Can Communication Skills Training for Veteran’s Spouses Increase Positive Communication Patterns?

By A Hassanzadeh , F Bagheri and M Amidi Mazaheri In   Issue Volume 29 No. 2 Doi No https://doi-ds.org/doilink/06.2021-76278424/JMVH Vol 29 No 2

Fatemeh Bagheri, Maryam Amidi Mazaheri, Akbar Hassanzadeh

Abstract

Background: War veterans are at risk for lower relationship satisfaction and higher rates of separation and divorce. Addressing communication patterns between veteran’s spouses is crucial in promoting family relationships and marriage stability.

Purpose: This study determines communication training’s effect on communication patterns and positive feelings in veteran’s spouses in Iran.

Material and methods: This quasi-experimental study was conducted on veteran spouses in the city of Najaf Abad, Iran. Ninety-six veteran spouses were selected and randomly assigned to experimental and control groups. The educational intervention was implemented only in the experimental group during six sessions. The communication patterns and positive feelings questionnaire were measured before the intervention and two months afterwards.

Results: After the intervention, the demand/withdraw pattern (P = 0.02) and mutual avoidance pattern (P ≥ 0.001) were significantly lower in the intervention group than in the control group; however, the constructive communication pattern in the intervention group was significantly higher than the control group (P = 0.01). Also in the intervention group, women’s positive feelings towards their spouse were significantly better than those of the control group (P < 0.001).

Conclusion: The finding provides evidence for the necessity of implementation of communication skills education in assistance services for veteran’s wives.

Keywords: Constructive Communication Pattern, Mutual Avoidance Communication Pattern, Demand/ Withdraw Communication Pattern, Veteran, Wives, Iran

Introduction

The Iran-Iraq war, which lasted eight years, was known as one of the catastrophes of human history in  the  twentieth  century.  In  this  war,  more  than 554 000 people became veterans.1 The negative effects of war on veterans’ health have been proven by numerous studies worldwide.2, 3 As a result, veterans face significant and ongoing  challenges with a high prevalence of adverse physical and psychological impacts.3-5 The emotional and psychological problems unfavourably affect many aspects of the veteran’s lives and put them at high risk for interpersonal problems, including lack of intimate relationships, partner aggression, parenting difficulties, lower marital satisfaction and divorce.

For instance, there is evidence that veterans are at risk for lower relationship satisfaction and higher separation and divorce rates.4-6

Therefore, numerous research focuses on the effects of veterans’ mental and physical symptoms on their partners and their relationships.7, 8 As a result, the specific needs of veterans’ family members, especially their spouses, have led to the development of various interventions to provide support in different forms with some promising results found.9, 10

In this respect, some studies showed that to promote proper family relationship and marriage stability, addressing couples’ communication patterns is crucial.11, 12

There are three main kinds of communication patterns in couples: constructive communication, mutual avoidance, and demand/withdraw behaviour. These communication patterns are strongly  associated with a varied range of relationship variables.13, 14 Constructive communication is referred to positive behaviours that lead to promoting a cooperative approach to problem solving, understanding and engender trust. This type of communication is positively and strongly associated with marital satisfaction.14 Mutual avoidance is referred to behaviours in which both partners avoid the conflict, for example, by changing the subject, becoming silent or walking away from each other.15 Another pattern of communication behaviour is demand/ withdraw, a dyadic pattern in which one partner complains, criticises, nags or tries to initiate change. In response, the other partner terminates, avoids or withdraws from the communication.14 Contrary to constructive communication, mutual avoidance and demand/withdraw behaviour patterns sustain and intensify conflict and are associated with negative affects during and following communication between couples.14

Various research revealed that constructive communication pattern is critical for  couple stability,  forgiveness  and   marital   satisfaction.14, 16-19 In contrast, a study in Iran that compared communication patterns of veteran’s and other person’s spouses, revealed that veteran’s  spouses use constructive communication less and mutual avoidance and demand/withdraw more than other spouses.20

It is clear that  for  a  family  relationship  to  serve the much-needed support function for  veterans, their spouse’s communication patterns need to be recognised and addressed. Several studies have investigated the mental health of the veteran’s spouses and their marital satisfaction in Iran;9,21 however, there has been less focus on their communication patterns. Furthermore, most of the studies in the Iranian veteran’s family population focused on veterans with post-traumatic stress disorder (PTSD), but very few focused on veterans with other health difficulties.

