Couples' Prior Quality of Relationship, Present Attachment, Adjustment, and Depressive Symptoms

309 Pages·2016·4.94 MB·English

Florida State University Libraries
Electronic Theses, Treatises and Dissertations The Graduate School
2015
Couples' Prior Quality of Relationship,
Present Attachment, Adjustment, and
Depressive Symptoms with Early Stage
Alzheimer's
Shirley J. Zahn
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FLORIDA STATE UNIVERSITY

COLLEGE OF HUMAN SCIENCES

COUPLES’ PRIOR QUALITY OF RELATIONSHIP,

PRESENT ATTACHMENT, ADJUSTMENT, AND DEPRESSIVE

SYMPTOMS WITH EARLY STAGE ALZHEIMER’S

By

SHIRLEY J. ZAHN

A Dissertation submitted to the
Department of Family and Child Sciences
in partial fulfillment of the
requirements for the degree of
Doctor of Philosophy

Degree Awarded:
Spring Semester, 2015

© 2015, Shirley J. Zahn
Shirley J. Zahn defended this dissertation on March 23, 2015.
The members of the supervisory committee were:

Wayne H. Denton
Professor Directing Dissertation

Robert L. Glueckauf
University Representative

Marsha L. Rehm
Committee Member

Kendal N. Holtrop
Committee Member

The Graduate School has verified and approved the above-named committee members, and
certifies that the dissertation has been approved in accordance with university requirements.

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I dedicate this work, with love and gratitude to my sons, Derek Zahn and Devin Zahn, and thank
them for all they have given to support and encourage the effort to achieve this goal, and to my
almost-daughters, Marie Legras Zahn and Krystal Freedom.
I also dedicate my life’s work to my mother and father, Joyce Bush Nash and Charles Bush, and
to my devoted significant supporter, John E. Waters, and to my early source of encouragement
towards academic achievement and doctoral work, my grandfather, Dr. E.D. Miller.

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ACKNOWLEDGMENTS
As I have traveled on this journey to a lifetime goal I have been fortunate to learn from
many, but I wish to acknowledge those most influential in my professional development.
I want to express my gratitude for the opportunity to learn from and study with Dr.
Wayne Denton, my major professor, and an inspiring healer, therapist, and teacher, and to thank
him for his wise direction and encouragement.
I want to thank Dr. Marsha Rehm for serving on my committee and for her helpfulness
and expertise in introducing me to the study of qualitative research.
I want to thank Dr. Kendal Holtrop for her helpfulness in joining my committee as an
expert in family science and marriage and family therapy.
Dr. Robert Glueckauf has generously served on my committee, and I want to thank him
for his expertise and support in this work with persons with Alzheimer’s and their caregivers.
I am especially grateful to Dr. Mary Hicks, a great teacher, who served on my committee
over my years at FSU, for her encouragement and her remarkable wit and wisdom.
I also want to thank other professors for their direction on my committee or in my
studies, Dr. Christine Readdick for her helpful direction, Dr. Nicholas Mazza, Dr. Calvin
Zongker, and Dr. Ron Slaby at Harvard University for their teaching and encouragement.
I thank my friend Adonica Gieger for her skill in transforming my written words into a
digital manuscript.

