ORIGINAL PAPER
A Test of Contextual Theory: The Relationship Among
Relational Ethics, Marital Satisfaction, Health Problems,
and Depression
Heath A. Grames  Richard B. Miller  W. David Robinson 
Derrel J. Higgins  W. Jeff Hinton
Published online: 14 August 2008
Ó Springer Science+Business Media, LLC 2008
Abstract Few studies have examined the theoretical underpinning of contextual theory.
Using structural equation modeling, the relationship among relational ethics (recognized as
the most important aspect of contextual theory), marital satisfaction, depression, and illness
was examined. Data came from a national sample of 632 mid-life, married individuals.
Results supported Nagy's contextual theory. The total score of the Relational Ethics Scale
was a significant predictor of marital satisfaction, and marital satisfaction was significantly
associated with depression and health problems. Vertical and horizontal subscales of
relational ethics also were significant predictors of depression and health problems through
the mediating variable of marital satisfaction.
Keywords Contextual theory Á Relational ethics Á Marital satisfaction Á
Depression Á Health
Introduction
Considered a pioneer of family therapy, Ivan Boszormenyi-Nagy began work in the 1950s
that lead to the creation of contextual theory (Boszormenyi-Nagy 1987; BoszormenyiNagy
et al. 1991). From his clinical experiences, issues such as family loyalty, fairness, and
H. A. Grames (&) Á W. J. Hinton
Department of Child and Family Studies, Marriage and Family Therapy Program, University
of Southern Mississippi, 118 College Drive # 5035, Hattiesburg, MS 39406-0001, USA
e-mail: heath.grames@usm.edu
R. B. Miller
School of Family Life, Brigham Young University, Provo, UT, USA
W. D. Robinson
Department of Family Medicine, University of Nebraska Medical Center, Omaha, NE, USA
D. J. Higgins
Department of Psychology, Mesa Community College, Mesa, AZ, USA
123
Contemp Fam Ther (2008) 30:183­198
DOI 10.1007/s10591-008-9073-3
trust emerged as cornerstones of the contextual approach to therapy (Boszormenyi-Nagy
et al. 1991). Contextual theory became an accepted and widely used approach to therapy
through which an emphasis on relational ethics became the impetus for change
(Boszormenyi-Nagy and Krasner 1986).
It has been suggested that contextual theory is a valuable resource for psychotherapists
(Grunebaum 1987; Hargrave and Pfitzer 2003) and that contextual theory principles have
influenced family therapists around the world (Watson 2007). Nichols and Schwartz (2001,
p. 50) referred to contextual theory as being ``among the most thoughtful and underappreciated
approaches to family therapy.'' More recently, they wrote that ``Among
psychodynamic family therapists, few have made more important contributions than Ivan
Boszormenyi-Nagy's contextual therapy'' (Nichols and Schwartz 2008, p. 244). Contextual
theory has been described and used extensively in clinical and theoretical literature (e.g.,
Boszormenyi-Nagy and Krasner 1986; Boszormenyi-Nagy and Spark 1984; Goldenthal
1996; Hargrave et al. 1991; Van Heusden and Van den Eerenbeemt 1987). Clinicians have
found it helpful in their work with families, including children, adolescents, and couples
(Jones and Flickinger 1987; Lee 1995), and aging adults (Anderson and Hargrave 1990;
Hargrave and Anderson 1990; Hargrave and Hanna 1997; Jones and Flickinger 1987).
Feminist therapists also have suggested that because of the ethical dimension of contextual
theory, it is a desirable approach to use in working with individuals, couples, and families
(Dankoski and Deacon 2000; Grunebaum 1987). The basic systems concepts of contextual
theory have been applied to larger systems. For example, it has been used to enhance
understanding and therapeutic application within a cultural context, including being used
as a ``theoretically relevant (marriage and family therapy model) to Korean cultural contexť'
(Moon 2000, p. 9). The tenets of contextual theory were applied to better
comprehend and explore intervention for the international issue of ethno-political conflict
(Zeo 2001). Finally, contextual theory concepts were used as a means of understanding
larger social system relationships as researchers explored difficulties among agencies that
were collaborating to do research (Diamond et al. 1991).
Despite the influence of contextual therapy in the field of family therapy, there have
been few attempts by researchers to study it empirically. Several studies have used contextual
theory concepts as a theoretical basis for their conceptualization of a problem or for
analyses (e.g., Moon 2000; Stokes 2003; Zeo 2001), although the theory wasn't explicitly
tested. Yet, in a comprehensive review of family therapy outcome research, Miller et al.
