CHAPTER 12

Fraenkef'P'' & Markman, H' J. (2002). Preventionof marital disorders. In D. S. Glenwick & L. A' Jason(Eds'), rnltolltneytrategiesfor promoting health and mental health across the life span (pp.245-271). New york: Springer.

Preventing Marital Disorder

Peter Fraenkeland Howard Markman

In this chapter,we describethe currentstateof theory, intervention,and research pertainingto the preventionof marital disorder.In the first section we review the stateof marriagein the United States and abroadand the mental, physichl, and socialproblems associated with maritaldistress disrupand tion (i'e', separation divorce).Thesefindings provide and a powerfulrationale for developing and disseminating preventive interventions. also reviewthe We literatureon the variables that distinguish distressed from satisfiedcouples, as well as thosethat predict marital distress and disruptionfrom groupsor linitially) happypremaritalor newlywedcouples. the second In sectionwe describe the typical contents and rangeof formatsof preventive interventions coufor ples,and reviewthe empiricaloutcomeliterature on theseinterventions. the In third section, a caseexample, describe development as we the andcontents of one suchintervention, focusingon issues programimplementation disof and semination' the fourth and final sectionwe discussfuture In directions preof ventiveinterventions couples. for Beforeturningto the first section, few noteson language a are in order.The notion of preventionof marital disordermarks a territory that includesboth the goal of preventingseriousdistress disharmony marriage, or in as well as the marital disruptionor dissolutionthat often followsfrom such distress, ln recentyears'somein the broader profession coupleand family therapyand of beyond havelookedwith somedegree suspiciourn.r, of and alarmat theirow_ ing field of preventive coupleinterventions whenthe activitiesof this field are 245

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castas divorceprevention. Feminist family therapists, particular in (e.g.,Lair4 1999),have raisedconcerns aboutthe so-called"marriagemovement"often associated with preventive programs, especially because somewithin the movement seekto tighten divorcelaws and redirectfe{eral funding from welfare programs(which largely supportpoor, single,or divorcedwomen with children) to marriageeducation programs. Our positionis to castthe field as maritaldistress, conflict,or discord prevention ratherthan as divorceprevention per se.Not only doesthis language potentially allow groupsof varyingreligious, political,and socialpolicy persuasions regarding divorceto agreeon the unquestionable goal of promoting couplewellness and reducingrisk of seriousconflict, but it also is, in fact, a more accurate description the focusof preventive of efforts.The readerof this book is no doubt familiar with the termsprimary, secondary,andtertiary prevention(Glenwick & Jason,lg93).In the domainof couples, primary preventionrefersto interventions targetingnondistressed, well-functioningcouples to help them remain so, with the reasoningthat currentlyhigh divorce rates suggest that all couplesare at risk simply by virtue of being married.Secondary prevention refersto interventions targetingeither groupsof happycouples known to be particularlyat risk, or couplesbeginningto show signsof distress.As in other areasof mentaldisorderfor which prevention programsare developed, tertiary preventioncomprisestreatmentof thosecouplesalready experiencing significantdistress and/orconsidering separation divorce. or Technically speaking, sortsof interventions formats(typicallybrief the and contactin a group setting)that characterize most preventive programsare not adequate assista couplein moving back from the brink of divorce.Indeed, to assisting distressed coupleswhen one or both partners considering are divorce may requirea specialized form of marital therapy(which Fraenkel (1999)has entitled "last chancecouple therapy") to work with the damagedone to the couple'slevel of commitmentand trust.Two theoriesof the path towardmarital dissolution (Gottman,1993;Stanley, 1995)locatethoughts separation of and divorceas several stepsinto this sequence, somedata (Notarius& and Buongiorno,1992)suggest that the average lengthof time couples experience prior to seekingmarital therapy(not necessary distrOss with divorceyet in mind) is 6 years.Thus, true preventiveefforts are bettercastas distressor contermsthat characterize much of what is meantby marital disflict prevention, order.If effective,sucheffortshavethe addedbenefit of assisting couplesand childrento avoid the extrapain often associated with divorce.However. the to extentthat divorceis associated with negative sequelae adultsand children for alike, it appears be due,at leastinitially, to the high conflict that often preto cedes and accompanies divorce(Howes& Markman,1984).Indee4 separat i o n a n d /o rd i vo rcema y b e the best option when high conflict,especially accompanied violenceor abuse,seems by unlikely to abatebecause the of

unwillingnessof one or both partners engagein changeefforts. to We alsowould like to note that althoughthis chapterfocuses exclusively on preventionof marital disorder,and thus on research with heterosexual. legallymarried,or engaged be marriedcouples, believethat the basic to we preventive principlesand practicesdescribed apply as well to other forms of long-termcommittedrelationships, includingcommon-law marriages and gay and lesbiancommittedrelationships. Althoughthereare a numberof excellent studies and clinical writings on gay and lesbianrelationships (Julien, Arellano, & Turgeon,1997; Kurdek, 1998;Laird & Green,1996), much more research is needed, which might in turn indicateimportantadaptations the prevenin tive practices best suitedto promotingthem.

