selection (check one): __ The condition being studied occurs only in the selected group(s) X Other, please specify: This research is being conducted in Taiwan; the population are all of Asian origins. g. If subjects are either children, pregnant women, prisoners, mentally retarded, or legally restricted or if the study includes fetal research, give a brief explanation of the need to use these particular individuals. Not applicable. h. Will the investigator also be the subjects' physician? No J<_ Yes i. Is there potential for direct benefit to these subjects? No Yes _X, If yes, please describe: Subjects mav benefit from either treatment. j. If students are involved, is the investigator their instructor or advisor? No Yes* NA^ k. if employees are involved, are they directly supervised by the investigator? No Yes* NA J< *lf yes. the Informed Consent Form must include specific information for those subjects. See the Investigators Manual and standard statements available in electronic form from the IRB.

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1 1 1 11. Will the study involve the use of a placebo? No _X_ Yes If yes. complete a and b. a. Is there a proven effective therapy for this condition? No Yes please specify: b. Please give an ethical (not a scientific) justification for the use of a placebo. Note : Stating that the Food and Drug Administration or a sponsor requires a placebo is not sufficient. 12. Compensation to research subjects a. Reimbursement of expenses: No X Yes Amount: b. Monetary compensation: No X Yes Amount: If compensation will be provided, pro-rated payments are generally required. Please check below which condition applies to your study. Pro-rated payment. Give amounts and schedule: No pro-rated payment. Please explain: c. Given the subjects you will recruit, could the monetary compensation unduly influence a subject to participate in this study or remain in this study when other factors in the subject's health/environment would keep the subject from doing so? Not Applicable J<_ No Yes If yes, please explain: d. If the study involves treating patients, will any of the drugs, devices, or treatment procedures be given to the subject free of charge? Not Applicable No Yes X_ If yes, please explain: Solution-Focused Group Therapy will be provided at no charge to subjects. 13. Funding of study procedures a. Will any study interventions such as tests, surgical procedures, or x-rays, be performed that are additional to the routine work or therapy for these types of patients? No Yes J(_ If yes, please list: Tests include the pretest; posttest and follow-up test utilizing the Chinese Beck Depression Inventory, the Dyadic Adjustment Scale, the Marital Status Inventory, and the Conflict Tactics Scale. All of these tests are surveys. b. Who or what agency will pay for the above tests? Subiects receive treatment, tests. and medication at no charge. c. Are there specific medications that must be used to meet the requirements of this protocol? No Yes J( If yes, please list: Standard antidepressant medication. d. Who or what agency will pay for the medications listed in c? The government of Taiwan

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14. Location University of Florida Cancer Center Center for Exercise Science Clinical Research Center Inpatient Outpatient Dental Clinics Gainesville Clinic. Name below: Student Health Center Shands Shands at UF Shands at AGH Shands at Lake Shore Shands at Live Oak Shands at Starke Shands at Vista Shands Children's Hospital Shands Rehabilitation Hospital Shands Surgical Center VAMC Inpatient Outpatient clinic Jacksonville University Medical Center Nemours Baptist Faculty Clinic. Name below: -JL Other: Kaohsiung Military General Hospital in Kaohsiung. Taiwan 15. Plans for medical emergency management, if needed: J<_ On site physician with emergency medications and equipment. Public or community emergency services, for example. 91 1 Other; please explain: 16. Confidentiality. What measures will be taken to protect the confidentiality of the information obtained, including what will be done with all tapes, pictures, and personal documentation of the subjects. Note: The IRB must be assured that data will be stored securely and will not be shared inappropriately. If using videotanes : There is standardized videotape consent text, available from the IRB in electronic form, that mus be included in the Informed Consent Form a. During the research: Confidential tiles will be maintained bv the Princi pal Investigator and will onlv be viewed bv the principal investigator and subjectsphvsicim 1 12

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1 13 b. After the research is completed: All identifying information will be destroyed when the research is completed. All audiotapes will be erased and any publications will report only group information and no identifiable information will be included. 17. Recruitment of subjects. How will subjects be recruited for the study? Note : Any print or broadcast announcement used to directly recruit subjects, including press releases, video scripts, electronic mail, or internet or web announcements, must first be reviewed by the IRB before being released to the public. Please be sure any media representative you are working with understands this condition. Outpatients will be referred to the Principal Investigator by the patients' psychiatrist/psychologist. Written Informed Consent will be obtained after the study has been thoroughlv e.xpiained to subjects. 18. Enroilment of subjects. Who will request the participation of the subjects in the study and in what manner will consent be obtained? Subjects' psvchiatrist/psychologist will ask of subjects who exhibit depression symptoms related to marital problems if they are interested in participating in the research. The Principal Investigator will obtained Informed Consent from subjects. 19. Informed consent. Who will provide informed consent (check all that apply); refer to Investigators Manual for explanations of each: X The subject The subject's parent The subject's guardian; may require court order to sign for experimental research A surrogate A durable power of attorney A proxy 20. Oversight review. Is there a person, other than the Principal Investigator, or a group responsible for reviewing adverse events and other issues related to the safety of the study? No X Yes If yes, complete a-c: a. Check all that apply: Sponsor Data Safety Monitoring Board (DSMB) Data Monitoring Committee (DMC) Local Departmental Committee Other please explain: ***However, it should be noted that subiects' psvchiatrist/p .svc hologist will work with the Principal Investigator while subiects are being treated. b. Describe its specific role, how often it will meet, and how often it will produce a report that can be shared with the IRB:

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I 14 c. Is there a provision for interim analysis of the data and early closure of the study? Yes No X ; please explain: Conflict of interest a. Do you. or does the University of Florida, hold a patent or license for any material, object, or process used in the study? No _X Yes b. Is a patent or license pending or under consideration or do you intend to file a patent application at a later date? No _X Yes c. Do you own stock in the company sponsoring this study? Not applicable X No Yes d. Do you give presentations for or serve as a consultant to the sponsoring company on their behalf? Not applicable J< No Yes e. Do you have any other possible conflict of interest? No _X Yes If yes, please explain: Conducting Research through the Clinical Research Center (CRC) — Optional. The CRC offers the services listed below; please indicate if you are interested in any of the services: • Timed blood sampling. NoJ( Yes • Facility to process and store blood samples. No X Yes • Inpatient or outpatient facility staffed by research-oriented nursing and dietary personnel. No J<_ Yes • Controlled dietary intake and computerized nutrient analysis of diets. No X Yes • Data Services Lab to manage and analyze your research data, correspond electronically with colleagues throughout the world, or access and analyze large public data bases? No _X_ Yes • Consultation with Clinical Research Center (CRC) staff about conducting your research through the CRC? No X Yes