(2000) reported that no contextual therapy outcome studies have been published. However,
progress has been made towards creating measures that may assist in doing contextual
theory research. There was an effort to develop a Contextual Family Therapy Therapist
Action Index as part of an outcome study of contextual family therapy to examine the
conformity of the therapists' behaviors to contextual theory (Bernal et al. 1990). However,
the results of the outcome study were never published.
Some research has focused on the development of a reliable and valid scale to measure
relational ethics, called the Relational Ethics Scale (RES) (Hargrave et al. 1991). Relational
ethics, which will be described later in detail, is one of the four dimensions of
relating within relationships that are considered core to contextual theory. It refers to the
balance of give and take that exists within relationships. In addition to the few studies to
test its reliability and validity, the RES has been used to support concurrent validity of
other scales (Hargrave and Sells 1997; Pollard et al. 1998) and to measure horizontal and
vertical relationships in different populations (Lee 1995; Shokouhi-Behnam et al. 1997).
Burke (1999) designed a tool to measure the ledger of merits within a relationship.
Comparing the concept to financial transactions, Boszormenyi-Nagy (1987, p. 154)
184 Contemp Fam Ther (2008) 30:183­198
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describes the ledger of merits as ``the mutually quantitative, balance-like nature of the
fluctuations of give-and-take of human relationships.'' Burke's measure has yet to be
normed and reliability and validity of the tool are unknown.
Of importance to this study is the relationship between relational ethics and marital
satisfaction. To date, only one study has examined the association between relational ethics
and marital satisfaction (Hargrave and Bomba 1993), and this study had a sample of only
36 people. The primary focus of the study was on understanding variables that impact the
RES rather than on marital relationships. In addition, no research has tested Nagy's theoretical
propositions that relational ethics is related to psychological and physical health
problems. Consequently, more research is needed to examine the relationship between
relational ethics and marital satisfaction, as well as psychological and physical health.
Beyond the aforementioned studies, little basic research has been done on contextual
therapy concepts and theoretical propositions. The purpose of this study was to examine a
key concept of contextual theory, relational ethics, and to test its hypothesized relationship
to marital satisfaction, depression, and physical health.
Relational Ethics and Contextual Theory: An Overview
Relational ethics is one of four dimensions of relational reality in contextual theory, which
is considered the premise on which the theory is built (Boszormenyi-Nagy et al. 1991;
Boszormenyi-Nagy and Krasner 1986). The four dimensions include facts, psychology,
transactions, and relational ethics, and are separated only for purposes of gaining a conceptual
understanding. However, Boszormenyi-Nagy believed the dimensions are
intertwined, having great impact on each other, with relational ethics being of greatest
importance because this is where healing occurs in therapy when problems exist (Boszormenyi-Nagy
and Krasner 1986; Hargrave et al. 1991).
The facts dimension refers to preexisting factors, conflict that is unavoidable, and
consequences (Boszormenyi-Nagy and Krasner 1986). The second dimension is individual
psychology. Contextual therapy places importance on considering the emotional and
cognitive functioning of each individual member of the larger system, the family (Goldenthal
1993). Transactions, the third dimension, is based on concepts of family systems and
refers to issues of power and transactions in family relationships. According to Goldenthal
(1993, p. 6), the third dimension considers issues such as ``patterns of communication
among family members, triangulation, coalitions, boundaries within family members and
between the family and the environment, family roles and the potential for scapegoating,
and issues of interpersonal power and control.'' Relational ethics, the fourth dimension of
contextual theory, requires that each family member assume accountability for how his/her
actions impact all relational members. When accountability is not attended to and when the
give and take of relationships become imbalanced, Boszormenyi-Nagy (1987) theorized
that the result may entail a plethora of problems, including depression, sexual malfunction,
anorexia, stagnant relationships, and psychosomatic illness.
To illustrate the concept of relational ethics, Hargrave and Pfitzer (2003) suggest that in
a horizontal relationship (i.e., a relationship between equals, such as a husband and wife,
rather than between generations), both individuals are entitled to give and receive respect,
care, love, intimacy, nurture, financial responsibility, and fidelity. When relational ethics
are balanced, each can focus on giving these things rather than on what they are entitled to
receive. However, for example, if one partner is not faithful and controls all the family
resources, the other partner may become angry, depressed, manipulative, consider divorce,
or have an affair in an attempt to seek what he or she is entitled to from the partner.
Contemp Fam Ther (2008) 30:183­198 185
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On the other hand, when people feel destructively entitled, they may seek what they are
entitled to or become negative and hurtful to others. The unfairness that they have experienced
may leave them blind to the distress of others (Dankoski and Deacon 2000).
Constructive entitlement refers to the process in which people are compassionate and
concerned with and for others, but not at such an expense that they lose themselves
(Goldenthal 1996).