DESCRIPTION OF THE PROBLEM The Stateof Marriage Although divorceprevalence statistics vary somewhat amongstudies, depending on time frameand othersamplingissues, all accounts, by divorcehasbeen an alarminglyfrequentoutcomeof marriagefor many years-alarming especially when one considers that this outcomeis the last one newlyweds expect or intendas they confirm plansto sharea life together. 1970,the divorce In rate for first marriages (Cherlin, 1981)and by the mid-1980s was 50% was found to be 670/o (Martin & Bumpass,1989).It is commonfor divorcedpersonsto marry again,but the divorcerate for second marriages estimated is to be evenhigher than for first marriages (Brody,Neubaum,& Forehand" 1998; Cherlin, 1992),and,according Glick (1984),up to 10%higher.More recent to statistics suggest that beginning the late 1980s (National in Centerfor Health Statistics, 1996)up to the most currentestimate published the late 1990s in (U.S.Bureauof the Census, 1998)therehasbeena steady declinein divorce rates.Even so, currentfindings indicatethat between (Norton & Miller, 40o/o 1992)and50oh(Teachman, Tedrow, Crowder, & 2000)of couples will divorce. Although for many yearsthe United States held the dubiousdistinctionof world leaderin divorce,international statistics indicatethat divorceratesin many othercountries now quite high, including42o/o the United Kingdom, are in 35ohinAustralia, and37o/o Germany(Berger& Hannah 1999).In addition, in , althoughevenmore couplesmay experience separation without divorce,sepa r a t e dc ou p l e sa re 7 5 o hmo re l i kely to divor cethan to r econcile( Bloom, Hodges, Caldwell,Systra, Cedrone, & 1977). Of course,most couplesdo not divorce within days of first experiencing conflict.Although a largepercentage marriages of end within 2 years,and

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PROBLEMSIN ADULTHOOD

the average lengthof marriageis only six years(olson & Defrain, 1997),the path to divorcetypically involvesmany monthsor yearsof conflict. Thus, in any periodsampled divorcerates, percentage intactmarriages for a of that may or may not eventually end in divorceare experiencing significantlevelsof discord. Mace and Mace (1980)reportedthat approximately half of thosewho r e ma i n ma rri e d d o so u n happily,and other s( o' Lear y, Bar ling,Ar ias, & Rosenbaum, 1989;Straus Gelles,1990)havefound that manymarriages & are characterized high levelsof discord, by and evenviolenceand abuse. Given the centralrole of marriageto an individual'soverall life satisfaction (Glenn & Weaver, 1981), finding of a significant the decrement maritalqualitysince in rhemid-1970s (Glenn,1991, Rogers Amato, 1997) & suggests importance the of efforts to staveoff marital disorder.

correlates and sequelaeof Marital Discord and Disruption Marital discordand dissolution typically highly stressful are and are described by the majority of peopleseekingany form of therapyas the primary source of their malaise(Veroff,Kulka, & Douvan,l98l), Indeed research increasingly has identifiednegative mentalhealthcorrelates maritaldiscordand of dissolution. describe We theseconditions correlated as with, ratherthan caused by, maritaldisorder because, date,most of the research not clearlyestabto has lisheda causalrelationbetween thesevariables (Bradbury, Fincham,& Beach, 2 0 00 ;Go tl i b & Mcca b e , 1990) .In addition, must notethat most of th e we research the effectsof marital disorderhas not teasedapartthe impact of on distress from the impact of divorce,nor fbr that matterhasit usuallysimultaneouslystudiedpredictorsof distress versuspredictorsof divorce(Karney & Bradbury,1995;Rogge& Bradbury,1999). Giventhat divorceis almostalways preceded accompanied maritaldistress, may be difficult if not imposand by it sibleto definitivelyestablish their separate impact.Evenwhencertainsequelae only appear followingdivorce, these might alsobe dueto the accumulated impactof maritaldistress ratherthan divorceper se. From a systemic theoretical and interventive perspective looks at probthat lems from a circular or reciprocalcausalframeworkratherthan a linear unidirectionalframework(Fraenkel, 1997),it may be just as importanrto notethe correlationbetweenmarital discordand an individual mentalhealthdisorder as it would be to identify a clearcausalpathwayfrom discordto sucha disorder.For instance, numberof researchers clinicians a and (Gotlib & McCabe, 1990;Papp,2000) havearguedcoherently a systemic for perspective the on relationship between maritaldiscordand depression, notingthat a discordant marrlage may elicit and maintaindepression an individualpartner, in and in