To the best of the author’s knowledge, no training has been developed for communication skills and positive feelings towards spouses that include veteran’s in Iran. Hence, the present study focused exactly on training and reinforcing these behaviours to help veterans’ spouses become more satisfied. The purpose of this study was to assess the effectiveness of the communication skills educational intervention.

It was hypothesised that veteran’s spouses would show significant increases in their positive feelings towards their spouse, constructive communication and decreases in negative communication after completing the educational intervention.

Materials and methods

Study design

This controlled quasi-experimental pre-test–post- test research was conducted in 2018 in Najaf Abad, one of the cities of Isfahan province in the centre of Iran.

Study participants

The study was performed at the ‘Veterans Affairs’ in Najaf Abad, from September to December 2018, on the spouses of veterans who met the inclusion criteria. According to the study’s specific limitations, 150 females were selected from the target population by the convenience sampling method. Selected women were invited to participate in the study by phone call. The response rate was 73.3%. Interested women were evaluated for inclusion. The eligible participants were randomly assigned to either intervention (n = 48) or control (n = 48).

The included criteria were being willing to participate, being literate, experiencing at least two years of married life with the veteran and being a Najaf Abad resident. In addition, they could not have severe mental or  physical  disorders  and  must  not  have a history of drug abuse. The spouses  of  veterans with PTSD or drug abuse, and women who were absent more than two sessions from the educational sessions were excluded.

The Research Deputy of Isfahan University of Medical Sciences  (397797)  approved  the  study. The Ethics Committee of Isfahan University of Medical Sciences also approved the study proposal (ID code: IR.MUI.RESEARCH.REC.1398.238). The required permission was obtained from the Najaf Abad ‘Veterans Affairs’. Before starting the  study, the researcher explained the research protocol and objectives to the participants and assured them of data confidentiality and their ability to withdraw from the research at any phase. In addition, all participants and their spouses signed written informed consent. It is important to mention that after collecting post-test data at the end of the study, a briefing educational session was presented to the participants in the control group.

Data collection and educational intervention

Data collection tools in the study were self-report questionnaires as follows.

  1. The Demographic Information Checklist: included age, number of marriages, duration of living with a veteran, level of education and number of family
  2. Communication Patterns Questionnaire (CPQ): this self-report measure, developed by Sullaway and Christensen (1983), contains 35 Likert scale items. It evaluates how couples usually deal with their relationship problems at three periods: when a problem or challenge occurs, in the course of a problem or challenge, and after discussion of a problem. Each item assesses spouses’ perception of how probable a specific type of behaviour occurs when faced with a relationship problem, from 1 (very improbable) to 9 (very probable). The subscales of CPQ has undergone numerous revisions since its development.14 The study used the three- subscales scoring method22 as follow: demand/ withdraw behaviour, mutual avoidance and constructive communication. Higher scores on the demand/withdraw behaviour and mutual avoidance subscales indicate that negative communication patterns are in use; however, higher scores on the constructive communication subscale indicate that positive communication patterns are being used. For comparison, study scores of each pattern were set out of 100. The CPQ is freely available and one of the most commonly used in various studies that reported 0.74 to 0.78 of reliability for its subscales.14 Also, in Iran, the previous study translated and normalised this  measure  and  evaluated its validity and reliability. This study examined the correlation between the subscales of CPQ and the Marital Satisfaction Questionnaire. The correlation coefficients for constructive communication, mutual avoidance and demand/ withdraw behaviour were 0.58, -0.58 and 0.35, respectively.23 The reliability of the three subscales of CPQ was also measured by Alpha Cranach’s method in the present study, as 0.79, 0.82 and 0.78, respectively.
  1. Positive Feelings Questionnaire (PFQ): This self- report measure was developed and revised by O’Leary and her colleague (1983), is internally consistent, relatively stable over time in nonclinical groups, correlated with numerous significant measures of marital interaction and sensitive to changes during marital 23