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I 15 23. Request for Expedited Review. Expedited review may be granted both of the following conditions apply: (1) The study involves no more than minimal risk (probability and magnitude of harm or discomfort are no greater, in and of themselves, than those in daily life or in a routine physical or psychological examination or test). (2) The only involvement of human subjects will be one or more of the categories below, carried out through standard methods. Explanatory Notes • Activities listed below should not be deemed to be of minimal risk simply because they are included on this list. Inclusion on this list means the activity is eligible for review through the expedited review procedure when the specific circumstances of the proposed research involve no more than minimal risk to human subjects. • The categories in this list apply regardless of the age of subjects, except as noted. • The expedited review procedure may not be used where identification of the subjects and/or their responses would reasonably place them at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability. insurability, reputation, or be stigmatizing, unless protections will be implemented so that risks related to invasion of privacy and breach of confidentiality are no greater than minimal. • The expedited review procedure may not be used for classified research involving human subjects. 'IRBs are reminded that the standard requirements for informed consent (or its waiver, alteration, or exception) apply regardless of the type of r^v/^w-expedited or convened-utilized by the IRB. [• Categories one (I ) through seven (7) pertain to both initial and continuing IRB review. Please indicate under which category you are requesting expedited review: |_X_] No More Than Minimal Risk and Select One of the Following Categories: [ J 1 • Clinical studies of drugs and medical devices only when condition (a) or (b) is met: (a) Research on drugs for which an investigational new drug application (21 CFR Part 312) is not required. Note: Research on a marketed drug is not eligible if the research significantly increases the risks or decreases the acceptability of the risks associated with the use of the drug, (b) Research on medical devices for which (i) an investigational device exemption application (21 CFR Part 812) is not required; or (ii) the medical device is both cleared/approved for marketing and being used in accordance with its cleared/approved labeling. [ ] Collection of blood samples by finger stick, heel stick, ear stick, or venipuncture as follows: (a) Subjects are healthy, nonpregnant adults who weigh at least 1 1 0 pounds: amount drawn may not e.xceed 550 ml over 8 weeks; and collection may not occur more" frequently than 2 times per week. OR (b) Subjects are other adults and children". considering the age, weight, and health of the subjects; the collection procedure; the amount of blood to be collected; and the frequency with which it will be collected. For these subjects, the amount collected may not exceed the lesser of 50 ml or 3 ml per kg over 8 weeks, and collection may not be occur more frequently than 2 times per week. "Children are defined in the HHS regulations as persons who have not attained the legal age for consent to treatments or procedures involved in the re.search. under the applicable law of the Jurisdiction in which the research will be conducted. 45 CFR 46.402(a)

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1 16 [ ] 3. Prospective collection of biological specimens for research purposes by noninvasive means. Examples: (a) hair and nail clippings, if collected in a nondistlguring manner; (b) deciduous teeth at time of exfoliation or if routine patient care indicates a need for extraction; (c) permanent teeth, if routine patient care indicates a need for extraction; (d) excreta and external secretions (including sweat); (e) uncannulated saliva collected either in an unstimulated fashion or stimulated by chewing gumbase or wax or by applying a dilute citric solution to the tongue; (0 placenta removed at delivery; (g) amniotic fluid obtained at the time of rupture of the membrane before or during labor; (h) supraand subgingival dental plaque and calculus, provided the collection procedure is not more invasive than routine prophylatic scaling of the teeth and the process is accomplished in accordance with accepted prophylactic techniques; (i) mucosal and skin cells collected by buccal scraping or swab, skin swab, or mouth washings; Q) sputum collected after saline mist nebulization. [ ] 4. Collection of data through noninvasive procedures (not involving general anesthesia or sedation) routinely employed in clinical practice, excluding procedures involving x-ravs or microwaves. Where medical devices are employed, they must be cleared/approved for marketing. (Studies intended to evaluate the safety and effectiveness of the medical device are not generally eligible for expedited review, including studies of cleared medical devices for new indications). Examples: (a) physical sensors that are applied either to the surface of the body or at a distance and do not involve input of significant amounts of energy into the subject or an invasion of the subject's privacy; (b) weighing or testing sensory acuity; (c) magnetic resonance imaging; (d) electrocardiography, electroencephalography, thermography, detection of naturally occurring radioactivity, electroretinography, ultrasound, diagnostic infrared imaging, doppler blood flow, and echocardiography; (e) moderate exercise, muscular strength testing, body composition assessment, and flexibility testing, where appropriate to the age, weight, and health of the individual. [ ] 5. Research involving materials (data, documents, records, or specimens) that have been collected or will be collected solely for nonresearch purposes (such as medical treatment or diagnosis). Note: Some research in this category may he exempt from the HHS regulations for the protection of human subjects. 45 CFR 46. 10 1 [b] [4]. This listing refers only to research that is not exempt. [ ] 6. Collection of data from voice, video, digital, or image recordings made for research purposes. [-2L] 7. Research on individual or group characteristics or behavior (including, but not limited to. research on perception, cognition, motivation, identity, language, communication, cultural beliefs or practices, and social behavior) or research employing survey, interview, oral history, focus group, program evaluation, human factors evaluation, or quality assurance methodologies. Note: Some research in this category may he exempt from the HHS regulations for the protection of human subjects. 45 CFR 46. 101(h)(2) and (h)(3). This listing refers only to research that is not exempt. [ ] 8. Continuing review of research previously approved by the convened IRB as follows: (a) where (i) the research is permanently closed to the enrollment of new subjects; (ii) all subjects have completed all research-related interventions; and ( Wi) the research remains active only for long-term follow-up of subjects. OR (b) where no subjects have been enrolled and no additional risks have been identified. OR (c) where the remaining research activities are limited to data analysis. [ ] ^Continuing review of research, not conducted under an investigational new drug

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117 application or investigational device exemption where categories 2-8 above do not apply, but the IRB has determined and documented at a convened meeting that the research involves no greater than minimal risk and no additional risks have been identified.