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TABLE OF CONTENTS
LIST OF TABLES ....................................................................................................................... viii
ABSTRACT ................................................................................................................................... ix
CHAPTER 1 INTRODUCTION .....................................................................................................1
1.1 Theoretical Framework ........................................................................................................5
1.2 Statement of the Researchable Problem ............................................................................10
1.2.1 Research Questions ...................................................................................................13
1.2.2 Quality of the Relationship Prior to Illness...............................................................15
1.2.3 Measure of Couplehood ............................................................................................18
1.2.4 Spouses’ Attachment, Depressive Symptoms, and Marital Adjustment ..................21
1.2.5 Self of the Researcher ...............................................................................................23
1.3 Case Study Method ............................................................................................................24
1.3.1 Case Study Research Designs ...................................................................................29
1.3.2 Single and Multiple-Case Studies .............................................................................34
1.4 Conclusion .........................................................................................................................38
CHAPTER 2 LITERATURE REVIEW ........................................................................................40
2.1 Alzheimer’s Disease: An Increasing Threat to Surviving Elders As They Age ................40
2.2 Marital Therapy Research with Persons with Alzheimer’s Disease ..................................48
2.3 Advances in Case Study Research .....................................................................................60
2.4 Multiple Theories Used in Alzheimer’s Couples Research ...............................................92
2.5 Viewing the Research Through the Lens of Attachment Theory ......................................97
2.5.1 Attachment Is the Emotional Bond Connecting a Couple ........................................98
2.5.2 Ten Principles of Adult Attachment Theory ...........................................................100
2.6 Historical Highlights in the Development of Trends in Couple Therapy ........................103
2.6.1 Development of a Focus on Emotions in Couples Therapy ...................................112
2.6.2 Emotionally Focused Processes and Couple Therapy Techniques .........................115
2.6.3 Affective Processes in Couple Relationships .........................................................123
2.6.4 Emotional Connection in Couples Therapy ............................................................131
2.7 Couples Research on Emotional Processes ......................................................................134
2.7.1 The Prior Quality of Relationship in Gottman’s Oral History Interview ...............134
2.7.2 Attachment Research Related to Couples and Caregiving .....................................140
CHAPTER 3 METHOD ..............................................................................................................148
3.1 Participants .......................................................................................................................148
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3.2 Measurement Instruments ................................................................................................150
3.2.1 Dyadic Adjustment Scale ........................................................................................151
3.2.2 Prior Quality of Relationship Scale ........................................................................153
3.2.3 Experiences in Close Relationships-Revised Questionnaire ..................................156
3.2.4 Geriatric Depression Scale ......................................................................................158
3.2.5 Screen for Caregiver Burden ..................................................................................159
3.2.6 Mini-Mental State Examination ..............................................................................161
3.3 Procedures ........................................................................................................................163
3.3.1 Recruitment of Participant Couples ........................................................................163
3.3.2 Preliminary Tasks Completed with Couples ...........................................................164
3.3.3 Couple Interview Processes ....................................................................................167
CHAPTER 4 FINDINGS .............................................................................................................172
4.1 Research Questions Investigated .....................................................................................174
4.2 Couple Interview and Questionnaire Findings ................................................................183
4.2.1 Couple 1, Mr. and Mrs. Lark ..................................................................................184
4.2.2 Couple 2, Mr. and Mrs. Green ................................................................................196
4.2.3 Couple 3, Mr. and Mrs. Farmer ..............................................................................212
4.2.4 Couple 4, Mr. and Mrs. Taylor ...............................................................................216
4.2.5 Couple 5, Mr. and Mrs. Day ...................................................................................224
4.3 Couple Interview Session Comparisons ..........................................................................235
4.3.1 Couple 1, Mr. and Mrs. Lark ..................................................................................235
4.3.2 Couple 2, Mr. and Mrs. Green ................................................................................236
4.3.3 Couple 3, Mr. and Mrs. Farmer ..............................................................................236
4.3.4 Couple 4, Mr. and Mrs. Taylor ...............................................................................237
4.3.5 Couple 5, Mr. and Mrs. Day ...................................................................................238
4.4 Spouses’ Attachment Relationships .................................................................................239
4.4.1 Mrs. Rose Lark’s Attachment Relationship ............................................................239
4.4.2 Mr. Bob Lark’s Attachment Relationship ...............................................................240
4.4.3 Mrs. Jill Green’s Attachment Relationship .............................................................240
4.4.4 Mr. Frank Green’s Attachment Relationship ..........................................................241
4.4.5 Mrs. Gina Farmer’s Attachment Relationship ........................................................242
4.4.6 Mr. Dave Farmer’s Attachment Relationship .........................................................242
4.4.7 Mrs. Ann Taylor’s Attachment Relationship ..........................................................243
4.4.8 Mr. Larry Taylor’s Attachment Relationship .........................................................244
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4.4.9 Mrs. Jane Day’s Attachment Relationship..............................................................244
4.4.10 Mr. Tom Day’s Attachment Relationship .............................................................245
CHAPTER 5 DISCUSSION ........................................................................................................247
5.1 Research Questions ..........................................................................................................250
5.2 Limitations of the Study...................................................................................................256
5.3 Implications......................................................................................................................257
5.3.1 Implications for Theory Development ....................................................................257
5.3.2 Implications for Research .......................................................................................258
5.3.3 Implications for Practice .........................................................................................262
5.3.4 Implications for Public Policy ................................................................................262
5.4 Conclusion .......................................................................................................................263
APPENDICES .............................................................................................................................264
APPENDIX A INTERVIEW GUIDE .....................................................................................264
APPENDIX B PRIOR QUALITY OF RELATIONSHIP SCALE (PQRS) ...........................268
APPENDIX C SCREEN FOR CAREGIVER BURDEN (SCB) ............................................270
APPENDIX D FLORIDA STATE UNIVERSITY HUMAN SUBJECTS COMMITTEE
APPROVAL LETTER.................................................................................................................271
APPENDIX E CONSENT FORM ..........................................................................................275
APPENDIX F COPYRIGHT PERMISSIONS .......................................................................279
REFERENCES ............................................................................................................................282
BIOGRAPHICAL SKETCH .......................................................................................................299