 

The PFQ consists of 17 items in two segments. In the first segment (8 items), the participants are asked to determine their feelings towards their spouse on a scale of one (very negative) to seven (very positive). In the second segment (9 items), the participants are asked to select a phrase that best describes their overall feelings towards their spouse with numbers 1–7. Higher scores on the  PFQ  indicate  feelings that  are  higher  in  positivity.  The  previous  study in Iran translated  and  normalised  this  measure and evaluated its validity and reliability that was acceptable.24

Completing the mentioned tools took about 30 minutes. The participants in the intervention and control groups  completed  research  tools  before and two months after the intervention. During the questionnaires’ completion, the instructor explained the importance of accurate answers to the answering of all questions.

The education was provided for women only in the experimental group and included lectures, group discussions, practice and role-playing.

This intervention was a 6-week group education that was designed to increase spouses’ communication skills. The groups were conducted in a closed-group format, with 6–8 women in each group. The group atmosphere was nonconfrontational and supportive. Each 90-minute session contained brief didactic material, group activities and discussions, the practise of new behaviours, flexible time to explore change efforts and solve ongoing problems, and construct group unity.

Skilled instructors in the field of communication delivered the training. The communication skill training’s intention was to increase positive communication patterns (constructive) while decreasing negative interactions (mutual avoidance and demand/withdrawn behaviours). Over six sessions, once a week, skilled instructors taught spouses practical communication skills. At the first session, the researchers wanted to produce rapid increases in relationship satisfaction that enabled women to engage in the more challenging work in their relationships. The instructors taught  them ways to identify behaviours of their spouses that were positively reinforcing and worked to increase the instances of such behaviours. At the next sessions, the instructors taught  participants  to listen carefully and reflect on their spouse’s words, confirm the words through their spouse’s point of view, and understand and empathise  with  what their spouse might be  experiencing  emotionally. The instructors also taught participants such skills to increase empathic levels between them during emotional conversations and skills to help them stay calm and avoid negative interactions that can cause overwhelming emotions. The participants learned skills to request behaviour changes from their spouse in a manner that decrease resistance and reduce the pressure of the change requested. Finally, in the last session, the instructors showed the participants how to reduce their negative communication patterns such as mutual avoidance and demand/withdraw behaviour and the importance of increasing positive behaviours to enhance relationship satisfaction levels. During each session, by engaging in group work, participants  had  a  good  chance  to  listen and pay attention to others and share similar communications skills experiences. Participants could alter their family conditions and gain support and confirmation for their practices to become more confident.

During the post-intervening interval, the instructors answered participant’s questions by email, text messages and phone calls. Two months later, the participants (both experimental and control groups) were invited to complete the research tools again.

Table 1 Comparison of demographic variables between intervention and control groups at the beginning of the study (N = 90, 100%)

Variable Intervention Control P-value
Age (years) Mean ± SD 45.4±7.3 43.8±7.7 a0.36
Family size Mean ± SD 2.96±0.8 2.98±0.7 a0.89
Duration of living with a veteran (years) Mean ± SD 18.6±5.5 19.4±5.2 a0.46
Education Illiterate 0 1(2.1) b0.9
Below diploma 9(18.8) 11(2.2)
Diploma 22(45.8) 18(37.5)
Associate degree 15(31.2) 14(29.2
Bachelor’s degree 2(4.2) 4(8.3)

a independent t-tests (for quantitative variable)
b Chi-square 2 (for qualitative variable)

Table 2 Comparison of communication patterns and positive feelings towards spouse mean scores between groups, before and after the intervention