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118 Protocol 1. Project Title: A Comparison Among Three Treatment Groups on Effectiveness to Depression Symptoms and Marital Problems 2. Principal Investigator: Mei-quei Huang Supervisor/Committee Chair: Dr. Silvia Echevarria Doan 352-392-073 1 x 237 Supervisors/Committee Members: Marital problems, such as marital adjustment, marriage dissolution, and spouse abuse have been found to be associated with the etiology and course of depression, which has become the most common psychiatric disorder seen by mental health professionals in the United States (Dobson & Jackman 1996). Research efforts in the treatment of depression, although extensive, have been rather limited in several ways. These include "the comparative effectiveness of psychological and pharmacological treatments, as well as combination treatments, for treating depression" (Barlow & Hoffmann 1997. pp. 102). This study will compare the effectiveness among three treatment groups provided for depressed patients in Military Kaohsiung General Hospital (MKGH). located in Kaohsiung, the second largest city in Taiwan. The three treatment groups are: ( I ) Solution-Focused Brief Therapy (SFBT) Group (Group 1 ), (2) antidepressant medication (Group 2). and (3) Solution-Focused Brief Therapy Group combined with antidepressant medication (Group 3). Forty-five (45) subjects diagnosed with affective disorder(s) such as minor depression, major depressions, and dysthymia will be referred by psychiatrists at MKGH. These subjects will be assigned to one of the three treatment groups previously described. Dr. James Pitts Dr. Ellen Amatea Dr. Davis Miller 352-392-0731 x 236 352-392-0731 x 232 352-392-0723 x 224 3. Abstract:

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1 19 The study question is: "Are there any differences among the three treatment groups in eliminating depression symptoms, stopping the dissolution of marriage, improving marital adjustment, and the reduction of spouse abuse of depressed patients with marital problems after eight weeks of treatment and four weeks of follow-up?" 4. Specific Aims: The intent of this study is to collect valid and reliable data to determine optimal treatment regimens and to evaluate the use of Solution-Focused Brief Therapy Groups for depression patients with marital problems and whether these treatments make a difference in their well-being after a three-month treatment period. 5. Background and Significance: Beach et al. (1990) state that experiencing marital distress is one of the six vulnerability factors found in depressed patients. Meichenbaum (1996) concludes a relationship between depression and marital distress based on the work of Beck et al. (1979), Beach et al. (1990), and Hollon and Beck (1993). Meichenbaum ( 1996) noted that twenty percent (20%) of all married couples are martially distressed, half of the patients (50%) who request psychotherapy do so because of marital discord, thirty percent (30%) of marital problems involve at least one spouse who is clinically depressed, fifty percent (50%) of those who request treatment for depression also evidence marital discord, and fifty percent (50%) of discordant couples have a depressed spouse. As more individuals seek treatment for depression, these studies indicate that there are growing concerns about the marital relationship as well. This study will base its inquiry on effective methods of intervention in the treatment of marital problems of depressed patients. Jarrett states in the Handbook of Depression (1995) that "No study conducted to date has produced main effects showing that antidepressants used alone reduce depressive symptoms in depressed outpatients significantly more than short-term psychotherapy." Furthermore. Chinese patients oftentimes request that psychiatrists avoid prescribing medication for the treatment of depression due to concerns of drug dependence and side effects. Many Chinese look for alternative methods for dealing with emotional problems, such as Chinese medications. TaiTze, Chie-Kaon, Buddhism, and meditation since many believe more in the natural methods of healing themselves. Chinese patients tend to believe that, while Western medicine may be more efficient, it also deprives a person's ability to heal themselves. It should be noted that, at this time, there is no standard of care for depressed individuals who suffer marital problems in Taiwan. The results of this study will have implications for mental health professionals, researchers, and for

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120 social policy. Solution-Focused Brief Therapy Groups may also be particularly useful for treatment options for patients who reject antidepressant medication as a standard treatment. 6. Research Plan: Subject selection The subjects for this study will be patients suffering from depression who also have marital problems. They must meet the criteria in the Diagnostic and Statistical Manual for Mental Disorders (4"" edition. DSM-IV; American Psychiatric Association, 1994) for major depressive disorder, dysthymia. adjustment disorder with depressed mood, or depressive disorder not otherwise specified. They must not meet criteria for schizophrenia, bipolar disorder, mood disorder due to a general medical condition, or substance-induced mood disorder. They must not have suicidal or homicidal thoughts or intentions. Medication alone and group psychotherapy alone both must be viable treatment options for the patients, and neither must put the patients at more risk than the care they would receive if they were not in the study. Patients must not be in any type of treatment for their depression at the time of referral. Psychiatrists working with outpatients in the psychiatry department of the Military Kaohsiung General Hospital will refer patients who meet these criteria to the principal investigator. The princiupal investigator and the psychiatrists assisting with the study will screen referalls to verify that the patients meet the criteria for the study. The study psychiatrists will confirm the diagnosis and confirm that the study treatments are viable alternatives for the patients and do not place the patients at increased risk. Referrals excluded from the study will be referred back to the referring psychiatrists for further assessment and treatment. The study This study will be an experimental design with a pre-post test and a four week follow-up test. A self-reporting questionnaire will be utilized to gather information from groups of subjects. The self-reporting questionnaire booklet will contain demographic information (age. years of marriage, status of marriage, number of children, socio-economic status, and prior diagnostic history), the Chinese Beck Depression Inventory (BDI 2! items), the Chinese Dyadic Adjustment Scale (DAS 32 items), the Chinese Conflict Tactics Scale (CTS 19 items), the Chinese Marital Status Inventory (MSI 14 items), and the SolutionFocused Brief Therapy Scaling questions. The data gathered from this questionnaire will be used for the comparisons between the three groups to determine the differences of pre-post and follow-up test results based on treatment group. Dependent variables include depression symptoms, likelihood of divorce, dyadic adjustment, spousal abuse, and goal accomplishment. Therapeutic elements of the treatment process will also be investigated. Transcription of the audiotape information will become part of each subjects" medical record and audiotape data will insure that group therapy sessions follow planned discussion topics as well as

