Original Research

Validation of the Timberlawn Couple and Family Evaluation Scales–Self-Report in Veterans with PTSD

Fed Pract. 2019 October;36(6):S14-S21

References

1. Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress. 2013;26(5):537-547.

2. Lehavot K, Goldberg SB, Chen JA, et al. Do trauma type, stressful life events, and social support explain women veterans’ high prevalence of PTSD? Soc Psychiatry Psychiatr Epidemiol. 2018;53(9):943-953.

3. Galovski T, Lyons JA. Psychological sequelae of combat violence: a review of the impact of PTSD on the veteran’s family and possible interventions. Aggress Violent Behav. 2004;9(5):477-501.

4. Ray SL, Vanstone M. The impact of PTSD on veterans’ family relationships: an interpretative phenomenological inquiry. Int J Nurs Stud. 2009;46(6):838-847.

5. Cloitre M, Miranda R, Stovall-McClough KC, Han H. Beyond PTSD: emotion regulation and interpersonal problems as predictors of functional impairment in survivors of childhood abuse. Behav Ther. 2005;36(2):119-124.

6. McFarlane AC, Bookless C. The effect of PTSD on interpersonal relationships: issues for emergency service works. Sex Relation Ther. 2001;16(3):261-267.

7. Itzhaky L, Stein JY, Levin Y, Solomon Z. Posttraumatic stress symptoms and marital adjustment among Israeli combat veterans: the role of loneliness and attachment. Psychol Trauma. 2017;9(6):655-662.

8. Dekel R, Monson CM. Military-related post-traumatic stress disorder and family relations: current knowledge and future directions. Aggress Violent Behav. 2010;15(4):303-309.

9. Allen ES, Rhoades GK, Stanley SM, Markman HJ. Hitting home: relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for Army couples. J Fam Psychol. 2010;24(3):280-288.

10. Laffaye C, Cavella S, Drescher K, Rosen C. Relationships among PTSD symptoms, social support, and support source in veterans with chronic PTSD. J Trauma Stress. 2008;21(4):394-401.

11. Meis LA, Noorbaloochi S, Hagel Campbell EM, et al. Sticking it out in trauma-focused treatment for PTSD: it takes a village. J Consult Clin Psychol. 2019;87(3):246-256.

12. Lewis JM, Gossett JT, Housson MM, Owen MT. Timberlawn Couple and Family Evaluation Scales. Dallas, TX: Timberlawn Psychiatric Research Foundation; 1999.

13. Fincham FD, Linfield KJ. A new look at marital quality: can spouses feel positive and negative about their marriage? J Fam Psychol. 1997;11(4):489-502.

14. Kaplan KJ. On the ambivalence-indifference problem in attitude theory and measurement: a suggested modification of the semantic differential technique. Psychol Bull. 1972;77(5):361-372.

15. Buhrmester D, Furman W. The Network of Relationship Inventory: Relationship Qualities Version [unpublished measure]. University of Texas at Dallas; 2008.

16. Busby DM, Christensen C, Crane DR, Larson JH. A revision of the Dyadic Adjustment Scale for use with distressed and nondistressed couples: construct hierarchy and multidimensional scales. J Marital Fam Ther. 1995;21(3):289-308.

17. Davis MH. A multidimensional approach to individual differences in empathy. JSAS Catalog Sel Doc Psychol. 1980;10:85.

18. Fraley RC, Waller NG, Brennan KA. An item-response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol. 2000;78(2):350-365.

19. Tabachnick BG, Fidell L. Using Multivariate Statistics. 6th ed. Boston, MA: Pearson; 2013.

20. Sautter FJ, Armelie AP, Glynn SM, Wielt DB. The development of a couple-based treatment for PTSD in returning veterans. Prof Psychol Res Pr. 2011;42(1):63-69.

21. Jacobson NS, Christensen A, Prince SE, Cordova J, Eldridge K. Integrative behavioral couple therapy: an acceptance-based, promising new treatment of couple discord. J Consult Clin Psychol. 2000;9(2):351-355.

22. Makin-Byrd K, Gifford E, McCutcheon S, Glynn S. Family and couples treatment for newly returning veterans. Prof Psychol Res Pr. 2011;42(1):47-55.

23. Peterson K, Anderson J, Bourne D. Evidence Brief: Use of Patient Reported Outcome Measures for Measurement Based Care in Mental Health Shared Decision Making. Washington, DC: Department of Veterans Affairs; 2018. https://www.ncbi.nlm.nih.gov/books/NBK536143. Accessed September 13, 2019.

24. Fortney JC, Unützer J, Wrenn G, et al. A tipping point for measurement-based care. Psychiatr Serv. 2017;68(2):179-188.

