UNIVERSITY OF TENNESSEEDEPARTMENT OF PSYCHOLOGY

KRISTINA C. GORDON PH.D.

Relationship Rx: An Effective, Brief, Motivational Intervention for Diverse Couples

Film clip from Pixar’s UP

Why work on your relationship?

Relationships and Physical Health

Even considering other stressful life factors, those in pleasurable marriages have been found to have lower systolic blood pressure

Stressful interactions between distressed couples has been linked to lowered immune functioning

Married people 2.5 more likely to be alive 15 years after heart surgery

Relationships and Physical Health

Wounds even heal faster in less distressed couples

Major reviews 2001 and 2015 found 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 mechanisms

Relationships and Emotional Health

Depression Relationship dissatisfaction can play a causal role in

development of depression Might be more predictive than genetics Particularly problematic for women

Anxiety Partner behaviors are predictive of willingness to

enter treatment and response to treatmentAlcoholism

Partner dynamics can affect motivation Partner criticism can affect cravings, urges to use Adding couples treatment can improve outcomes

Effects on Children

Problematic parentingPoorer child adjustment

More conduct problems Poorer social adjustment Lowered academic achievement Poorer psychological adjustment More likely to smoke, drink, drop-out and

engage in sexual behavior as teenagers

Effects on Children

Negative effects of an unhealthy relationship can get passed on to children: More likely to divorce More likely to report more

relationship discord More likely to display poor

communication with partners More likely to marry at a young

age Have more negative attitudes

about marriage

Relationship distress is the leading reason for seeking mental health counseling. (Swindle, Heller, Pescosolido, & Kikuzawa, 2000)

Relationship distress and work

Work loss associated with marital problems converts into a cost of approximately $6.8 billion per year.

Higher marital conflict on one day strongly predicts lower levels of work productivity the next day.

Minority/Income Disparity

The unmarried birthrate varies greatly by race and education – 72% of African-American children are born to unmarried parents vs. 36% of White children.

Among pregnant minority couples with low-income levels, only 44% will be together by the child’s 1st birthday.

Kathy Edins – Promises I Can KeepMarriage as a capstone, not a cornerstoneCDC report – parental relationship instability

is a major problem for low-income children

Enormous Financial Consequences

After divorce, net financial worth tends to fallTaking into account only the effects of family

breakdown on poverty rates, the United States is estimated to spend $112 billion dollars per year on the costs of family breakdown13.

A mere one percent reduction in rates of family fragmentation would save taxpayers $1.12 billion annually in expenditures related to poverty.

Despite these demonstrated needs, no federal entity currently has the responsibility and authority for funding science to advance either a deeper understanding of intimate relationships or the development of new and/or improved interventions to strengthen their quality and longevity.

Significant Disparity

The federal government will have spent $150,572,217 in FY 2012-2013 on projects with “depression” in the title and only $2,981,495 on projects with “marriage” in the title.

6.7% of the population is depressed during a 12-month period14 while

31% of those who are currently married report clinical levels of marital distress15.

Benefits of Healthy Relationships

Better and stronger communities Fewer reports of intimate partner violenceIncreased financial stability

Less financial stress Over time, married individuals tend to increase

their net worth; after divorce, net worth tends to fall

Fewer missed workdaysHigher worker productivityLower use of medical servicesHealthier children

Why do a Marriage Checkup?

Most people do not go to couples counseling - why?

How can we get them in?Most therapy is not long-lasting Maybe we need a different approach?

Public health?

Definition of Checkup

an examination of a person made by a doctor to make sure the person is healthy; also : an instance of looking at the parts of a machine to make sure it is working properly

Marriage Checkup

Developed by Dr. James Córdova at Clark University

Consists of two sessions – Assessment Feedback

Based on Integrative Behavioral Couple therapyMotivational Interviewing

Marriage Checkup

The MC is effective at Attracting high-risk but skeptical couples Has a high completion rate Safe for use with high risk couples

Initial findings suggest that the MC: Increases intimacy Reduces relationship distress even at 2

years follow-up Increases help-seeking in wives

Does the Marriage Checkup work?

New results from larger scale study suggest: improved relationship satisfaction feelings of deeper intimacy a greater acceptance of partners for each

other greater collaboration between partners improved help-seeking attitudes an increase in motivation to actively attend

to the health of the relationship

Marriage Checkup findings (cont.)