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121 provide assurance that all group members are involved in the therapy process. The audiotapes will be destroyed at the end of this research study. Participants in Group I (Solution-Focused Brief Therapy Groups) will attend weekly group sessions that include an introduction, focusing on what works, pattern recognition, hunting for exceptions, thinking positively, doing something different, keeping the change going, and goals for the future. Participants in Group 2 (antidepressant medication) will take antidepressants prescribed by the psychiatrist. Participants in Group 3 (combined psychotherapy and antidepressant medication) will attend group therapy sessions in addition to taking antidepressants. Treatment duration is 8 weeks with a 4 week follow-up. The study psychiatrists will assess the subjects weekly, and at any time can stop, start, or change medications if they decide this is necessary. Participants in Group 1 who start and participants in Groups 2 & 3 who stop medication during the study will not be included in the data analysis. Participants in Groups 1 & 3 (the psychotherapy groups) who start or stop medication during the study can elect to continue in their groups. All participants can continue to see a psychiatrist after the study. There is a serious lack of marriage and family therapists in Kaohsiung, therefore, the Principal Investigator will co-lead psychotherapy group sessions with a psychiatrist. Dr. Lieu. Both group leaders will facilitate the groups under the supervision of Drs. Tzeng and Lung. All three psychiatrists will continue to see subjects weekly during the treatment phase of this study. Data analysis A Split Plot ANOVA will be used to detect differences across the three treatment groups (within subject factors), among the three treatment groups (between subject factors), and to investigate whether there is interaction between sessions and treatments. A one-way ANCOVA model will then be used to measure scores for both posttreatment and followup tests as the response variable and measures of scores at pretreatment as covariates in each case. The purpose is to determine whether there is a difference between treatments in postsession and follow-up. All pair-wise comparisons will be conducted using simultaneous confidence intervals (Westfall, Tobias. Rom. Wolfinger& Hochberg, 1999) in two statistic methods respectively. In the ANCOVA method, the presence of interaction will also be investigated between preintervention measures and the three treatments by employing the Johnson-Neyman technique. Sample protocol Any subject in this research will go through the following steps: a. Visit the Department of Psychiatry in the hospital. b. Assessment and diagnosis. c. If meets inclusion and exclusion criteria, refer to the Principal Investigator. d. Screening by Principal Investigator and study psychiatrist.

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122 e. If does meet the inclusion and exclusion criteria, the study will be discussed and Informed Consent obtained, f Random assignment to one of three treatment groups. g. Pretest. h. Two month treatment period. i. Posttest. j. One month follow-up. k. Further treatment or referral. 7. Potential Health Risks: Risks include the possibility of discomfort experienced by psychotherapy group participants as they reveal information to each other that might be embarrassinii or difficult to discuss. Risks otherwise are no more than the risks of the standard treatment the subjects would receive at the hospital, and may be less, since during the study the subjects will be more closely monitored than they would be if they were not in the study. If the treatment becomes too uncomfortable or potential harm is noticed by the Principal Investigator or the supervising psychiatrists, the participants will be able to withdraw from the study without penalty. Debriefing will be provided by a trained therapist associated with this project and referrals for on-going marital/family therapy will be provided if needed. 8. Potential Health Benefits: Participants may become less depressed and their marital problems may improve. 9. Potential Financial Risks: The Military Kaohsiung General Hospital is a facility that is open to ail citizens of Taiwan. There are no potential financial risks associated with this research project. 10. Potential Financial Benefits: There are no potential financial benefits to research subjects. 1 1 Conflict of Interest: There is no conflict of interest in this research project.

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123 IRB# 504-2000 Informed Consent to Participate in Research The University of Florida Health Science Center Gainesville, Florida 32610 You are being asked to participate in a research study. This form provides you with information about the study. The Principal Investigator (the person in charge of this research) or his/her representative will also describe this study to you and answer all of your questions. Read the information below and ask questions about anything you don't understand before deciding whether or not to take part. Your participation is entirely voluntary and you can refuse to participate without penalty or loss of benefits to which you are otherwise entitled. Title of Research Study A Comparison Among Three Treatment Groups On Effectiveness To Depression Symptoms And Marital Problems Principal Investigator(s) and Telephone Number(s) Mei-quei Huang 07 3681002 (Taiwan) Dr. Forwey Lung 07 7490782 (Taiwan) Dr. Silvia Doan 2 1 352-392-073 1 x 237 (USA) Sponsor of the Study None. What is the purpose of this study? The purpose of this study is to determine which of three treatments most improves the symptoms of depression and marital discord. The treatments are Solution-Focused Brief Group Therapy {Group 1 ), antidepressant therapy (Group 2). and the combination of Solution-Focused Brief Group Therapy and antidepressant therapy (Group 3). What will be done if you take part in this research study? You are being asked to take part in this research study because you have come to the Military Kaohsiung General Hospital for the treatment of marital problems and depression.

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and your psychiatrist has decided that either brief group psychotherapy or antidepressant medication is a good treatment for you. If you choose to be in the study you will be randomly assigned (like the flip of a coin) to one of three treatment groups: Group 1 is the Solution-Focused Brief Group Therapy only group. Group 2 is the antidepressant medication only group, and Group 3 is the combination Solution-Focused Brief Group Therapy and antidepressant medication group. No matter which group you are assigned to, you will to see your psychiatrist every week. After the study is over you can continue to see your psychiatrist, or be referred to another psychiatrist at the hospital. GROUP 1 Solution-Focused Brief Group Therapy group. You will complete a survey of 87 questions at the beginning of the study. You will then attend a therapy group every week for 8 weeks. In the group you and the other participants will talk about your marital problems and depression, and with the help of the therapists will work out possible solutions. At the end of 8 weeks you will complete the survey a second time, and at the end of 12 weeks you will complete it again. All group therapy sessions will be audiotaped. Your psychiatrist will assess your depression every week, and will prescribe medication for you if you should need it. If this happens you can elect to continue in the group. GROUP 2 Antidepressant Medication group. You will complete a survey of 87 questions at the beginning of the study. Your psychiatrist then will prescribe commercially available antidepressant medication for you. Your psychiatrist will monitor your progress weekly, and will adjust the medication on the basis of how it affects you. At the end of 8 weeks you will complete the survey a second time, and at the end of 12 weeks you will complete it again. GROUP 3 Solution-Focused Brief Group Therapy and Antidepressant Medication group. You will complete a survey of 87 questions at the beginning of the study. You will then attend a therapy group every week for 8 weeks. Your psychiatrist also will prescribe commercially available antidepressant medication for you. In the group you and the other participants will talk about your marital problems and depression, and with the help of the therapists will work out possible solutions. Your psychiatrist will monitor your progress weekly, and will adjust the medication on the basis of how it affects you. At the end of 8 weeks, you will complete the survey a second time, and at the end of 1 2 weeks you will complete it again. All group therapy sessions will be audiotaped. If you and your psychiatrist decide to stop your medication during the study you can elect to continue in the group. What are the possible discomforts and risks? If you are in Group 1 or Group 3. you will be talking about your marital problems and feelings of depression with other members of the group, and may feel uncomfortable or embarrassed.