To understand how the dimensions of contextual theory interact, we need to
remember that it is an intergenerational theory. Hargrave and Pfitzer (2003) explained
that the dimensions interact among generations, acting as a megaphone. Facts and
interactions impact individual psychology, or the manner in which we perceive the
world cognitively and emotionally. Due to this perception created by facts and transactions
(systems), our relational ethics are formed and passed on to other generations.
Relational ethics serves as a megaphone in that the balance of give and take, loyalties,
and issues of trust are amplified among the generations. Therefore, considering genetics,
birth order, and other facts combined with system issues from a person's family of
origin such as parentification, a person may leave his or her family of origin feeling
entitled to be taken care of and may then expect his or her children to take care of him
or her respectively. These actions amplify the feelings of entitlement from one generation
to the next.
In creating contextual theory, Boszormenyi-Nagy offered a theoretical approach that
gives insight into human behavior and offers an understanding of how to move partners
and families from dysfunction to health. On this topic, Boszormenyi-Nagy et al. (1991, p.
210) wrote ``Contextual therapy converges with advances in the fields of immunology, in
the sense that its ultimate goal is the prevention of dysfunction and the rehabilitation and
strengthening of the family's own `immune system'--the resources of care, concern, and
connection.'' The four dimensions of relational reality support the basis for assessment, the
use of technique, and offer leverage for creating change that results in the aforementioned
goal.
Contextual Theory, Marriage, Depression, and Health
Based on the premise that relationships are healed through strengthening trust, commitment,
loyalty and reciprocity between family members (Boszormenyi-Nagy 1987;
Boszormenyi-Nagy and Spark 1984; Hargrave et al. 1991), contextual therapy works
towards balancing relationships and moving people towards health (Jones and Flickinger
1987). Boszormenyi-Nagy et al. (1991) offered insight concerning the purpose of contextual
theory when they wrote that ``the entry point and purpose of interventions are to
provide healing for an individuaľs pain or symptoms, as well as to address relational
problems'' (p. 201). Concerning relational functioning, which is the basis of contextual
theory and health, Boszormenyi-Nagy (1987, p. 311) stated:
The party who fails to earn merit vis-a`-vis his relational partners or lastingly ignores
his factual accountability for damaging consequences to posterity may become
depressed, insomniac, anorectic, addicted, ruined by success, sexually malfunctional,
relationally stagnant, accident-prone, or psychosomatically ill. As a psychological
consequence, conscious or unconscious feelings of guilt may or may not accompany
the person's disentitlement, i.e., the accumulation of existential guilt on his or her
side.
186 Contemp Fam Ther (2008) 30:183­198
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Therefore, if a person is not ethical in the give and take of relationships, the consequences
are negative and can impact physical and psychological health. Furthermore, issues of
trustworthiness can abound, and Boszormenyi-Nagy (1987, p. 230) asserted that ``The lack
of trustworthiness in one's relational world is the primary pathogenic condition of human
life.''
From the contextual theory perspective, it is through a focus on the balance of give and
take that exists within relationships that individuals, couples, and families can be healthier.
Boszormenyi-Nagy et al. (1991, p. 204) explained that ``the preservation of a long-term,
oscillating balance among family members, whereby the basic life interests of each are
taken into account by the others, is the criterion for healthy functioning.''
The assertion by Boszormenyi-Nagy that there is a relationship between relational
functioning and problems including depression, marital dysfunction, and psychosomatic
illness (Boszormenyi-Nagy 1987; Van Heusden and Van den Eerenbeemt 1987) has been
supported by empirical research. Marital dissatisfaction has been shown to be linked to
general psychological distress (e.g., Hawkins and Booth 2005; Whisman 1999; Williams
2003), depression and anxiety (e.g., Beach et al. 2003; Choi and Marks 2008; Fincham
et al. 1997; Rodrigue and Park 1996; Thompson et al. 1995; Whisman 1999; Whisman and
Bruce 1999), and post traumatic stress disorder (e.g., Whisman 1999). Marital dissatisfaction
also has been linked to physical health problems (e.g., Bookwala 2005; Campbell
2003; Hawkins and Booth 2005; Umberson et al. 2006; Wickrama, et al. 1997), including
chronic fatigue and immune dysfunction syndrome (Goodwin 1997), congestive heart
failure (Coyne et al. 2001), angina pectoris (Medalie and Goldbourt 1976), mortality
(Hibbard and Pope 1993), coronary heart disease (Orth-Gomer et al. 2000), poorer blood
glucose control and increased depression among diabetics (Trief et al. 2006), and healthrelated
behaviors (Wickrama et al. 1997). In a comprehensive review of the marriage and
health research, Kiecolt-Glaser and Newton (2001, p. 472) concluded that ``marital
functioning is consequential for health,'' and that ``negative dimensions of marital functioning
have indirect influences on health outcomes through depression and health habits,
and direct influences on cardiovascular, endocrine, immune, neurosensory, and other
physiological systems.''