Variable Groups Time P-valuea
Before intervention Mean ± SD After intervention Mean ± SD
Communication patterns CPQ Constructive communication Intervention 19.8±5.9 23.5±8.8 0.01
Control 20.5±8.1 19.3±7.3 0.48
P-valueb 0.62 0.01
Mutual avoidance Intervention 27.3±13.4 16.8±10.1 ≤0.001
Control 28.3±12.5 27.3±10.9 0.6
P-valueb 0.77 0.02
Demand/withdraw Intervention 26.4±7.1 22.4±8.8 0.009
Control 25.9±10.2 26.4±7.6 0.76
P-valueb 0.72 ≤0.001
PFQ Positive feelings towards spouse Intervention 61.4±5.2 67.8±5.6 ≤0.001
Control 61.3±5.5 62.5±5.4 0.31
P-valueb 0.96 ≤0.001

a Paired sample t-test
b Independent t-tests

Statistical analysis

The researcher analysed the data by the  IBM SPSS/21.0 (IBM Corp., Armonk, NY, USA) through descriptive statistics, such as frequency, mean and standard deviation, and inferential  statistics,  such as paired and independent t-tests, Chi-Square, the Fisher’s Exact Test, as well as one-way analysis of variance (ANOVA). They confirmed the normality of data using the Kolmogorov-Smirnov test. The level of significance was P = 0.05.

Results

The participants mean age in the intervention and control groups was 45.4±7.3 and 43.8±7.7 years, respectively. Almost all of them were homemakers. As shown in Table 1, participants in the intervention and control groups were comparable on demographic variables such as age, duration of living with a veteran, level of education and number of family members. In addition, as shown in Table 2, t-tests revealed no significant differences between the study groups in the main study variables (communication patterns and positive feelings towards spouse) at the pre-test (P ≤ 0.05).

To understand the effect of the educational intervention on participating women from pre to post-intervention, we used paired sample t-tests. Table 2 summarised the subscale mean scores for the study groups.

Participant scores on the constructive communication subscale revealed a statistically significant increase in the intervention group from pre-test to post-test (P < 0.05), but no significant differences were found from pre-test to post-test in the control group. In addition, the mean score of the mutual avoidance subscale revealed a statistically significant decrease in the intervention group after the intervention (27.3±13.4versus16.8±10.1; P < 0.001) as well as a significant decrease was seen in the demand/ withdraw subscale (P < 0.05).

As shown in Table 2, the post-test results also showed that the participant’s positive feelings towards their spouse in the intervention group was significantly better than that of the control group (P < 0.001).

Discussion

The study’s first aim was to examine whether communication  patterns  changed  two  mounts after the educational intervention. Since previous research  revealed  that  Iranian  veteran  families lack the  necessary  communication  skills  and,  as a result, engage in  excessive  negative  behaviour and limited positive communication behaviours,20 the educational intervention focused on increasing positive communication behaviours and decreasing negative ones. During the educational intervention, spouses were taught ways to more effectively communicate by using both listener skills (e.g. paraphrasing) and speaker skills (e.g. using ‘I’ statements instead of blaming ‘you’ statements).

The results showed that the intervention group evidenced a significant increase in positive communication patterns (constructive) from pre- test to two months after intervention than did the control group. In addition, intervention participants used fewer negative interactions (mutual avoidance and demand/withdrawn behaviour) than the control participants.

The significant changes in the communication patterns of the intervention group after the education was consistent with the results of Schmidt et al.22 Results were also consistent with the findings of a study in Iranian PTSD veterans and their spouses, indicating that emotionally focused couple therapy results in a decrease in mutual avoidance, demand/ withdrawal, and an increase in constructive communication patterns.25

The present study  provides  introductory  support for the efficacy of communication skills as an intervention to reduce negative interactions and increase positive ones in veteran spouses. Practical communication skills enable spouses to use a more sustainable and effective communication form to exchange accurate messages and effectively manage familial disagreements and conflicts. Positive communication between couples allows them to discuss and exchange ideas and be aware of their needs.26