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125 If you are in Group 2 or Group 3. you will be taking antidepressant medication. Your psychiatrist will discuss the risks of this with you. Whichever group you are in, you must notify your psychiatrist if your marital problems or depression get worse, or if anything unexpected happens with your health. If you are a woman of childbearing potential, antidepressant medication may have special risks for you or for the embryo or fetus if you become pregnant. According to the policy of the hospital, you will not be prescribed any antidepressants if you are pregnant or if you intend to become pregnant. If you wish to participate in this study and are assigned to Group 2 or Group 3 (the antidepressant medication groups), it will be necessary for you to have a pregnancy test and use birth control to prevent pregnancy. If treatment becomes too uncomfortable, or becomes potentially harmful, the Principal Investigator or the supervising psychiatrists will withdraw you from the study. A trained therapist will debrief you and. if needed, will refer you for marital and family therapy. You can continue to see your psychiatrist, or be referred to another psychiatrist in the hospital. If you wish to discuss the information above or any other discomforts you may experience, you may ask questions now or call the Principal Investigator listed on the front page of this form. What are the possible benefits to you or to others? If you are in Group 1 or Group 3 the group therapy may help you identify and resolve problems that contribute to your marital discord and depression, but there are no guarantees this will happen. If you are in Group 2 or Group 3 the antidepressant medication may help your depression, and your marital problems may improve as a result, but there also are no guarantees this will happen. If you choose to take part in this study, will it cost you anything? It will not cost you anything to take part in this study. You will have to pay the fees charged by the hospital that are not related to this research study. Will you receive compensation for your participation in this study? You will not be paid for taking part in this research study.

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126 What if you are injured because of tlie study? If you experience an injury that is directly caused by this study, no compensation is offered. Hospital expenses will have to be paid by you or your insurance provider. If you do not want to take part in this study, what other options or treatments are available to you? Participation in this study is entirely voluntary. You are free to refuse to be in the study, and your refusal will not influence current or future health care you receive at the hospital. If you choose not to be in the study you will continue to see a psychiatrist at the hospital. The psychiatrist may prescribe medication for you, or may refer you for marital and family therapy. How can you withdraw from this research study? If you wish to stop your participation in this research study for any reason, you should contact: Mei-quei Huang at (07)3681002 or her supervisor. Dr. Lung at (07) 7490782 You may also contact Ms. Huang's faculty supervisor. Dr. Doan at 0021 (352) 3920731 extension 237 You are free to withdraw your consent and stop participation in this research study at any time without penalty or loss of benefits to which you are otherwise entitled. Throughout the study, the researchers will notify you of new information that may become available and that might affect your decision to remain in the study. In addition, if you have any questions regarding your rights as a research subject, you may phone the University of Florida Institutional Review Board (IRB) office at 002 1 (352) 8461494. How will your privacy and the confidentiality of your research records be protected? Your privacy will be given the highest priority and your data will be kept confidential to the extent provided by law. Steps to protect your privacy include ( 1 ) disguising any identifying information in the final report, (2) keeping all of your records in confidential flies to be seen only by those who participate in this research project (for example, psychiatrist, transcribers, the principal investigator, and her research assistants), and (3) erasing or destroying all audiotape records at the end of this research study. You may have access to any of your information and the analysis of your information. You will also be given the opportunity to comment on the results of this research study. Authorized persons from the University of Florida, the hospital or clinic (if any) involved in this research, and the Institutional Review Board have the legal right to review vour

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127 research records and will protect the confidentiality of those records to the extent permitted by law in the United Stales of America and the law in Taiwan. Otherwise, your research records will not be released without your consent unless required by law or a court order. If the results of this research are published or presented at scientific meetings, your identity will not be disclosed. Will the researchers benefit from your participation in this study (beyond publishing or presenting the results)? The researcher will not benefit from your participation in this study beyond fulfilling the requirements for a Doctoral Dissertation in the Department of Counselor Education at the University of Florida and publishing or presenting the results.

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128 Signatures As a representative of this study, I have explained the purpose, the procedures, the benefits, and the risks that are involved in this research study: Signature of person obtaining consent Date You have been informed about this study's purpose, procedures, possible benefits and risks, and you have received a copy of this Form. You have been given the opportunity to ask questions before you sign, and you have been told that you can ask other questions at any time. You voluntarily agree to participate in this study. By signing this form, you are not waiving any of your legal rights. Signature of Subject Date Signature of Witness (if available) Date You also give your permission to be audio taped while taking part in the group therapy sessions. These audiotapes will be transcribed for your medical record and to obtain research data, however, all identifiable information will not be included in the research data and these tapes will be destroyed at the end of this research study. Signature of Subject Date

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129 Gainesville, Florida 32601, USA (07)3681002 (ai^) fiff fw (07)7490782 mM) Dr. Silvia Doan 0021-352-392-0731 x 237 (; ittw^!^g6^it ( 1 ) mmm (3) ^t=wT • it^w^^n^^i^xm^mxm^m&mmmxmmmm^'ih 1 ) fn:a##M (2) mm'bm^mm ^Jc^ (3) mwwrm

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131 nxmm^m (o?) 368 1002 : ^w^'gism^Mf^fwifii mm (o?) 7490782 o mmtmmmmm ti^aJl-^llT'aHSJfJ^aMMilA^flS^ Dr. Doan, TEL: 0021-352-3920731, 237. mmm'^mm.'U^ mwtmmm'mmm u it^'^i^Ai^m'tm^mm-^miLim (02) 23210151 = i^^Hwit-g. M;^^fiWf95#^#M# TEL: 0021-352-8461494. ^W^Sii^i^^f^ m^it^^mUlt