contrast,a positive,supportive marriagemay provide a powerfulbuffer or mediatoragainstnonmaritalcauses depression. of From this perspective, preventivemarital interventions lower whatever percentage risk for depression of can be attributedto marital conflict and strengthen protective factorsattributable to a satisfyingmarriage. similar perspective A captures contemporary thinking aboutthe relationship betweenmarital discordor dissolutionand physical health (Schmaling& Sher, 1997),as well as other negativecorrelates of maritalproblems, suchas employment (Barling, 1990).Indeed" conissues this ceptualization preventive of interventions simultaneously as decreasing risk and increasingprotectionrepresents currentparadigmin preventionscithe ence(Coie et al. 1993). Keepingthesepoints in mind, we can summarize findings on the corthe relatesof marital distressand divorce.Distressand divorce are relatedto an increased risk for psychopathology, includinganxietyand depressive disorders,as well as substance alcoholabuse(seeextensive and reviewsby Bloom, Asher,& White, 1978;Gotlib & McCabe,1990; Kelly & Fincham,1999; and several chapters Halford & Markman, 1997).ln additionto its relationto a in higher likelihoodof psychopathology, maritaldissolution(separation divorce) or is predictiveof a higher risk of automobileaccidents and resultingfatalities, a higherrisk of suicideand homicide, greater a likelihoodof physicalillness and mortality from disease, overallshorterlifespan(seereviewsin Gottman, and 1994a,1999).The emergingliterature(Burman & Margolin, 1992;KiecoltGlaseret al. 1993;Schmaling Sher,1997)documents physicalhealth & the risks of marital distress and divorceA large body of literaturedocuments impact of marital distress the and divorce on the mental and physicalhealth and the social adjustment chilof dren (seereviewsby Amato, 2000; Emery, 1982;Gottman,1994a,1999;Grych & Fincham 1990;Jenkins, 2000; Luthar &. Zigler, 1991).Many of the stud, ies are cross-sectional cannotestablish causallink betweenmarital disand a tress,divorce,and child problems. However, leastone longitudinalstudy at assessed relationshipquality before marriageand after the birth of the child level of and found a causallink betweenpremaritalrelationshipsatisfaction, quality, and quality of premaritaland marital conflict and communication (Howes& Markman, 1984).As alludedto earlier, mother-child attachment (Amato, 2000; Emery, 1982;Gottman, 1999;Markman & Jonesresearch Leonard,1985)suggests that it is marital conflict or parentalconflict during or and and following separation divorce,ratherthan the separation divorceper impact on children. se,that has a negative and dissolutionto In sum, there is much evidencelinking marital distress all mannerof mental and physicalhealth problemsfor both adults and chilthe dren.Aside from the enormous sufferingentailed" economiccostsof mari t a l s t r i f e fo r fa mi l i e s a n d so cietyas a whole due to health car e needs,

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PROBLEMSIN ADULTHOOD

engagement the legal system, of and decreased work productivityis estimated to be in the billions of dollars yearly (Forthofer,Markman, Cox, Stanley,& Kessler,1996).Preventive approaches marital disorder, to therefore, potentially could haveenormous impacton the general well beingof society.

Limitations of Marital Therapy Anotherproblemwith marital disorderis that it is difficult to reverse. numA b e r of stu d i e sa n d re vi e w s( Gottm an,1999;Hahlweg& Mar km an, 1988; Jacobson Addis, 1993)suggest & that althoughmarital therapymay result in statistically significant improvement compared as with no treatment, majorthe ity of treatedcouplesdo not move from distressed nondistressed to status, and there is a high rate of relapse.Furthermore, althoughit is estimated that the majority of distressed couplesdo not seektreatment(Bradbury & Fincham, 1990;Kelly & Fincham,1999),if they did, the needwould far outstripthe availability competent of services.

What GoesWrong in Distressed and Disrupted Marriages? There are a number of excellentreviews of longitudinalstudieson the variablesthat predictseparation divorce,as well as a growingnumberof studand (i.e.,cognitive, ies that examinethe interpersonal intrapsychic and emotional, physiological)processes that charactenze distressed couplesor thosebound (Gottman,1994a,1999; for future distress Gottman& Levenson,1999a,1999b; Karney & Bradbury,1995;Rogge& Bradbury,1999).As the focus of this interventions couplesthan on for chapteris more on the natureof preventive review and critique of thesestudies, will summarize main we the a careful findings, particularlyas they provide the basisfor creationof interventions. Karney and Bradbury(1995)reviewed115 longitudinalstudies, many of which had seriousmethodologicalflaws. Their review identified a few pretheir dictive variablesthat we would describeas stableattributesof persons, backgrounds, their contexts-those not readily amenable impossible or to or preventor changethroughshort-terminterventions. Theseincludedivorceof young ageat marriage,poverty,and personality one'sown parents, variables "neuroticism"(which is essentially tendency view life negasuchas the to tively). Other variablesidentified can be describedas dynamic,in that they are more amenable changeor preventionthroughacquisitionof skills and to ideas(Stanley, Markman,St. Peters, Leber,1995). &