The Present Study
Unfortunately, as noted, few researchers have examined contextual theory. BoszormenyiNagy
has suggested that relational ethics, which is recognized as the most important aspect
of contextual theory, is associated with marital functioning, depression, and psychosomatic
illness. Therefore, the purpose of this study was to use structural equation modeling to
conduct basic research to test Boszormenyi-Nagy's theoretical proposition that there is a
relationship among relational ethics, marital satisfaction, depression, and illness.
The primary research hypotheses were:
1. There will be a significant association between the RES (Hargrave et al. 1991), the
horizontal and vertical RES sub-scales, and the Revised Dyadic Adjustment Scale
(Busby et al. 1995), suggesting that couples who report high relational ethics will also
report high dyadic adjustment.
2. Marital satisfaction will be a significant mediating variable between relational ethics
and depression and physical health.
3. There will be a negative association between the RES (total, horizontal, and vertical
sub-scales) and the Center for Epidemiological Studies Depression Scale (Kohout
Contemp Fam Ther (2008) 30:183­198 187
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et al. 1993), suggesting that couples who report high relational ethics will report less
depression.
4. There will be an inverse association between the RES (total, horizontal, and vertical
sub-scales) and global health, suggesting that couples who report high relational ethics
will have fewer reported health problems.
Methods
Procedure
Data for this research were taken from a national study of midlife marriages. The survey
was mailed to 3,000 midlife married individuals throughout the country who were between
the ages of 40 and 50, selected from a national probability sample purchased from InfoUSA,
formally known as the Donnelly Corporation.
To maximize response to the survey, Dillman's (2000) procedures for conducting
survey research were used, including an initial mailing, reminder post cards being sent two
weeks after the initial mailing reminding participants to respond, and re-mailing questionnaires
to non-responders after four weeks of the initial mailing. Individuals who had
not sent in either questionnaire (initial or second mailing) were later called by researchers
and invited to participate in the study.
Of the initial sample, 518 questionnaires were undeliverable due to incorrect addresses,
and 566 members of the sample were eliminated because they did not fit the study criteria
of being married and between the ages of 40 and 50. Of the remaining surveys, 632 were
returned, resulting in a 33.0% response rate. While response rates are expected to vary
based on the research population, survey methods used, and other variables (Babbie 2001;
Dillman et al. 2007), the 33.0% response rate for this study may be considered relatively
low.
Sample
Research participants were 43% female (n = 275) and 57% male (n = 357), with a mean
age of 43.7 years. Ninety percent of participants were Caucasian (n = 569), 5% were
African American (n = 30), and the remaining 5% were of other ethnicities (n = 32).
Participants had been married from 1 to 30 years, with a mean of 13.7 years. The majority
(64%; n = 402) of participants in the sample were in their first marriage, with 27%
(n = 168) being in their second marriage, and 9% (n = 55) in their third or fourth marriage.
The mean number of children in each participant family was 2.8, with a range of 0­
10. Most of the participants reported being employed full-time (75%; n = 473), with only
11% (n = 67) reporting part-time employment. Participant family income ranged from
$10,000 to over $150,000. The median family income was between $70,000 and $79,000.
The mode income level reported by participants (11%; n = 71) was between $40,000 and
$49,999. Two participants (.03%) reported an income of less than $10,000 and 65 participants
(10%) reported an income of $150,000 or more.
Compared with the general U.S. population of married individuals between the ages of
40 and 50, this sample has a somewhat above-average percentage of college graduates
(43%). In addition, minority mid-life married people are underrepresented in the sample.
However, the median income of the participants in this study is consistent with the national
188 Contemp Fam Ther (2008) 30:183­198
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median income of $75,482 for married people in this age group (U.S. Census Bureau
2002).
Description of Measures
Relational Ethics Scale
The main independent variable for the study was the Relational Ethics Scale (RES), a
24-item scale that was developed to measure the contextual theory concept of relational
ethics. The RES includes two 12-item subscales to measure vertical and horizontal
relationships. Examples of items on the vertical subscale include, ``I could trust my
family to seek my best interests,'' ``I received the love and affection from my family
that I deserved,'' ``At times, I was used by my family unfairly,'' and ``I felt life was
dominated by my parents' desires.'' Examples of items on the horizontal subscale
include, ``I try to meet the emotional needs of my spouse,'' ``My spouse stands beside
me in times of trouble or joy,'' ``When I feel angry, I tend to take it out on my spouse,''
and ``I am taken for granted or used unfairly by my spouse.'' Negative items were
reversed scored, and higher scores on the RES, including the two sub-scales, suggest
better relational ethics. A Cronbach's alpha demonstrated the scale's reliability (.93),
and concurrent validity was established by finding significant correlations between the
RES and the Dyadic Adjustment Scale, as well as the Personal Authority Questionnaire
(Hargrave et al. 1991).