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132 m.%BmH ********************************************** ******:|,*##*#:^## mmBm_^_Fi_B ********************#****:^**#:^*^^^^^^^^^^^^^^^^^^^^^^^^^^^^_l^^^^^^^^^^^^_^ w^am^w : Bm

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133 MEMORANDUM FOR APPROVAL UNIVERSITY OF FLORIDA Health Center Institutional Review Board MEMORANDUM DATE: April 9, 2001 TO: Mei-Kuei Huang FROM: R. Peterlafrate, Pharm.D. Chair, IRB-01 SUBJ: I RB Protocol #172-2001 Expires on 4/4/02 TITLE: A COMPARISON OF THREE APPROACHES TO REDUCE MARITAL PROBLEMS AND SYMPTOMS OF DEPRESSION You have received IRB approval to conduct the above listed research project. Approval of this project was granted on 414/01 Enclosed is the dated, IRB-approved Informed Consent Form that must be used for enrolling subjects into this project from 4/4/01413102. You have approval for 12 months only. You are responsible for applying for renewa/ of this project prior to the expiration date. Re-approval of this project must be granted before the expiration date or the project will be automatically suspended. If suspended, new subject accrual must stop. Research interventions must also stop unless there is a concern for the safety or well being of the subjects. You must respond to the continuing review questions within 90 days or your project will be officially terminated. The IRB has approved exact/y what was submitted. Any change in the research, no matter how minor, may not be initiated without IRB review and approval, except where necessary to eliminate hazards to human subjects. If a change is required due to a potential hazard, that change must be promptly reported to the IRB. Any severe and unanticipated side effects orproblems, and all deviations from federal, state, university or IRB regulations must be reported, in writing, within 5 working days. Upon completion of the study, you are required to submit a summary of the project to the IRB office. Research records must be retained for three years after completion of the research: if the study involves medical treatment, it is recommended that the records be retained for eight years. If VAMC patients will be included in this project, or if the project is to be conducted in part on VA premises or performed by a VA employee during VA-compensated time, review by the VA Subcommittee for Research is required. You are responsible for notifying all parties about the approval of this project, including your co-Investigators and Department Chair. If you have any questions, please feel free to contact the IRB-01 office at (352) 846-1494. Cc: IRB File Pharmacy VA Research Center Clinical Research Center

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APPENDIX G THE SCALING QUESTION IN PRETREATMENT ON A SCALE ZERO TO TEN Please briefly write down the problem you would like for us to work on during the following eight weeks. We would also like for you to consider a zero to ten scale, where 10 is when the problem was at its worst, and 0 is when it is solved to your satisfaction and the number that best describes where you are now. My goal for the treatment is to solve the problem as described as follows: I am now standing at: 0 1 2 3 4 5 6 7 8 9 1 0 134

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APPENDIX H THE SCALING QUESTION IN POSTTREATMENT ON A SCALE ZERO TO TEN We appreciate your effort be part of the group for two months. Now that the group is over, we would like for you to use a score on the same zero to 10 scale, where 10 is when the problem was at its worst, and 0 is when it is solved to your satisfaction, where you are now. My goal for the treatment is to solve the problem as described as follows: I am now standing at: 0 1 2 3 4 5 6 7 8 9 1 0 Did I make any difference on the problem? How did I do to make it happen? 135

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APPENDIX I READING MATERIAL Depression In counseling families on how to help a depressive patient, we try to make several points. First and uppermost, the patient has an illness. Second, the patient is not trying to exploit the family members. Depressed patients have feelings of hopelessness, decreased initiative, and feelings of helplessness. They need help to perform many activities they could easily handle alone when well, when the depression becomes more severe, they are unable to perform such activities even with help. Third, as our case examples illustrate, the patient's illness can disrupt and disorganize family life. At the simplest level, for adults, there is often a loss of function. The wage earner may work less effectively and sometimes cannot work at all. The housewife neglects her house or children. Depressed patients can also be extremely difficult to live with. In contrast to a family member who is psychotic and hears voices or has visions, depressives have problems that appear to be only exaggerations of normal human problems. It is easy for family members to understand that a psychotic person is ill, but depressed individuals may not seem to have a disease. They often engender familial unhappiness and anger by being a "wet blanket." They do not enjoy things. They do not initiate activities-they must be pushed or pulled. They do not fulfill appropriate duties in their relationships. It is difficult not to see this as laziness or selfishness if the family does not recognize the real pain involved. The black, pessimistic views of these patients become tedious. Things are no good, things never were any good, things will never be any good. They may be irritable, complaining, a "sour puss." They are not affectionate-in depression, many lose feelings of warmth and love. Since depressives are uninterested in sex, it is difficult for their partners not to experience this as rejection and as lack of love. Other members of the family tend to react with resentment and anger and to distance themselves from the sufferer. Because depressed patients have feelings of helplessness and feel increasingly dependent, such reactions, even though completely understandable, may worsen the depression. Fourth, in some instances the depressive's feelings may be completely unrelated to what is really happening in her life. The depressive's business, marriage, and children may be flourishing, and yet she will feel that life is empty and barren. It is pointless to say, "Look at all you have to live for." Her feelings are irrational, and she cannot be argued out of them. When she says, "I 'm no good.... My life has been a failure.... Things will not get better," telling her that she's mistaken is not useful and may add to her demoralization. Notice that we are not say that the family members should agree with the patient, but merely 136

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137 that they should not try to talk her out of her feelings, since she experiences such arguments as another putdown. It is useful for family members to tell the patient that they are sorry that she feels so bad and to tell the patient that they are sorry that she feels so bad and to remind her that these feelings are a part of the depressive illness and will eventually diminish. The family's job is to maintain optimism and perspective. The most serious symptom the family must recognize in a depressed person is suicidal thinking. When a depressive illness has become that severe, skilled professional help is necessary immediately. The depressed person oftenbut not always-expresses the suicidal feelings he experiences, saying, for example, "Life is not worth living." or "I'd be better off dead," or "Life seems purposeless." Furthermore, because the mood of some suicidal patients lifts when they finally decide to commit suicide, the family should not take an apparent improvement at face value. When family members are in doubt, they should seek a psychiatric consultation at once. When they are in doubt, they cannot leave matters to the patient. Depressed patients who are suicidal may, because of their feelings of grave pessimism, reject any notion that treatment could be of help. In some instances the depressed patient must be hospitalized involuntarily. If the family suspects that the situation calls for hospitalization and the patient does not have a psychiatrist, then should contact the psychiatric crisis unit at a large hospital. If none are available, they should call the police. In many localities the police have been trained to deal with psychiatric emergencies and can help take the depressed patient to an appropriate treatment unit. Occasionally, a depressed patient may not want the family involved. If so, he and the doctor should discuss that option and come to a decision together. Cited from D. F. Klein. & P. H. Wender. 1993. Understanding depression : A complete guide to its diagnosis and treatment. New York: Oxford University Press.