of and patterning are amongthesedynamicvariables the quality Foremost particularlyaround the in-cludirrg types of affectsexpressed communication, genprocedure research and solving pioblemt. rn. paradigmatic discussing data involvesthe couple identifying the topic or eratingtheseobseruational d o m a i n ( e . g . , h o u s e w o r k , c h i l d c a r e , t i m e t o g e t h e r ' m o n e y ' s e x )with u t w h i c h abo the level of conflict and discussing topic their greatest experience they and are video- or audiotaped later an attemptto resolv. it. Th.r. discussions coding using one of a numberof available observers codedby independent 1987)'Indeed'in (Gottman& Notarius,2000;Notarius & Markman, systems and Bradbury(1999,p.338) of a recentreviewof predictors divorce,Rogge with follow-up and self-reportstudies observation found that both behavioral "reportedratesof accuracy between75% periodsrangingfrom 2 to 12 years of categories eithermarriedversussepin and 95o/o" predictingdichotomous basedlargely on thesevarior arated/divorcedn satisfiedversusunsatisfied, that particularpatternsof affect expression ables.Thus, it is widely accepted couplesand versusnondistressed distressed characteiize and communication powerfullypredictmarital outcomes' & Bradbury,1999)alsohave A numberof studies(DeMaris,2000; Rogge of to be strongpredictors found incidentsof physicalviolenceand aggiession to programs Suchstudiessupportthe needfor prevention marital dissolution. to the address precursors relationalviolence' behavcommunication destructive usedto describe Although the language as thereis generalagreement to the urio* laboratories, iors variessomewhal than satcouplesmore interactionsof distressed patternsthat characterrzethe of later problemsin presently isfied couplesand that are strongpredictors includecontempt'critpatterns happyn.*ly*.Jor.ngug.d coupiei. Problem of withdrawal (a withdrawal,stonewalling particularstyle icism, defensiveness, a of the faceassumes frozen' more commonin men, in which the musculature inexpressivestate),negativeescalation(describedindifferentstudieseitheras or as a negativeaffect,particularlythoselisted above' repetitiveexchanieso-1 comment)'invalto response a neutralor mildly negative powerfullynegative and efforts of thl partner)' and idation (putting down the thoughts,opinions, negativeintent lstatementsthat assume negativeinterpretations/mindreading Gottman'Coan' ,lgg3,l994a,Igg1b,1999; on the part of the partner(Gottman Carrere,&Swanson,1998;Markman'1981;Markman'Floyd'Stanley'& St o r a a sl i ,l 9 8 8 ;Ma rkma n ,Renick,Floyd"Stanley,&Clements1993;Rober ts , of found that expression anger c"u*.n andhis "oueagues 2000).Importanirv, was not predictiveof later marital per se (without contemptor criticism) 1998; Coan,Cafr er e,& Swanson, d i f f i c u l ti e s (Go ttma n ,1 9 9 3 ;Gottm an, proby myth perpetuated numerous Gottman& Krokoff, lggg), correctinga fessionaland popularpsychologybooks Gottman(1993,1994a,1999)hasprovidedthemostcomprehensivetheory

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PROBLEMSIN ADULTHOOD

of the "cascade"toward marital dissolution. The theory providesconceptual and empirical links among moment-to-moment marital interaction,prceptions/cognitions, physiology. brief, the theory suggests marital interand In that actionscharacterized the above-described by destructive behaviorsresult in the experience physiological of floodingand thoughts eitherof hurt and..righteous indignation" (accompanied feelingsof sadness, by anger,contempt)or hurt and perceived attack(accompanied internalwhining, sense .iinnoby of cent victimhood""fear,and worry). In addition,hypervigilance behavioral to cuesassociated with flooding leadsto interpretation otherwiseaffectively of ambiguouspartnerbehavioras negative.Over time, theseinterpretations becomecodified into fixed attributions that castthe partner's behavioras selfish, characteristic them in multiple contexts(globality),and stable(based of on a trait ratherthan on current stateor context)(seeFincham,Bradbury,& Scott, 1990,and Karney & Bradbury,2000, for reviewsof the impact of negative attributions marriage). on Theseattributions then guide perception of subsequent interactions and eventsthroughthe process confirmationbias, of vrhichin turn leadsto more negative behaviorand flooding. In addition,Gottmanhaspresented datasupporting notion that the critthe ical issueis to achievebalanceboth within eachsubsystem involvedin marital functioning (interactional behavior,cognition,physiology)and amongthese subsystems. this model, balanceis not necessarily In achieved throughequal occurrence oppositebehaviors. instance, of For Gottman(1994a)found that a ratio of 5:1 for positiveto negative behaviors predicted marital stabiliry whereas a ratio closerto 1:1 predicted maritaldisruption. addition, notedabove, In as not all "negative"behaviors havethe sameinterpersonal effects,and the eripression of contemptor criticism,evenif lessfrequent, can undo the relationshipstrengthening impact of positivestatements (Notarius& Markman, 1993).

REVIEW AND CRITIQUE OF THE LITERATURE Efforts to strengthen couplesso as to prevent seriouslevels of distressand divorceactuallycharacterized many of the activitiesof the earlymaritalcounselorsas far back as the 1930s(Gurman& Fraenkel,2000). However,virtually none of theseearly effortswere basedon empiricalresearch, in many and cases not evenon cleartheory aboutprocesses relatedto preventing negative maritaloutcomes. The contemporary field of maritaldistress prevention began i n t h e e a rl y 1 9 7 0 sw h e n i n ter ventions beganto be basedon the r esear c h reviewed the previoussection, in which involvedcarefulempiricalstudy of variables that distinguishdistressed from happycouplesand that predict distressand divorce.At aroundthe sametime, a numberof more theoretically

the we . s b a s e da p p ro a ch e e me rg e d In this section, descr tbe char acter tsttc for interventions couplesand the rangeof theoof preventive .o-po*ts on research and we review the efficacy and effectiveness retical premises, theseinterventions.