Revised Dyadic Adjustment Scale
The Dyadic Adjustment Scale (DAS; Spanier 1976) is a standardized assessment used to
assess the quality of the marital relationship (Busby et al. 1995). The Revised Dyadic
Adjustment Scale (RDAS; Busby et al. 1995) is a 14-item measure that was created from
the DAS. Like the DAS, the RDAS also assesses marital quality, but is more brief.
Furthermore, previous research has demonstrated adequate internal consistency, split-half
reliability and construct validity (Busby et al. 1995). Low scores on the RDAS suggest
greater marital distress, whereas higher scores represent marital non-distress, with a cutoff
score of 48. Nondistressed couples are expected to score 48 and above on the RDAS and
scores of 47 and below are indicative of distressed couples.
The Center for Epidemiological Studies-Depression Scale
The Center for Epidemiological Studies-Depression Scale (CES-D) was designed to
measure symptoms of depression in the general population (Radloff 1977). It is
intended for use in research rather than for clinical work (Radloff and Teri 1986).
Originally consisting of 20 items, a shortened 11-item CES-D was used for this study
(Kohout et al. 1993). When compared to the original CES-D, the 11-item CES-D has
been shown to tap into the same dimensions, is briefer, and does not lose its reliability.
Likeliness of having clinical depression is indicated by higher scores on the scale. The
scale ranges in score from 0 to 22. Testing of the CES-D has shown the scale to be
valid and reliable, with Chronbach's alphas ranging from .85 to .92 (Radloff 1977;
Radloff and Teri 1986).
Contemp Fam Ther (2008) 30:183­198 189
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Health Questions
This study used two questions to assess and compare general health to the RES. The first
question asked the participant ``Compared to people your own age, how would you rate
your overall physical health at the present time?'' The participant could then check a box
indicating ``Excellent,'' ``Good,'' ``Fair,'' or ``Poor.'' Because the distribution of responses
was skewed towards good health, the variable was recoded a zero for responses of
excellent, good, or fair health, and a one for poor health. The second question was ``What
major health problems do you presently have? (Circle all that apply.)'' The participants
were given a list of 21 health problems, including items such as ``Heart conditions,''
``Diabetes,'' ``Alcoholism,'' ``Anxiety problems,'' and ``Other,'' with a space provided
where they could fill in any health problem not listed. The items from the two measures
were combined and summed, creating a scale ranging from 0 to 22. Measures of selfreported
global health and self-reported health problems have been shown to be valid
measures of health when compared with doctors' evaluations of health (Ferraro and Farmer
1999). Moreover, previous research has successfully combined these measures (Kahn and
Fazio 2005), with one study finding factor loadings of over .90 when using these two
measures to assess health (Sandberg et al. in press).
Control Variables
Several control variables were included as part of the data analysis, including gender, years
married, and education. These variables were included because they have been shown to
interact with marital satisfaction (e.g., Burr 1970; Holman et al. 2001; Miller 2000; Whyte
1990). Gender, number of years married, and education were measured using standard
demographic questions. The education measure had seven response options ranging from
``completed grade schooľ' to ``completed a graduate degree.''
Results
Correlations
Before testing the hypotheses, correlations were conducted among the variables used in the
study. As indicated in Table 1, the RES and its subscales were all significantly correlated
with measures of marital satisfaction, depression, and health problems. In addition, marital
satisfaction, depression, and health problems were significantly intercorrelated.
Structural Equation Models
Three Structural Equation Models (SEM) using LISREL (Linear Structural Relationships;
Joreskog and Sorbom 2003) were performed to test the hypotheses of the study. The three
models were similar in that they tested the effect of RES on marital satisfaction, depression,
and health problems. Marital satisfaction was an intervening variable between RES,
depression, and health problems. The models also included gender, education, and years
married as control variables. Disturbance correlations were included between depression
and health problems to represent the correlation between the two variables, which shared
common variance due to questions concerning depression from the CES-D. One model
190 Contemp Fam Ther (2008) 30:183­198
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used the total RES score for the main exogenous variable, while the second model used the
horizontal subscale of the RES, and the third model used the vertical subscale of the RES.
SEM was used in these analyses for two reasons. First, an advantage of SEM over
traditional regression procedures is that SEM controls for measurement error, which leads
to more accurate regression, or path, coefficients, than does regression analysis (Byrne
2001). Second, SEM allows the testing of direct paths between the main variables, as well
as indirect paths (Kline 2005). The analyzed indirect paths included the paths from RES
(total score, horizontal, and vertical) to depression and to health problems via their prior
effect on marital satisfaction.