Two year follow-up shows:improvements in marital satisfaction

and/or intimacy due to treatment also are associated with

decreases in partners’ depressive symptoms

less frequent use of medical services

greater marital stability

Tim

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FeedbackTX Assessment

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Tim

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Tim

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Tim

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Tim

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Tim

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MC Timeline

FeedbackBooster Assessment +

Overall Results

Treatment group significantly improved on Intimacy and Quality of Marriage over time

Control Group did notTreatment group significantly improved on

Intimacy and Quality of Marriage over time compared to Control Group

Results – Between Group Differences

Intimacy scores smoothed profile

2.852.902.953.003.053.103.153.203.253.303.35

Baseline Feedback 2 Wk 6 mo 1 yr 1yr+FB 1yr+2wk

CON

MC

Summary/Discussion

MC found a highly significant differential linear change effect (F(1,358)=51.46, p<0.0001, d=.42) for intimacy.

Why linear? Intimacy gets “kick started” and builds over time. Naturally reinforcing

Marital Satisfaction-smoothed profile

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Baseline Feedback 2 Wk 6 mo 1 yr 1yr+FB 1yr+2wk

CONMC

Summary/Discussion

We found a significant differential cubic trajectory between the MC condition and control (F(1,277)=9.77, p=0.002, d=.41) for distress.

We call this a “climbing M”

Implications/ Discussion

Comparable to previous MC studies, with some improvement

Role of the booster visit Regular checkups

Limitations

Generalizability Diversity Efficacy vs. Effectiveness

So that is where Relationship Rx comes in We go to them We oversample low-income couples We take everybody

(except severely violent couples)

ADAPTING TO THE COMMUNITY AND LOW-INCOME POPULATIONS

What is Different about RX

Why oversample a low-income population?

Marriage rates lower/ divorce rates higher for less-educated or lower income

individualsPoverty stresses marriageSome evidence that marriage increases

financial stability Over time, married individuals tend to

increase their net worth; after divorce, net worth tends to fall

Why is Relationship Rx important in TN?

Our immediate geographic area has: Higher than the national average poverty rate – 12.7% vs. 9.9% Lower rate of high-school graduation – 75.8%. vs. 84.6%Higher than national average divorce rate – 12.7% vs. 10.4%Fourth largest number of domestic violence crimes in the state

Appalachian Regional Commission Report citedstigma as major barrier to treatmentThere are no ongoing community programs that provide relationship assistance to low-income individuals

Unique challenges for low-income populations

Financial Struggles - poverty Scarcity hypothesis

Multiple JobsSerial relationships – blended families

HomelessnessDiscrimination and subtle biasesSubstance Abuse

Barriers and Benefits

Barriers Time Childcare Stigma Cultural norms about familial boundaries

Benefits Tight-knit communities Value relationships Responsive and grateful for help

Basic Relationship Rx

Two-session Intervention Enrolled couples meet with a facilitator in their home

in an effort to reduce traditional barriers to participation, unless they prefer to meet at a clinic

Intervention Two 1.5-hour assessment/feedback and a motivational

interview For couples in need of additional help

Within Our Reach couples skills groups Jobs skills workshops via Workforce Connections

Couples are connected to community resources

IN BRIEF – SEEMS SIMPLE BUT DECEPTIVELY SO….

How to do the Checkup

Weird Things Couples Fight About

Theoretical Models

Attachment and Evolutional Theory Neurologically wired to be in close relationships

Acceptance and Change Models (Third-wave CBT) – Integrative Behavioral Couple Therapy Second order change is the best kind of change Acceptance paradox

Motivational Change Models Humanistic Avoids Resistance

Why is communication so hard?

Personality differences and preferencesintensityapproach vs avoidfacts vs. feelings“flip/flop factor”

Why so hard?