Components of PreventiveInterventions and R'angeof TheoreticalPremises of are marriages basedon a philosophy psyto designed strengthen All programs and/or choeducation-the notion that ideasand skills believedto enrichmarriages a fairly in conflict canbe directlytaughtto couples protectthem from destructive put trief period of time, mostly in a group setting,and that couplesthen can Virtually theseideasand skills into practicewithout much ongoingassistance. and,usually,skills trainall programsincludeinformationaboutcommunication and aboutintimacyandmarriage; to ing; utl.ast someattention partners'beliefs of aspects relathe to somefocus andioractivitiesdesigned increase pleasurable However'as a groupthe proand sensuality' tionship,suchas fun, friendship, of grams vary greatly in terms of theoreticalpremisesabout the nature of with all major theories coupletherapy and change, problems, ielationships, expeintergenerational, psychodynamic, (i.e., represented cognitive-behavioral, belief systems' riential),as well as somemore religiousor cosmological that only programsdirectly focusedon Although somehave suggested factorsbe considered protective maritalrisk factorsand enhancing decreasing to as approaches, opposed thosethat focus solelyon enriching true preventive as potenr-nuriiug.,(Kelly & Fincham,1999),we view all of theseprograms is In tially pieventiveinterventions. our view, whetheror not an intervention entirelyby empirical,longitudinalstudyof its p..u.ntiu. must be determined happycouplesor thosejust beginningto show signs in effectiveness assisting of quality of distressto remain stableand to maintain relatively high levels with couplesthat did not participatein yearsafter the program,as compared the demonstrating positiveimpactof a programimmeih. p.ogrum.Research (For a meta-analyit doesnot establish as preventive. alatetypost-intervention programsare generallyeffective' ,1, of ru.t studiesconcludingthat enrichment 1985' However,seealso critiquesof this & seeGiblin, Sprenkle, Sheehan, 1999')Likewise' in analysis Bradbury& Fincham,1990,and Kelly & Fincham' with distressed of the studiesdemonstrating effectiveness theseinterventions as them as preventive, theseconstitutetreatmentstuddo samples not establish within the contextof a programstated ies, whetheror not they are conducted of (seeDeMaria,1998,and Durana,1996,fOrexamples this to be preventive confusion).

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PROBLEMS ADULTHOOD IN

Our hopeis that all programs interested the prevention maritaldistress in of and divorcewill engagein the hard but excitingwork of conducting randomized,long-termclinical trials as well as more naturalistic effectiveness studies with primary or secondary preventionsamples. However, date,only the to Prevention Relationship and Enhancement (PREP)hasbeensubjected Program to this sort of rigorousscrutiny(Kelly & Fincham,l9g9). Thus,our reviewof efficacy and effectiveness research focuses PREP. on

Efficacy and Effectiveness PreventiveInterventions of The originalefficacystudyof PREPwas reported Markmanet al. (1988) by and by Markmanet al. (1993).Nondistressed, premarital participatcouples ing in a largercommunitystudy of predictorsof marital quality and stability were matchedin dyads or triads on the basis of variablesfound in previous research (Markman, l98l ) to predictfuturesatisfaction stability(engaged and versusplanningmarriage,relationshipsatisfaction, self-ratings communiof cation impact, confidencein getting married).one or two couplesin each matchedset werethen randomlyinvited to participatein the intervention, while the other servedin an untreated control group. Half of thoseinvited into the intervention declined, that therewere threegroups:intervention, so decline control,and no-treatment control.With respect relationship to stability,at ltlzand 3-yearfollow-up,intervention couplesweresignificantlymore likeiy than no-treatment control couplesto be together(datawere not presented the in 1988articlefor declinecontrolcouples), and at 4- and 5-yearfollow-up,interventioncoupleswere significantlymore likely than eithercontrol group to be together. With regardto marital quality,as expected a preventionstudy,there in were no group differences immediatelyafter intervention. However,at IIlz-, 3-, and 4-yearfollow-up, intervention couplesshowed higherrelationship satisfactionthan did control couples, and,for men, this difference continuedat 5 years.In addition,at 3 years,interventioncouplesshowedhigher sexualsatisfactionand lower problemintensity, well as more positiveself-ratings as of communication impact. Concerning interaction processes, postintervention at PREPcouples demonstratedmore positiveand lessnegative communication, determined ratas by ings of independent coders. This indicates that intervention coupleslearned and usedthe skills. At 4-yearfollow-up, interventioncouplesshowed greater useof communication skill, greater positiveaffect,moreproblem-solving skill, andmore support and validation thandid controlcouples, lessdenial,domand inance, negative affect,conflict, and overallnegative communication than did controls. Similarresultsdistineuished intervention the from the declinecon-

lvllll\l

Lt'LL'

rJrJ\)-l\vLl\

LJJ

(excepttor trol group. Thesedifferencesdid not appearat 5-yearfollow-up men),possiblydueto attriskill by intervention gr.ulr useof communication to a fadtion of the leastskilled control couplesby that time or possiblydue that couples findings suggest impact.Thesebehavioral ing of the intervention skills for yearsfoland improvedcommunication problem-solving can sustain might be critical lowing a relativelybrief program,but that boostersessions many to promote long-ierm use. Indeed,at the completionof the workshop the anticipating declinein their use paiticipantshaveaskedfor suchsessions, or memory of the skills. couone other striking finding was that at 5-yearfollow-up, intervention of ples were significanily less iit.ty than control couplesto report instances hanthat PREPhelpscouples physicalviolence.As well as further suggesting lowersthe likeit dle conflict more successfully, may be that the intervention physiological to lihood of someof the precursors violencein somemen, suchas & (Jacobson Gottman,1998)' flooding and withdrawal/stonewalling relationin Other studieshavereplicatedPREP'seffectiveness decreasing quality over time' For instance' ship dissolutionand maintainingrelationship in Thurmaier,Engl, & Eckert, 1998)conducted a study (Hahlweg,Ivlarkman, in engaged the Germanycomparedcoupleswho took PREP with thosewho as to thosewho as typical premaritaltraining offered in their churches, well training. Five yearslater,PREP coupleshad significantly tltt no^p.emarital than either control lower divorceratesand higher relationshipsatisfaction lack of randomassignment the group,However, findingt ut. limited because beensystematto conditionsmeantthat coupleswho chosePREPmight have ically differentfrom the other couples' thesefindSeveralongoingstudiesare attemptingto replicateand extend a longitudinal are and ings. For instance,-Fraenkel his colleagues conducting health'and stress' study of the impact of PREP on partners'quality of life, to This study also is designed examinethe variables behavior. health-related and skills in couof or that enhance impedeimplementation programideas I and 2 years ples' daily lives. In-depthinterviewswith interventioncouples of couplesexpeafter the coursefound amongotherthings,that the majority exactlyas taught' riencedit as useful but did not frequentlyuse the skills to be essential they believedthe skills trainingand practicesessions However, their partners'differing in their becomingmore attunedto the needto respect patterns to destructive opinionsand forlesolving problemswithout resorting & (Fraenkel Whittet, 1998). Van Widenfelt' study has reportednull findings on PREP'sefficacy' One in a und Vun Der Staakif qqO)conducted controlledstudy Hosman,Schaap, with concompared Holland and found no benefits for interventioncouples later,or 2 yearslater' trols immediatelyfollowing the course,or 6 months problemswith this study,includtherewere certainmethodological However,