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APPENDIX J GROUP WORKBOOK 1 The coversheet of the workbook 1 39 2. The contract of the group 140 3. Homework assignment after precession meeting 141 4. Session one: Becoming a group 142 5. Session two: Stepping back and moving on 145 6. Session three: Noticing the track and the pattern 148 7. Session four: Hunting for exceptions 151 8. Session five: Thinking positively 154 9. Session six: Doing something different 157 10. Session seven: Keeping the change going 160 1 1 Session eight: Setting goals for the future 163 138

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139 GROUP WORKBOOK NAME: FROM: TO:

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140 Group Contract RULES FOR US: 1. 2. 3. IMPORTANCE THINGS TO REMEMBER: 1 Please call us if you are not able to come. 2. You can contact Miss Huang at (07) 368 1 002 or 093 1 -890895 at any time during the research period. YOUR RIGHT TO CONFIDENTIALITY: Without your consent, the researcher will not disclose anything that is said or done in the group unless there is risk for suicide or homicide among our group members. Your privacy will be given the highest priority, and any data gathered in the group will be kept confidential to the extent provided by law. Steps to protect your privacy will include (I) disguising any identifying information in the final report, (2) keeping your records in confidential files to be seen only by those who participate in this research project (i.e., the group leaders, the psychiatrists, transcribers, and principal investigators) and (3) erasing or destroying audiotapes and/or videotapes at the end of this project (by December 1 5, 2001). You may have access to any of your data and the analysis of your data, and you will be given an opportunity to comment on the research findings made by the researcher. THE PAYMENT: 1 There will be no extra fee for this group under the National Insurance System. I have read the description of the group and understand rules decided by the group. I voluntarily agree to participate in the group and to keep to myself anything that is said in the group. 1 have received the copy of the group guidelines. Signature of the participant Date Signature of the group leaders Date

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Homework Assignment: I think I after the group is over. I think I have already seen a positive change since I decided to join the group. It was: I think I may be different from the way 1 am now in terms of I guess what may be different between me and my husband/wife from we are now will be I surely hope my family will be different then from the way it is now in terms of Fmi:! Sharing

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142 Session 1 Becoming a Group Somewhere in my childhood or youth, I must have done something good. For there you are standing there loving me. In "The Sound of Music"

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143 WORKSHEET 1 Laugh and Smile. Let the trouble go by. Introduction of a group that values joyful experience featuring curiosity, connection, collaboration, and co-construction. It starts with "to tell the truth, laughter is very good for your well being." Hey, if s a jolce! "What a coincidence!" Husband says to wife, I don't know why you wear a bra, you don't have anything to put in it." Wife says, "you wear underpants, don't you?. **A couple has been married for 30 years. They enjoy having sex each night. Unfortunately, the wife had some kind of illness recently. Their family doctor said that they should discontinue sex for six months or the wife might risk her life. So the couple decided to sleep in separate rooms. The husband was on first tloor. and the wife on the second floor. However, after three months of lonely nights, the husband decided to end his abstinence. When he stepped on the stairs, he saw his wife coming down from the second floor. She said. "oh. dear. I am coming to you to give my life." The husband replied, what a coincidence, my darling. I am on my way to take your life."

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144 Homework Assignment 1 What I want to continue to happen Guide: ''Between now and the next time we meet, I'd like you to observe what happen in your (marriage, family, life, relationship, etc.) that you want to continue to happen. Please be able to describe your observation at the next meeting. Fmiim Sharing

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145 Session 2 Step Back & Move On "Don't lose us. Don't throw us away. I'll only say this once. I've never said it before. But this kind of certainty comes but once in a lifetime." In "The Bridges of Madison County."

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146 Worksheet 2 Myth makes us miss. Guide: ''Today I would like for everyone to comment on the following statements'' Our problem has lasted so long, it's too late to change. My husband/wife can't communicate. My wife nags all the time. We've grown apart. My spouse had an affair, the marriage can't work. 1 don't love him/her any more. "There may be more. Please write them down. It^s a joke! "It depends on how you put it! Dr. Lin: "Mrs. Huang. I understand you do not want any children. I would like you to use this small loop instead of pills. All you have to do is to put it in the position where sperms enter the womb. It will prevent pregnancy". After a week. Mrs. Huang came back to the clinic. Dr. Lin: "How did the loop work? Did it cause you any trouble?" Mrs. Huang: "Nothing troubled me actually. But my husband felt it quite annoying. That loop always got caught up with the zipper of his trousers. And every time he went to the rest room, the other guys would stop to see how he took off that loop."

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147 Homework Assignment 2 It happens all the time. I found out that there is a pattern to our (me and my husband/wife) reactions to each other. Futn Sharing

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Session 3 Noticing the track and the pattern

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149 Worksheet 3 Breaking the pattern Guide: // sounds like we are humans who tend to stay in a track that used to work fine for us. However, it is not quite the same now. Would you like to give feedback about anyone 's story? Tell him/her about your ideas leading in different direction and what you might have done differently With help from others, we might be able to free ourselves from avers ive patterns. Ifs a Joke! No problem is unsolvable.[ The couple was checking out of the hotel. I seldom saw two persons watching each other so passionately. After they left, 1 asked the manager, "are they newlyweds?" I am afi-aid I cannot answer that question. But when they checked in yesterday, they were really mad at each other. I bet when they entered the room, they would blow up right away. So I gave them room #7." "What is so special about room #7?" "Oh, that is a room with the worst bed. We planned to replace the bed long time ago. It was broken in the middle. No couple can sleep on either side of the bed."