Before examining the path coefficients to the three models, it was necessary to test the
goodness-of-fit of the models. Hu and Bentler (1999, 1998) have recommended reporting
the Standardized Root Mean Square Residual (SRMR), the Root Mean Square of
Approximation (RMSEA), and the Comparative Fit Index (CFI). Kline (2005) recommended
a cutoff value for the SRMR of .10 or less to show goodness of fit. For the
RMSEA, cutoff values of B.05 have been suggested to report good fit. Scores greater than
.90 suggest good model fit using the CFI. Hu and Bentler (1998) explain that chi-square
statistics are so sensitive to sample size that reporting them is of little value in studies with
large samples. Therefore, chi-square statistics were not reported.
Total RES Model
Model 1 (Fig. 1) represents the path model that includes the variable for the total RES
score. Based on the goodness of fit models reviewed and the recommended cutoff criteria,
model 1 appeared to be an acceptable fit to the data (SRMR = .054, RMSEA = .081, and
CFI = .94). Significant paths included the direct paths between the RES and marital
satisfaction, marital satisfaction and depression, and marital satisfaction and health problems.
The estimated standard path coefficient for the direct effects of RES on marital
satisfaction was .51 (p \ .01). Statistically significant inverse relationships existed
between marital satisfaction and depression and between marital satisfaction and health
problems, with respective estimated standardized paths of -.39 (p \ .01) and -.17
(p \ .01). Estimated standard path coefficients for the direct effects of the control variables
on marital satisfaction were not significant.
Table 1 Correlation matrix of variables representing RES total, RES horizontal, RES Vertical, depression
(CESD), health problems, marital satisfaction (RDAS), and control variables
CESD RES
total
Horizontal Vertical Health
problems
RDAS Years
married
Education
CESD 1.00
RES Total -.349** 1.00
Horizontal -.340** ­ 1.00
Vertical -.220** ­ ­ 1.00
Health problems .470** -.208** -.143** -.182** 1.00
RDAS -.391** .506** .752** .099* -.171** 1.00
Years married .051 -.018 -.038 .006 .083* -.04 1.00
Education -.068 .078 .032 .087* -.142** .039 -.073 1.00
* p \ .05 (2-tailed); ** p \ .01 (2-tailed)
Contemp Fam Ther (2008) 30:183­198 191
123
In addition to the direct paths, the indirect paths from RES to depression and from RES
to health problems were calculated and analyzed. The indirect estimated path coefficients
were -.199 (p \ .01) and -.087 (p \ .01) respectively. Both indirect paths were
significant.
Horizontal Subscale Model
Model 2 (Fig. 2) represents the path model that replaces the RES total score with horizontal
RES. Concerning goodness of fit, Model 2 appeared to be a good fit to the data
(SRMR = .04, RMSEA = .054, and CFI = .098). The estimated standard path coefficient
for the direct effect of horizontal RES on marital satisfaction was .76 (p \ .01). The
estimated standard path coefficients for the direct effects of marital satisfaction on
depression and on health problems were -.39 (p \ .01) and -.17 (p \ .01) respectively.
The estimated standard indirect path coefficients from horizontal RES to depression and to
health problems were both significant at respective values of -.296 (p \ .01) and -.129
(p \ .01).
Gender was the only control variable that had a significant effect on marital satisfaction,
with the estimated standard direct path coefficient value of .08 (p \ .01). This indicates
-.03
.00
.05
.51*
Error
Error
Problem
-.39*
-.17*
Health
Depression
(CESD)Marital
Satisfaction
(RDAS)
Total
RES
Gender
Education
Yrs Married
*p<.01
Fig. 1 Model 1. SEM path model including RES total score. Path values are standardized. Note. Indirect
paths were calculated, but not illustrated on the figure so it is easier to read. a
Indirect path coefficient from
RES to depression via its prior effect on marital satisfaction was -.199 (p \ .01). b
Indirect path coefficient
from RES to health via its prior effect on marital satisfaction was -.087 (p \ .01). SRMR = .054;
RMSEA = .081; CFI = .94
Error
Error
Problem
-.01
.02
.08*
.76*
-.39*
-.17*
Health
Depression
(CESD)Marital
Satisfaction
(RDAS)
Horizontal
RES
Gender
Education
Yrs Married
*p<.01
Fig. 2 Model 2. SEM path model including horizontal RES. Path values are standardized. Note. Indirect
paths were calculated, but not illustrated on the figure so it is easier to read. a
Indirect path coefficient from
RES to depression via its prior effect on marital satisfaction was -.296 (p \ .01). b
Indirect path coefficient
from RES to health via its prior effect on marital satisfaction was -.129 (p \ .01). SRMR = .04;
RMSEA = .054; CFI = .98
192 Contemp Fam Ther (2008) 30:183­198
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that female participants had lower levels of marital satisfaction while controlling for the
horizontal subscale of RES, as well as age and number of years married.