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PROBLEMSIN ADULTHOOD

ing relianceonly on self-report measures, samplethat was alreadysomea what distressedgroup differences length of relationships, in and differential attrition.

CASE EXAMPLE In this sectionwe describe PREP'scontentand format in more depth,and discussour efforts to disseminate program.In doing so, we also address the the "barriers" (Bradbury & Fincham,1990)and challenges facing efforts to promote primary and secondary preventive programsfor couples.

Program Content PREPfocuses teachingskills, ideas,and life practices on designed decrease to risk factorsand to enhance protectivefactors.Contentfocused mostly on reducing risk factorsincludes(a) identifying and illustrating(with videotaped examcommunication patterns; teaching constructive (b) a Bles)commondestructive approach expressing to concerns complaints, or one that actsagainstthe tendencyto developglobal, stable,and negative attributions focusinginstead by on specific partnerbehaviorsand the emotionalreactions thesegenerate; (c) teachingthe speaker-listener technique, form of structuredactivelistening, a as well as a problem-solving (d) sequence; discussing negative the impact of unrecognized undisclosed or expectations aboutmarriedlife, which canresult in conflict as well as form the basisof negative attributions when the partner violatestheseexpectations; raisingawareness potentialconflict around (e) of differences religiousand ethicalvaluesand practices, in which many couples seemto overlookuntil theseconcerns raisedby certainlife events, are suchas the birth of the first child; (f presenting model for identifying the hidden a issues relationship or themes, suchas control,caring,respect and recognition, commitment,trust, and acceptance, often underlierepetitive, that unresolved issuesor thosethat typically generate explosivereactionsor avoidance; and (g) encouraging partnersto commit to enactingcertaingroundrules for handling conflict and maintainingpositiveaspects the relationship. of Contentfocusedmostly on increasingprotectivefactorsincludes(a) lectures and suggested activitiesfor increasing and maintainingtime for fun, friendship,and sensuality and (b) lectures the two aspects commitment on of (dedication constraint) the importance forgiveness, suggestions and and of and abouthow to strengthen theseprotective aspects relationship. of Figure 12.1

of with the sequence conflict mancore components, depictsthe program's protectiveactivitiesarranged agementskills shownin a flow chart and the how thesecan form a critical boundaryaround aroundthe perimeterto represent that can impingeon their the coupleand the stressors conflict and between relationship.

Program Format and by delivered one or two workshopleaders PREPcombinesgroup lectures or facilitatedby coaches for individualskills practicesessions eachcouple, "consultants"trainedand supervised the workshopleader. The full PREP by involvedfive meetingsof 3 courseis 15 hours long. The original schedule found that busy New York City coupleshad hourseach.One of us (Fraenkel) day (8 hours) a difficulty attendingeachweek,and created format of I weekend of evenings 3tlz hourseach.This format resultedin followedby two Thursday and (for virtually zero missedsessions both research payingcouples)over the 24 past 6 years(approximately workshopsand roughly 120 couples).PREP as evenings) the day plus 2 Thursday this format (1 weekend hasnow adopted versionhasbeenusedin Denverand in the German A basic schedule. weekend earlier.A 1-dayworkshopalso has beenimplemente{ and a study described for specialmanualcreated it. Shorterversionsare possibleas well (for exam"learningevening"or "half-day intensive"),with the underple, an introductory skills lessin-session programcontent(and particularly, standingthat reduced practice)may meanreducedlong-termeffectiveness. that couplescan Although the longitudinalfindings from Germanysuggest benefit as much from a weekendversion as one that extendsover a few weeks, no study has yet directly comparedthe two versionsto determinewhich "dosage" is most effective.One important future direction for research to is for necessary couplesto notably the determine bareminimum of intervention manner. benefit in a sustained

ProfessionalTraining is A key aspectof preventionprogramdissemination training othersto present the materials.Since 1990PREP has offereda 3-day instructortraining to to as a requirement conductthe full 15-hourprogramand to train coaches Trainingin the 1-dayworkshopformat is now available in assist workshops. aswell.

PREPAT A GLANCE
Gripe/Concern/Complainr

Calla STOP ACTION

Character Assassination? Mind Reading? Catastrophic Interpretation? Blaming? KitchenSinking?

