Can questionnaire reports correctly classify relationship distress and partner physical abuse

Clinical researchers investigating the correlates, etiology, and treatment of relationship distress have long accepted the use of questionnaires to classify couples as “distressed” and “nondistressed” (see Gottman, 1979, 1994, for reviews). In contrast, clinical researchers investigating the correlates, etiology, and treatment of individual psychopathology have used structured clinical interviews with standardized criteria to classify individuals with and without disorders (e.g., the Structured Clinical Interview for DSM-IV Axis I Disorders—Clinical version; SCID; First, Gibbon, Spitzer, & Williams, 1997). Although such criteria have been criticized for imposing categories on dimensional phenomena and for deriving categories on a less than empirically sound basis (cf. Meehl, 1995), researchers have benefited from standardization of classification criteria and from the external validity provided by common research and clinical criteria. Despite such controversy, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) represents the consensus opinion among mental health professionals about the criteria for each mental disorder. No such consensus document exists for delineating the criteria for relationship distress. Instead, researchers have adopted a convention that distress is indicated by a score of 97 and below on the Dyadic Adjustment Scale (DAS; Spanier, 1976) or 100 and below on the Marital Adjustment Test (MAT; Locke & Wallace, 1959). Unfortunately, such an approach (a) makes it impossible to determine how often such determinations of distress are correct (Eddy, Heyman, & Weiss, 1991); (b) does not take into account measurement error that could render decisions based on a single score unreliable (Jacobson & Truax, 1991); and (c) mirrors Spanier’s tautology that relationship adjustment is both a process and an outcome of that process (by making adjustment scales both quantitative measures of the form and content of relationship problems and qualitative measures of clinical relationship distress). Perhaps most problematic, however, is the reification of the cutoff scores themselves. The DAS score of 97 and below appears to have been adopted as the cutoff because it was 1 standard deviation below the mean for Spanier’s original sample of factory workers in Eastern Pennsylvania (Spanier, 1976). The origin of the cutoff score of 100 on the MAT is more mysterious, given the brevity of the original report (Locke & Wallace, 1959) and the lack of any paper establishing the psychometric soundness of the cutoff. To be fair to the developers, despite the 40 years after the publication of the MAT and 25 years after the DAS, establishing the soundness of the cutoff is still difficult, considering that there is still no gold standard diagnostic interview to which they could be compared. Our prior work (Eddy et al., 1991; Heyman, Sayers, & Bellack, 1994) compared the DAS scores of clinic couples with those of community couples (eliminating community couples who declared themselves “unhappy” on the DAS global satisfaction question) and concluded that despite fairly good sensitivity and specificity, spouses classified as distressed on the DAS were truly distressed only 43%–71% of the time. Neither study had a well-operationalized “true diagnosis” criterion variable; the current study is intended to fill that gap by creating face valid diagnostic interviews for relationship distress and physical abuse. Jacobson and colleagues (e.g., Jacobson & Truax, 1991) have attempted to ameliorate the problem of declaring a treated couple as a treatment success if they score 98 and above on the DAS but a treatment failure if they score 97 or below by suggesting that an error band (based on the reliability of the scale) be placed around adjustment scores. Thus, some couples would be clearly “distressed,” some clearly “nondistressed,” and some indeterminate (i.e., their scores fall within the cutoff point ± standard error). Although this suggestion is an improvement, it still fails to allow for the testing of the validity of DAS cutoffs against an independent criterion. By not adopting more stringent standards (either Jacobson’s or others) for classifying couples as distressed or nondistressed, researchers may misclassify couples and thus confound between-groups comparisons. Only a comparison of relationship adjustment measures with clinical criteria will allow us to establish the extent to which adjustment scales misclassify couples. Classification for partner abuse has been much more straightforward, although ironically more controversial. The Conflict Tactics Scale (CTS; Straus, 1979) is the standard scale for assessing relationship aggression. Items are arranged from most constructive (“discussed issue calmly”) to most abusive (“used a gun or knife on the partner”). All physical assaults, beginning with the mildest (“threw something at the partner”), are classified as physical aggression (Straus, 1979). The CTS’s controversial status resides in the consistent finding that women are as aggressive or more aggressive than are men (e.g., Archer, 2000; Straus & Gelles, 1990). If aggression connotes physical assault and abuse connotes victimization, injury, fear, and subjugation, women are, by far, more frequently abused. For example, in the nationally representative 1985 National Family Violence Survey, severely assaulted women were seven times more likely to seek medical attention than were severely assaulted men (Stets & Straus, 1990). In clinical samples, women’s risk of injury was three to seven times that of men (Cantos, Neidig, & O’Leary, 1994; Cascardi, Langhinrichsen, & Vivian, 1992). The adverse mental health consequences of women’s victimization include increased rates of depression (Cascardi, O’Leary, Schlee, & Lawrence, 1995) and elevated levels of depressive symptomatology (e.g., Stets & Straus, 1990; Vivian & Langhinrichsen-Rohling, 1994); posttraumatic stress disorder rates are elevated (between 33% and 47%) in both outpatient treatment and shelter settings (e.g., Cascardi et al., 1995; Dutton, 1992; Housekamp & Foy, 1991; Schlee, Heyman, & O’Leary, 1998). In conclusion, when only behavioral acts are measured, men and women appear to be equally aggressive. When the physical and psychological consequences of aggressive acts are included, women are far more likely to be victims than are men. Recently, O’Leary and Jacobson (1997) reviewed the partner abuse literature for the DSM-IV Sourcebook. They also made recommendations for experimental criteria for the new DSM-IV codes (V61.1, Physical Abuse of Adult; 995.81, Physical Abuse of Adult [if focus of attention is on victim]). DSM-IV mandates that diagnoses be gender neutral (unless the disorder or problem is intrinsically gender related) posed difficulties for a field that typically views partner aggression as being a form of men’s domination and control of women (cf. Yllo, 1993). To set the threshold for diagnosable abuse, O’Leary and Jacobson (1997) proposed criteria that included a consideration of both the occurrence of abuse and its impact (i.e., resulting in injury or significant fear). We have used this interview (Heyman, 1993; see the appendix) in a study of patients in a family practice setting (Pan, Ehrensaft, Heyman, O’Leary, & Schwartz, 1997); this study extends this work by assessing the diagnoses when both spouses are interviewed. The purpose of this study is to evaluate whether questionnaire reports can correctly classify relationship distress and partner physical abuse when compared with diagnostic interviews. First, in keeping with our prior findings with adjustment measures (Eddy et al., 1991; Heyman et al., 1994), we expect that the DAS will be moderately capable of distinguishing distressed from nondistressed couples. Second, we believe that briefer measures of global satisfaction will perform equally as well. This is worthwhile to test because of both brevity and parsimony (i.e., adjustment measures contain a melange of constructs, including estimations about the future of the relationship, e.g., Fincham & Bradbury, 1987). Third, given the concrete nature of the CTS, we predict that it will be highly related to interview reports when the occurrence-only criterion is used, thus classifying an equal number of women and men. However, we believe that far more women than men will be classified as victimized when the occurrence and injury–fear criteria are used. Finally, we wish to test the reliability of the diagnoses in a variety of ways (interrater, interpartner, and intermethod, i.e., questionnaire vs. diagnostic interview).