According to a previous  study,  group  educations are regularly delivered for military veteran couples. Despite considerable expressed interest in potential referral sources, only a relatively small percentage of eligible couples engaged in the educational sessions.27 One pilot study showed veterans themselves want to preserve their relationships and seek assistance to do so but are reluctant to participate in educational intervention for different reasons. They described some as physical and mental difficulties, work scheduling conflicts, and issues related to social stigma and fear of discussing and sharing family conflict and relationship problems with other military couples. However, their wives were eager to learn new skills, such as communications skills. Likewise, Eaton and colleague’s study revealed that although spouses of military service members had similar rates of mental health problems than soldiers, they were more likely to seek care  for  their  problems and were less concerned with the stigma than were soldiers.28 Therefore, the present study, did not offer the veterans themselves any communication training as part of this intervention. This research aimed to examine if communication skills training for veteran’s spouses can change their communication patterns. We were able to successfully recruit from the veteran’s spouse population to fill the intervention groups—all but three of the women that began the group interventions completed them.

Another goal of the present study was to examine whether communication skills training could increase women’s positive feelings towards their spouses as an indicator of relationship satisfaction. Consistent with our hypothesis, the results showed that changes in positive feelings toward  their spouses two months after the intervention were only significant in the intervention group.

According to a relatively old study, women’s positive feelings  towards  a   spouse   is   relatively   difficult to define and measure as the most important characteristic of a worthy marriage.23 Earlier research in Iranian couples revealed that spouse’s positive feelings are significantly strongly associated with important relationship variables.24

Similar    to    our    results,    numerous    studies have confirmed the beneficial effects of family communication skills training. For instance, the study by Pardar indicated that after communication skills training, self-efficacy and hopefulness of veterans’ spouses were significantly increased.26

Likewise, Tavakolizadeh’s study revealed that communication skills training for couples could significantly reduce marital conflicts and lead to robust pair bonding and more emotional expression, especially positive.29 In addition, Ghazavi and colleagues’ study revealed  that  communication skills training enables individuals to begin more effective interactions, whereby they can exchange accurate messages and effectively manage familial disagreements and conflicts, therefore be happy in family life.30

There  are  several  limitations  to   the   current study. First, we could not attract the veteran’s participation. It is recommended that both couples attend educational intervention and participate in the study. Second, it is difficult to generalise our findings to the Iranian veteran’s spouse population because the sample was limited to veteran’s spouses of Najaf Abad.

Additional research with a larger and more varied sample is needed to provide accurate evidence of the communication skills training efficacy. Third, this study purposefully analysed self-report data. It is better to examine changes in communication patterns and the link between communication patterns and positive affect outcomes—observational methods such as video-recorded interactions may be used. Finally, this research’s most significant limitation was the  lack  of  long  time  follow-up  to  evaluate the continuity of educational outcomes after the intervention. This study’s findings are encouraging for those providing services to veterans’ family, bearing in mind the limitations. This training format, delivering communication skills training only for veteran’s spouses, can change their communication patterns and is more feasible and uses less time and resources than couple-based interventions.

Conclusion

After the education, participants significantly increased their positive feelings toward their husbands, decreased the use of negative communication patterns, and increased communication patterns involving positive interactions. These findings indicate that veteran’s spouses who learn and practice  communication skills and learn the important role of empathy between couples during emotional conversations can successfully incorporate what they have learned into their relationship.

This study demonstrated the feasibility of recruiting from veteran’s spouse population and the feasibility of attendance  for  6-week  group  education.  The results were promising for promoting communication patterns and positive feelings toward husbands in veterans’ spouses and provide the initial basis for future research on communication patterns and intimate relationships.

Corresponding Author: Amidi Mazaheri, Maryam maryamamidi@hlth.mui.ac.ir

Authors: Fateme Bagheri1, Maryam Amidi Mazaheri2, Akbar Hassanzadeh3

Author Affiliations:

  1. Student Research Committee, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
  2. Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
  3. Department of Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran

References

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Acknowledgements

Acknowledgements

This manuscript is derived  from  the  master’s degree  thesis  number  397797  and  approved  by the Department of Health Sciences of Isfahan University of Medical Sciences. The authors hereby express their appreciation to the Vice-Chancellor for Research at Isfahan University of Medical Sciences and the ‘Veterans Affairs’ in Najaf Abad city and all women who participated in the study. Appreciation comes into action

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