No time to talk?

XYZ Statement Whenyou do X in situation Y I feel Z

Timeto talk?

Speaker/Listener
Rulesfor Speaker l. Speak yourself. for Don't mindreadl 2. Keepstatements brief. Don't go on andon, 3. Stopto let thelistener paraphrase Rulesfor Listener l. Paraphrase you hear. what 2. Focus the speaker,s on message. Don,trebut.

Rulesfor Both
L The speaker the floor has 2. Speaker keeps floor while listener the paraphrases 3. Share floor the

-------.-f PrPr"br.ril *-'tt' I

Issue Resolved?

Congrats-Goon with iife! Problem-Solving Agenda Set Brainstorm Combine, Compromise, Contract FollowUp

Problem-Solving Impasse?

Problem Resolved? Congrats-Go on with lifel

Identify Hidden Issue Spinning your wheels?Avoiding a specific issue?Intenseemotional reaction? Look for hidden issues around Power and Control, Closeness and Car.ing, Respectand Recognition

Figure 12.1 Major components the Prevention Relationship of and Enhancement Program(PREP@).
e 1999PeterFraekel,Ph.D & Amanda Salzhauer, MSW ( P R E P ! a t N Y U C h i l d S r u d vC e n t e r 2 t Z \ 2 6 3 8 6 6 4

Initially we limited trainingto mentalhealthprofessionals pastoral and counselorsor thosein graduate schoolin theseprofessions. recentyearswe have In offeredthe trainingto selected paraprofessionals (suchas clergyor senior personsin a churchcongregation, who generallyprovidethe programin particular settings, such as in their religiouscommunities. Training of professionals and paraprofessionals eachpresents particularchallenges. Our experience is that experienced mentalhealthprofessionals often havea difficult time staying within the role of coachingskills; on the other hand,paraprofessionals must becomeacquainted with fundamental rules aboutconfidentialityand with how to respondsensitively personalmaterial. to As in the previousstepsin developingPREP, are attempting answer we to questions aboutthe relativestrengths professional of versusparaprofessional trainers throughempiricalstudy.We (Stanley aI.2001) currentlyare conet ducting a long-term effectiveness study comparingoutcomesfor couplesin church and synagogue communitieswho were randomly assigned receive to eitherPREPpresented the usualacademic in settingby our workshopleaders, PREPpresented the community'sown clergymenor clergywomen, the by or providedin that church.Initial preipostfindings usualpremaritalprograms supported conclusion the that paraprofessionals deliverthe programas can well as mentalhealthprofessionals. Data indicated differences no between the coupleswho receivedthe programin the universitysettingand thosewho received from their clergy,but a significantdifference it PREPdelivbetween ered in either contextand the usualpremaritalprogrampresented the reliin g i o u s i n s ti tu ti o n .T h e se fi n d i n gs ar e extr emelypr om ising,as r eligious institutionsprovide a naturalcontextfor implementation preventive of interventions,giventhat over 75o/o couplesstill marry in a churchor synagogue of and often alreadyreceivesomesort of premaritalinformationor counseling.

Materials presWe find a varietyof written and audiovisual materials criticalto program either in group workshops individualcounselentationand dissemination, or ing settings. self-administered A versionof the programthat reliesexclusively videois on thesematerials currentlyunderstudy.We useprofessional-quality patterns tapesthat presentPREP'score ideasand demonstrate both problem manin and skills.The programis alsocontained a manual,andtheinstructor's and demonstrations ual providesdetailedlectureoutlineskeyedto videotaped series an PowerPoint For slidesor overheads. couples'furtherstudy, audiotape books(seeespecially, summarizing programis available, well as several the as for instructions the Markman,Stanley, Blumberg, 1994,which provides & skills and the materialof eachlecture).

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Challenges Program lmplementationand Dissemination in Those interested establishing in community-based prevention programsface many challenges, our experience and with PREPis no exception. Challenges are presented widespread by cultural beliefs about marriageand couples,by mentalhealthprofessionals, by the largersocialcontext.Bradburyand and Fincham(1990)described numberof thesechallenges, a including(a) general pessimism aboutthe institution of marriageand the possibility of long-term happyrelationships, resultingin a passive, fatalisticattitude;(b) low motiva"if ticn of huppycouples who typicallybelievethe old adage, it ain't broke, don't fix it;" (c) a concernon the part of one or the otherpartner(typicallythe man)thatprograms will requiregroup experiential exercises which they are in "get in touch," urgedto cry, or express intimacy in public; (d) culturalmyths, suchas the notion that couplesshouldn'trevealthat they haveproblems (or "natueventhat they might needsskills for future problems)and the myth of ralism" (i.e.,the belief that relationships shoulddo well without any educational input or support,like in the moviesand othermediathat portrayromantic relationships an effortless, as consistently (e) thrilling experience); manymental healthprofessionals'view that preventive work is lessinteresting thantherapy,not lucrativeenough,or is a threatto their livelihood; (0 beliefs of funders of mental healthservices that preventive work is lessof a priority for limited funds than is money for treatmentservices; and (g) largersocialissues, such as economichardshipand increased demands the workplace, of that may erect financial or temporalbarriersto participationin suchprograms. We believethat a core solutionto thesechallenges imaginative is and persistent exposure alternatives the views listedabove, of to includingclearlypresented research datathat supportthesealternative views. Preventionists must use the media, short informationalsessions and demonstrations, other and modalitiesto promotethe ideasthat all couplesface problemsat one time or another;that this should not be a reasonfor shameand secrecybut rather a reason preventive for skill-buildingand creatingcommunities careand supof port; and that marriagecan be a challenging and enjoyable, long-livedadventure that with use of skills and a proactiveattitudeof teamworkwill require "hard work." Useful would somework but not necessarily be advertisements and public serviceannouncements contrast costsof marital distress that the and disruption with the costsof participating prevention in programs. With respect concerns to aboutthe activities within the workshop, clearly we describePREPto prospective attendees a course,not therapy. also assure as We them that they will not needto discuss privatematerialin a group settingand canchoose whetherand how much to discuss suchmaterialin the privatecoaching sessions. Probably bestlong-termapproach shiftingthe attitudes the prothe to of