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150 Homework Assignment 3 There were times when things were different. I remember in the past ****; we have been fighting for ********. But somehow, there were times things were different. It was like • I guess it was because • If I'd like it to happen again, maybe I could_ Fn r Shai-ing

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151 Session 4 Hunting for Exceptions -the palace of wind. That's all what I've wanted to walk In such a place with you... an earth without maps." In "The English Patient"

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152 Worksheet 4 Good will hunting Guide: "Let 's share one another 's exceptional stories ". Tfs 1* jotco! "What's the same maybe very different. A very pretty female undergraduate was embarrassed by being asked a physiology question. Which part of the human body will extend ten times as compared with the normal size?" She said, "I refuse to answer this question." She also avoided eye contact with the professor. Another student was asked the same question and answered correctly. "The pupil." "Miss Lee," The professor replied, "your refusal helps me come to three conclusions. Number one, you did not do your homework last night. Number two, you allow your mind to wander too much. Number three, you will be very disappointed when you get married."

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153 Homework Assignment 4 If a miracle happened in the night, how would your life be different? Guide: Suppose that one night while you were asleep, there was a miracle and this problem was solved. How would you know? What would he different? How would your husband/wife know without your saying a word to him/her about it?

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154 Session 5 Thinking Positively "Promise me that you will never give up. No matter how hopeless it can be. "I promise." In "Titanic"

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155 Worksheet 5 You decide your own reaction to the world. Guide: ''There is a story about a crying old lady and a laughing old lady in the Buddhist Bible. The lady eventually decided to show her smiling face everyday. Would someone tell this story for us? I would like to hear your comments on (1) why hadn 7 the thoughts come to the old lady 's mind before? (2) Will the old lady he pessimistic after that day? (3) How am I related to this story? It^s a joke! Upside down thinking. A female college student came back to her dorm at midnight. As she was changing her clothes, her roommate saw that there was a big "M" on her breast. She asked, "How did that happen?" She answered, it was all my boyfriend's fault. Every time he makes love to me, he wants to wear his school T-shirt And the capital letter of his school makes an "M" on my body." "Let me guess which college he is in. Minnesota? Michigan?" "No. it's Wisconsin."

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156 Homework Assignment 5 Turn your brain upside down. I know I can change the way I think about (Make it three). F 11 n Sharing

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157 Session 6 Doing Something Different My compliment to you is, you make me want to be a better man." In "As Good as it gets.

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158 Worksheet 6 Synchronicity Guide: "A psychologist, Jung, described a phenomenon called "synchronicity. It talks about how an agent in the universe would start to reinforce you once you decide to make your dream come true. Unless you give up, your dream will come true eventually. How do you feel when you hear this? It^s a joke! "Go for it!" A man was troubled by insomnia. He sought help from a psychologist. The psychologist taught him some relaxation techniques. He said, "first, you tell your toes, sleep, toes. Then, you tell your feet, sleep, feet. Then leg. then arm, and finally you will relax your whole body and fall asleep." The man went home and began to use these techniques. But when it came to relaxing eyes, the man saw his wife come into the room wearing very sexy pajama. He jumped off the bed and shouted, "Wake up! Wake up! All of you!"

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159 Homework Assignment 6 Even if there is no miracle, life has changed. Guide: "Did you notice that even if tliere is no miracle happened at night, life has been changed? Would you like to share some with us?" Guide: "Check out and watch the video "Indecent Bargain" Fun Shafjjmg

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160 Session 7 Keeping Change Going "If you really want something very badly, set it free. If it comes back to you. it will be yours forever. If it doesn't, it is not something for you to begin with." In "Indecent Bargain"

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161 Worksheet 7 It is not for-get; it is for-give. Guide: "In the movie "Indecent Bargain", it was stated "if a couple decides to continue staying together, it is not because they decide to forget what had happened, it is because they decide to forgive themselves. Would you like to share your thinking about this ? It's a Joice! "It's nice to /orgg/ sometimes." A wife had a concern about her husband's lack of sexual interest. She talked him into seeing a sex therapist. It turned out perfectly well, except her husband would leave the bedroom for a while when they were making love. One day the wife followed him and saw him staring in the mirror. TTie husband was murmuring to himself, "She is not my wife, she is not my wife,...."

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162 Homework Assignment 7 For both give and get Guide: "Please continue to observe what had been changed in your life. How can you keep it happening? It is a matter that you try to think and do in both/and minded.

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163 I want us to be a family as long as we can." In "Regarding Henry."

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164 Worksheet 8 A true encounter with our lives. Guide; One of the most popular writers, Lin Chin-Shan talked about the "Yen that made people meet one another. He said, "life is like a grain in the ocean, and the chance for people to meet one another is like the tip of this grain. We might have made engagements in countless previous lives so that we are able to meet one another in this life. Now, we finally got together. Please listen to the sound heard by one another 's heart This is the final session of the group therapy. I would like everyone to give some nice words to one another and wish we will meet again someday in this life and after. It's a joke 1 "It only needs imagination." My husband told me this story one day. — A man wanted to buy a bra for his wife but he did not know the exact size of her breast. The cleric tried to help him with the greatest patience and asked, "what do they remind you of? Melons, grapefruits, oranges, or eggs?" This man said, in fact, they are really not like any of them. But since you mentioned about eggs, hers are really like eggs, fried."" I asked my husband if the size really matter. He replied, not in my case. Because I can always operate my imagination."

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Homework Assignment 8 Plan for tomorrow. Guide: "Please describe your plan for the future again, but more in detail.

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BIOGRAPHICAL SKETCH Mel-Kuel Huang was born In September 26, 1954. Her father gave her this name because he wanted his first daughter as beautiful as "a yellow rose," which is the meaning of "huang mei-kuei" in Chinese. She grew up and earned her B.A. in education from the Taiwan Normal University in 1976, and her M.A. In educational psychology and counseling from the same university in 1995. She Is the mother of two sons; one Is 21 and the other Is 17. She has been married for 22 years. She cherishes her family very much.

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philos^p#fy ^ rrTvia F.chevarria Doan. Chair Associate Professor of Counselor Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Phj^ophy. •lien Aii^atea Professor of Counselor Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosodw. Professor of Counselor Education I certify that 1 have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. David Miller Professor of Educational Psychology This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. December, 2001 /earn. College of Edudatfbn Dean, Graduate School


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