Vertical Subscale Model
Initially, Model 3 (Fig. 3) was designed exactly as model 1 and model 2, except for
analyzing variable relationships with vertical RES instead of the total RES or horizontal
RES. Goodness of fit statistics revealed that this model provided unacceptable results
(SRMR = .061, RMSEA = .085, and CFI = .89). All three scores were beyond the recommended
cut-off values suggested by Hu and Bentler (1998, 1999) and Kline (2005).
Therefore, the model was rejected.
Tests of the missing paths in the initial model indicated that two additional direct paths
would contribute significantly to the goodness-of-fit of the model: vertical RES on
depression and vertical RES on health problems. After reviewing the data and theory, it
was evident that the additional paths were supported in the literature. Specifically, the
direct paths were added to better reflect the contextual theory proposition that, while
vertical relationships have a strong and lasting impact on marital functioning (i.e., loyalty
conflicts; Boszormenyi-Nagy 1987; Boszormenyi-Nagy and Krasner 1986), they also can
result directly in depression and health problems without marital functioning as an intervening
variable (Boszormenyi-Nagy 1987; Boszormenyi-Nagy and Krasner 1986). The
added direct paths from vertical RES to depression and to health problems improved model
fit, resulting in the model fitting the data well (SRMR = .037, RMSEA = .058,
CFI = .96). This was a substantial improvement over the initial model.
The estimated standard path coefficient for the direct effects of vertical RES on marital
satisfaction was .10 (p \ .05). While the z-value (2.26) revealed this to be a significant
path, it is much lower than the path between total RES and marital satisfaction (.51,
p \ .01) and between horizontal RES and marital satisfaction (.76, p \ .01). The estimated
standard path coefficient from vertical RES to depression was -.22 (p \ .01) and from
vertical RES to health problems was -.18 (p \ .01). In addition, the indirect paths from
vertical RES to depression (-.037, p \ .01) and from vertical RES to health problems
Yrs Married
Education
Gender
Error
Error
.03 .03 -.04
.10**
-.18*
-.16*
-.22*
-.37*
Depression
(CESD)
Health
Problem
Marital
Satisfaction
(RDAS)
Vertical RES
*p<.01, **p<.05
Fig. 3 Model 3. SEM model including vertical RES and added paths. Path values are standardized. Note.
Indirect paths were calculated, but not illustrated on the figure so it is easier to read. a
Indirect path
coefficient from vertical RES to depression via its prior effect on marital satisfaction was -.037 (p \ .01).
b
Indirect path coefficient from vertical RES to health via its prior effect on marital satisfaction was -.016
(p \ .01). SRMR = .037; RMSEA = .058; CFI = .96
Contemp Fam Ther (2008) 30:183­198 193
123
(-.016, p \ .01) were significant. There were no significant path coefficients from the
control variables to marital satisfaction.
Applying the results of the three SEM models to the hypotheses for the study indicates
that all of the hypotheses were supported. The significant relationships between the total
RES, horizontal RES, and vertical RES scales with marital satisfaction supported the first
hypothesis. In all of the models, marital satisfaction was significantly related to depression
and health, which supports the second hypothesis. There were significant direct paths
between vertical RES and depression, as well as significant indirect effects between total,
horizontal and vertical RES and depression. These results support the third hypothesis.
Similar results for health as the dependent variable support the fourth hypothesis.
Discussion
Relational Ethics
Of all variables examined in the three models, the strongest relationship was between
horizontal relational ethics and marital satisfaction. The RDAS, which was used to
examine marital satisfaction, focuses on aspects of the horizontal relationship (the relationship
between equals rather than among generations) of the couple. Couples who are
responsible for their own actions and who offer due merit and consideration in their marital
relationships are more likely to be satisfied in their marital relationship. They are also more
likely to experience no or low depression, and are at decreased risk for health problems.
While horizontal relational ethics appears to have a significant effect on marital satisfaction,
results from this study revealed that vertical relational ethics had a significant
relationship with marital satisfaction as well, even when horizontal relational ethics were
not considered. Boszormenyi-Nagy (1987), Boszormenyi-Nagy and Krasner (1986), and
others (e.g., Goldenthal 1996; Hargrave and Pfitzer 2003) have explained that when
conflicts, such as destructive parenting or abandonment occur to a child, the child may
attempt to realize unjust obligations to obtain love and acceptance from his/her family of
origin, and that these destructive attempts often occur in horizontal relationships. For
example, a man may be loyal to his physically abusive father by mistreating his wife. In
this case, his loyalty to his father is damaging to the horizontal relationship with his wife.