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LIST OF TABLES
Table 1 Demographic Descriptions of Spouses .........................................................................173
Table 2 Attachment Measure, Experiences in Close Relationships-Revised (ECR-R) .............176
Table 3 Ranked Attachment Dimensions, Less Secure to More Secure....................................176
Table 4 Prior Quality of Relationship Scale (PQRS).................................................................178
Table 5 Spouses’ Relationship Scores and Geriatric Depression Scores ..................................179
Table 6 Caregiving Spouses’ Themes of Stress .........................................................................181
Table 7 Emotional Lived Experience of Spouses with Alzheimer’s .........................................248

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ABSTRACT
This qualitative case study of five couples in which one spouse has Alzheimer’s disease
in the early stage, and the other spouse is a caregiver, investigated including both spouses in
couple interview sessions which included using emotionally focused couple therapy techniques,
and how their prior quality of relationship before the onset of Alzheimer’s was related to their
present attachment, depressive symptoms, and marital adjustment. The couples participated in
in-depth couple interviews which included an Oral History Interview (Gottman, 1994) and a
semi-structured Interview Guide. They individually completed four instruments: the Dyadic
Adjustment Scale (DAS) (Spanier, 1976); the Geriatric Depression Scale (GDS) (Yesavage,
1983); the Prior Quality of Relationship Scale (PQRS), a composite scale created by Zahn; and
the adapted Experiences in Close Relationships-Revised questionnaire (ECR-R) (Fraley, Waller,
& Brennan, 2000). The Screen for Caregiver Burden (SCB) (Vitaliano, Russo, Young, Becker,
& Maiuro, 1991) was given to the caregiving spouses. The researcher qualitatively analyzed the
audiotaped interviews and questionnaires, which all spouses with Alzheimer’s were able to
complete. All couples reported positive prior quality relationships of 16-63 years, and present
continued attachment. All couples reported problems of marital adjustment, and varying
depressive symptoms were reported for 2 out of 5 caregivers, and 2 of 5 persons with
Alzheimer’s. Implications of findings were that couples experiencing early stage Alzheimer’s
would benefit from couple interviews or therapy to assist with depressive and other symptoms
and marital adjustment problems, and that spouses in the early stage of Alzheimer’s are able to
fully participate in these couple procedures.
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