Emotionsanger, frustration, irritation, contempt

anxiety and fearhurtshame vs. guilt

What helps us communicate

Cultivating positive emotionsJoy, contentment, pleasure,

connectiongratitude and appreciationLove and companionshipEmpathy

What helps us communicate

Seeking UnderstandingPracticing Acceptance

Tolerate the discomfortLearning how to manage disappointment & emotional pain

Seeing problems as “uninvited guest”

Specific Practices

“Turning toward”Time and ritualsAppreciationBalancing acts

Provide supportViewing problems from a ‘we’ perspective instead of ‘you’

Specific Practices

Physical touch and intimacyEmotional intimacy

Emotional expressionMutual self-disclosure

Manage conflictProblem solvingTime outs

Format of Assessment Session

Why did they decide to do checkup?Who brought it up first?What do they hope to gain?How did they meet?How did they decide their partner was “the

one”?Choose most important strength and discuss

for each partner; then switchChoose largest concern and discuss for each

partner; then switchSummarize

Attention is the most basic form of love

The demands of day-to-day life often draw our attention away from the ones we love

The Relationship checkup is designed to deliberately turn partners back toward each other

Projecting acceptance

Acceptance is the key to healthy intimacy

Facilitator communicates and models acceptance

Radical acceptance without judgment can create a sense of intimacy

The other partner is always listening

When talking to one partner, the other partner has no choice but to listen and be influenced by the story

We can take advantage of this to help partners understand each other more compassionately

Be mindful of the impact on the listening partner

Reframe concerns to highlight compassion and understandable reasons for the complaint

The therapeutic pursuit of acceptance and change

Acceptance is change If you are going to incorporate acceptance

into your practice, you must incorporate it into your life and your relationships

Serenity PrayerBalance of working towards individual

growth and a radical acceptance of human nature

Distinction between change and acceptance is the wisdom to know the difference

Getting “under” the issue

Kickstarting Intimacy: Accessing more vulnerable emotions

Building Mutual Acceptance: Discovering understandable reasons and identifying themes and patterns

Building a Collaborative Set: Mutual traps and “itifying”

Common Patterns

Mutual Avoiders – turtles Mutual Escalation – kiss of the porcupinesDemand/WithdrawPursuer/DistancerCactus/FernSpender/SaverTortoise/HareGrasshopper/Ant

Format of Feedback session

Summarize historyCelebrate strengthsGive feedback on what research says about

concernsHelp them understand their pattern around the

concernsGive them menu optionsHelp them brainstorm solutions and think of how

they can use their strengths to address the problem

Follow up in one month and six months

Revlon Love Test

[REMEMBER THESE ARE PRELIMINARY]

Results From Rx

Numbers so far

1,309 completed assessment packets; 1,175 completed feedback measure

65% returned our 1 month packets; 60% return 6 1month – overall – but in last 9 months, that went up to 75% for both

Overall program satisfaction is great – average scores range from 4.4 to 4.8 on a scale of 1-5

Demographics – Rx

Married: 59%

Median length of relationship: 7 years

Meet cutoff for relationship distress: Baseline: 32% Month 1: 19% Month 6: 18%

Predominantly white (75%), household income (median = 35,000), poverty (26%), high school education or less (51%)

51% of men and 30% of women are employed full time

Rx – Individual Income

PooledMedian Income 10-19k/yrModal Income: < 10k/yr (39%)

MenMedian Income: 20-29kModal Income: < 10k (29%)

WomenMedian Income: 10-19k Modal Income: < 10k (48%)

Rx – Household Income

Median poverty ratio = 1.90

27% of couples living below the poverty threshold

51% of couples are low-income (2x poverty threshold)

1 month Effect Sizes for Outcome Variables

6 month follow-up:Relationship Satisfaction

Total (N = 1312) 

Relationship Satisfaction 2.06 (0.26)**

Poverty (n = 341) 

Relationship Satisfaction 1.34 (0.57)**

Married (n = 708)

Relationship Satisfaction 2.80 (0.31)**

Anecdotal Success Stories

Overheard in the staff rooms…“Relationship shoes”“Go sit in your corner”“He won’t stop talking about his emotions!!”“I didn’t think I wanted to do this but….” Ghost recruiters“She’ll never change.” to “She’ll never

change.”

Conclusions

Our effect sizes were small to moderate, but seem to last 6 months out

Effect sizes are larger for folks below poverty line

Why?

What is unique about MC/Rx compared to most relationship education

Final Comments

Many are struggling with external stressors, which brings them in – but this is less threatening than therapy

Reaching couples when they are struggling but not too deteriorated might allow for greater change with less therapeutic effort

Still have a long way to go with this – still a great deal of reluctance and resistance