25. Costello AB, Osborne JW. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Pract Assess Res Eval. 2005;10(7):1-9.

Convergent validity was assessed by conducting Pearson’s bivariate correlations between identified TCFES-SR factor(s) and other administered measures of interpersonal functioning (ie, PANQIMS positive and negative quality; NRI-RQV relative power subscale; RDAS decision making, values, affection, conflict, activities, and discussion subscales; IRI-empathetic concern subscale; and ECR-R attachment-related anxiety and avoidance subscales). Strength of relationship was determined based on the following guidelines: ± 0.3 to 0.49 = small, ± 0.5 to 0.69 = moderate, and ± 0.7 to 1.00 = large. Internal consistency was also determined for TCFES-SR factor(s) using Cronbach’s α. A standard level of significance (α=.05) was used for all statistical analyses.

Results

Eighty-six veterans provided complete data (Table 1). The Kaiser-Meyer-Olkin measure of sampling adequacy was indicative that sample size was adequate (.91), while Bartlett’s test of sphericity found the variables were suitable for structure detection, χ²(120) = 800.00, P < .001. While 2 eigenvalues were ≥ 1, visual inspection of the scree plot and subsequent parallel analysis identified a unidimensional structure (ie, 1 factor) for the TCFES-SR. All items were found to load to this single factor, with all loadings being ≥ 0.5 (Table 2). Additionally, internal consistency was excellent for the scale (α = .93).

Pearson’s bivariate correlations were significant (P < .05) between TCFES-SR total score, and almost all administered interpersonal functioning measures (Table 3). Interestingly, no significant associations were found between any of the administered measures, including the TCFES-SR total score, and the IRI-empathetic concern subscale (P > .05).

Discussion

These findings provide initial support for the psychometric properties of the TCFES-SR, including excellent internal consistency and the adequate association of its total score to established measures of interpersonal functioning. Contrary to the TCFES, the TCFES-SR was shown to best fit a unidimensional factor rather than a multidimensional measure of relationship functioning. However, the TCFES-SR was also shown to have strong convergent validity with multiple domains of relationship functioning, indicating that the measure of overall intimate partner relationship functioning encompasses a number of relational domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict). Critically, the TCFES-SR is brief and was administered easily in our sample, providing utility as clinical tool to be used in time-sensitive outpatient settings.

A unidimensional factor has particular strength in providing a global portrait of perceived intimate partner relationship functioning, and mental health providers can administer the TCFES-SR to assess for overall perceptions of intimate partner relationship functioning rather than administering a number of measures focusing on specific interpersonal domains (eg, decision making processes or positive/negative attitudes towards one’s relationship). This allows for the quick assessment (ie, 5-10 minutes) of overall intimate partner relationship functioning rather than administration of multiple self-report measures which can be time-intensive and expensive. However, the TCFES-SR also is limited by a lack of nuanced understanding of perceptions of functioning specific to particular domains. For example, the TCFES-SR score cannot describe intimate partner functioning in the domain of problem solving. Therefore, brief screening tools need to be developed that assess multiple intimate partner relationship domains.

Importantly, overall intimate partner relationship functioning as measured by the TCFES-SR may not incorporate perceptions of relationship empathy, as the total score did not correlate with a measure of empathetic concern (ie, the IRI-empathetic concern subscale). As empathy was based on one item in the TCFES-SR vs 7 in the IRI-empathetic concern subscale, it is unclear if the TCFES-SR only captures a portion of the construct of empathy (ie, sensitivity to partner) vs the comprehensive assessment of trait empathy that the IRI subscale measures. Additionally, the IRI-empathetic concern subscale did not significantly correlate with any of the other administered measures of relationship functioning. Given the role of empathy in positive, healthy intimate partner relationships, future research should explore the role of empathetic concern among veterans with PTSD as it relates to overall (eg, TCFES-SR) and specific aspects of intimate partner relationship functioning.²⁰

While the clinical applicability of the TCFES-SR requires further examination, this measure has a number of potential uses. Information captured quickly by the TCFES-SR may help to inform appropriate referral for treatment. For instance, veterans reporting low total scores on the TCFES-SR may indicate a need for a referral for intervention focused on improving overall relationship functioning (eg, Integrative Behavioral Couple Therapy).^21,22 Measurement-based care (ie, tracking and discussing changes in symptoms during treatment using validated self-report measures) is now required by the Joint Commission as a standard of care,and has been shown to improve outcomes in couples therapy.^23,24 As a brief self-report measure, the TCFES-SR may be able to facilitate measurement-based care and assist providers in tracking changes in overall relationship functioning over the course of treatment. However, the purpose of the current study was to validate the TCFES-SR and not to examine the utility of the TCFES-SR in clinical care; additional research is needed to determine standardized cutoff scores to indicate a need for clinical intervention.