Therefore, his vertical relationship with his father would have an impact on marital
satisfaction.
In addition to the relationship with marital satisfaction, reported vertical RES scores
were inversely related to depression and health. Study participants who reported low
vertical RES scores, or poor vertical relationships with their family of origin, were more
likely to experience depression and an increased number of health problems via their
previous effect through marital satisfaction. Therefore, lower scores on the vertical relational
ethics scale were significantly associated with an increase of depression scores and
number of health problems, with marital satisfaction acting as a mediating variable. For
this model (Model 3), the direct paths between vertical relational ethics and depression and
between vertical relational ethics and health problems were examined as well. These
relationships were significant, suggesting that regardless of marital satisfaction, participants
who indicated poor vertical relational ethics scores were more likely to experience
depression and an increased number of health problems.
These findings are consistent with contextual theory. Boszormenyi-Nagy and Krasner
(1986) identified depression as one of the grave consequences of poor vertical and/or
194 Contemp Fam Ther (2008) 30:183­198
123
horizontal relationships that can surface in children and adults alike. An individual may
internalize lack of trust after poor vertical relationships, resulting in depression or other
symptoms, such as psychosis. Hargrave and Pfitzer (2003) refer to this internalization as
shame, resulting in feeling unlovable. Concerning vertical relationships and health, Boszormenyi-Nagy
and Krasner (1986) clearly theorized that when a generational violation of
trust occurs (or when poor vertical relationships exist) psychosomatic illness may result.
Boszormenyi-Nagy and Krasner (1986) believed that the heart of contextual therapy,
derived from contextual theory, is the improvement of client quality of life. Given the
statements that have been made concerning the relationship between relational ethics and
marital functioning and physical and mental health, or illness (Boszormenyi-Nagy 1987), it
is understandable that an emphasis on improved quality of life would be made. With the
sample studied, it appears that there is support for the contextual theoretical claim that
people who fail to relate ethically may be more prone to have stagnant relationships (as
evidenced by the relationship between relational ethics and marital satisfaction), become
more depressed, and deal with health problems (Boszormenyi-Nagy 1987).
Limitations of the Study
The primary limitation of this study concerns the generalizability of the findings. This
sample, although large, underrepresented minority and less-educated populations and was
restricted to married individuals between the ages of 40 and 50. Hargrave and Bomba
(1993) studied small participant populations ranging in age from 20 to 68 years, but their
primary purpose was to further validate the Relational Ethics Scale. This study goes
beyond the goal of scale validation to testing key propositions of contextual theory.
However, additional research needs to be conducted with other samples that span greater
age, education, and ethnicity ranges.
While the results from this study suggest that there is a significant relationship between
relational ethics and number of reported health problems, the specifics of this relationship
were not explored. Future research should examine not only the number of health problems,
but also should consider etiology, severity, environmental and socioeconomic
influences, and other factors that influence health.
A general limitation of research using structural equation modeling is the potential
omission of predictor variables that impact the total criterion variance, referred to as
specification error (Kline 2005). While literature was reviewed and variables were discussed
and examined for this study, there is a possibility that specification error exists.
Directions for Future Research
This basic research study has set the foundation for other questions to be asked and
answered about contextual theory. For example, the focus was on the contextual theory
dimension of relational ethics. As basic research also focuses on the other key dimensions
of the theory-facts, psychology, and transactions-answers about the relationship among the
four dimensions can be explored, and the overall theory can be tested empirically in a more
holistic manner.
There is also a need to test the effectiveness of contextual theory in its clinical application.
Questions that need to be answered include the following: If therapy focuses on the
dimension of relational ethics with clients, will significant and lasting improvement result?
If the same variables used in this study are applied to an outcome study where therapists
Contemp Fam Ther (2008) 30:183­198 195
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use the concept of multidirected partiality to create change in therapy, will there also be a
change in reported RES as Boszormenyi-Nagy and Krasner (1986) have proposed? And
would the change in RES result in a change in marital satisfaction, depression, and health
problems?
It has been acknowledged throughout this article that relational ethics is the pinnacle of
contextual theory because it is the entry point where leverage for change and balancing
occurs and where therapists can mobilize the most powerful factors for healing (Boszormenyi-Nagy
1987; Boszormenyi-Nagy and Krasner 1986; Hargrave and Pfitzer 2003).
Research that supports the concept of relational ethics supports the most important and
greatest defining characteristic of contextual theory. Using a basic research design, this
study serves not only as evidence of the statistical significance of the relationships and
overall models analyzed, but it also may serve to lay the foundation for outcome studies to
further examine this ``thoughtful and underappreciateď' theory (Nichols and Schwartz
2001, p. 50).
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