Relationship Rx An Effective Brief Motivational Intervention for
Relationship Rx: An Effective, Brief, Motivational Intervention for Diverse Couples UNIVERSITY OF TENNESSEE DEPARTMENT OF PSYCHOLOGY KRISTINA C. GORDON PH. D.
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 treatment Alcoholism Partner dynamics can affect motivation Partner criticism can affect cravings, urges to use Adding couples treatment can improve outcomes
Effects on Children Problematic parenting Poorer 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 1 st birthday. Kathy Edins – Promises I Can Keep Marriage as a capstone, not a cornerstone CDC report – parental relationship instability is a major problem for low-income children
Enormous Financial Consequences After divorce, net financial worth tends to fall Taking 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 breakdown 13. 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 period 14 while 31% of those who are currently married report clinical levels of marital distress 15.
Benefits of Healthy Relationships Better and stronger communities Fewer reports of intimate partner violence Increased financial stability Less financial stress Over time, married individuals tend to increase their net worth; after divorce, net worth tends to fall Fewer missed workdays Higher worker productivity Lower use of medical services Healthier 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 therapy Motivational 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 e 6 Tim e 2 w k) ) ar) yea r FB ear (1 y 5 (1 (1 y e s) nth mo e 4 3 (6 s) eek (2 w TX Assessment + Feedback Tim e e 2 Tim bac k) eed 1 (F ) line ase 0 (B Tim e MC Timeline Booster Assessment + Feedback
Overall Results Treatment group significantly improved on Intimacy and Quality of Marriage over time Control Group did not Treatment group significantly improved on Intimacy and Quality of Marriage over time compared to Control Group
Results – Between Group Differences Intimacy scores smoothed profile
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
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)
What is Different about RX ADAPTING TO THE COMMUNITY AND LOW-INCOME POPULATIONS
Why oversample a low-income population? Marriage rates lower/ divorce rates higher for less-educated or lower income individuals Poverty stresses marriage Some 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 cited stigma as major barrier to treatment There 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 Jobs Serial relationships – blended families Homelessness Discrimination and subtle biases Substance 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
How to do the Checkup IN BRIEF – SEEMS SIMPLE BUT DECEPTIVELY SO….
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 preferences intensity approach vs avoid facts vs. feelings “flip/flop factor”
Why so hard? Emotions anger, frustration, irritation, contempt anxiety and fear hurt shame vs. guilt
What helps us communicate Cultivating positive emotions Joy, contentment, pleasure, connection gratitude and appreciation Love and companionship Empathy
What helps us communicate Seeking Understanding Practicing Acceptance Tolerate the discomfort Learning how to manage disappointment & emotional pain Seeing problems as “uninvited guest”
Specific Practices “Turning toward” Time and rituals Appreciation Balancing acts Provide support Viewing problems from a ‘we’ perspective instead of ‘you’
Specific Practices Physical touch and intimacy Emotional intimacy Emotional expression Mutual self-disclosure Manage conflict Problem solving Time 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 switch Choose largest concern and discuss for each partner; then switch Summarize
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 Prayer Balance 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 porcupines Demand/Withdraw Pursuer/Distancer Cactus/Fern Spender/Saver Tortoise/Hare Grasshopper/Ant
Format of Feedback session Summarize history Celebrate strengths Give feedback on what research says about concerns Help them understand their pattern around the concerns Give them menu options Help 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
Results From Rx [REMEMBER THESE ARE PRELIMINARY]
Numbers so far 1, 309 completed assessment packets; 1, 175 completed feedback measure 65% returned our 1 month packets; 60% return 6 1 month – 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 Pooled Median Income 10 -19 k/yr Modal Income: < 10 k/yr (39%) Men Median Income: 20 -29 k Modal Income: < 10 k (29%) Women Median Income: 10 -19 k Modal Income: < 10 k (48%)
Rx – Household Income Median poverty ratio = 1. 90 27% of couples living below the poverty threshold 51% of couples are low-income (2 x 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 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
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