graduate training in psychiatry, psychology, pastoralcounseling, socialwork, and allied professions. we do in our respective As doctoralprograms, graduate students and internscan be involvedas couplecoaches in conducting and research and therebyhopefully become"hooked,'on prevention. post-gradu_ professionals be encouraged view conducting ate can to prevention workshops as one component their careerratherthan as a substitute clinical of for work. Periodicworkshopswith lessdistressed nondistressed or couplescan provide a welcomechange pacefrom the challenges workingwith more of of distressed couples. an extraincentive, As suchworkshops often generate privatepractice referrals. Regarding the challenge providing the programto thosewith limited of financial resources, programsare alreadybeing oifered in religiousand community settingsat little or no cost.We are clear that relationship-strengthening programs will not in themselves solveall the problemsof economically and sociallymarginalized persons, they may represent usefulcomponent but a in assisting thesecouples facemultiple challenges to presented poveity.we by agree with those(Bradbury Fincham,1990; & Bradburyet al. 2000;Fraenkel, 1999)who maintainthat otherprogramsare needed address larger to the contextualforcesthat negatively affect the well-beingof couplesand fimilies. For coupleswho are "temporally challenged"and feel too busy to attend, short forms of the program are available.However,we hope that the abovedescribed public educationefforts will increasegeneralenthusiasm profor gramsthat requirerelatively little time commitmentcomparedwith the vast amountof time expended relationship on distress and disruption.

FUTURE DIRECTIONS Although the empirical literatureon determinants distress of and divorcehas produced wealthof rigorouslyderivedand usefulinformationto guidedevela opmentof preventionefforts, and interventionstuclies date generallysupto port the efficacy of preventive programs, thereare many areasfor further work. w e a g r e ew i th th e cri ti q u el e ve ledby some( Br adbur y& Fincham 1990; , Bradbury,et al' 2000; Kelly & Fincham lggg) that more artention needs be to placedon researching impactof the beliefs,emotionalvulnerabilities, the and physiological-response sensitivities that eachpartnerbringsto the relationship' and on incorporating interventions that address these;'enduring vulnerabilities" (Kelly & Fincham, 1999).For instance, given that, self-selection biasesaside,approximately half of all peoplewho enroll in preventive programs will be adult children of divorce,and that thoseindividualsmay have more insecurityaboutmarriage, tend to experience more stress and havemore anxietyand dissatisfaction with family and friendsthanadultsfrom intactfami l i e s ( G l e n n& K ra me r,1 9 8 5 ;K ulka & weingar ten, g7g) ,pr ogr am might s I

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want to includespecialattention theseissues to (Kelly & Fincham,1999).The field of marital studiesand prevention alsoneedsto makeuseof the burgeoning developmental/personality literatureon the impact of differing adult attachme n t styl e s(K l o h n e n& Ber a, 1998;Kobak&Hazan,199l) on r elations hi p functioningand stability,as well as examinethe related areaof differences in temperament and their impact on thresholds physiological for flooding and overall tolerancefor variousforms of marital interaction and emotionalexpression' Likewise,it could be interesting examinethe impact to on communication of differing cognitive styles (for example,divergent versusconvergent thinking),or the impactof one partnerhavinga learning disability(Walker& Shimmerlik,1994).Findingscould be translaied into psychoeducational modules that guide effectivecoping with such biologicaily and developmentally determineddifferences a mannerthat promot.s .esilience in and acceptance (Jacobson Christensen, & 1996). Kelly and Fincham(1999) also noted the seemingoveremphasis of pre_ ventionprograms containment conflict and avoidance on of of negative behavi o r , ra th e r th a n p ro mo ti on of positive behavior . They cited the gr owing literatureshowingthe critical impact of suchbehaviors as agreement, empathy, identifyingproblemsin a gentlefashion,creative and collaborative problem-solving,and spendingenjoyable time together. believethat both risk We reductionand enhancement protectivefactorsare of important.However, d a ta (B e h re n s& H a l fo rd, 1994; Renick, Blum ber g, & M ar km an, 199 2; Stanleyet al.200l) suggest that with a limited amountof time in which to deliver a preventive serviceto coupres, greateremphasis shourdbe placed on helping couplesmastercommunication and protlem-solvingskilis that can safeguard them from the primary intrarelationship risk factoiof destructive interaction aroundthe inevitable differences and problemsthat emerge when two peoplesharea life. It is also worth noting that many topicsand activitiesprimarily focusedon reducingrisk may simultaneously increase protectivefactorsand vice versa. For instance, coupleslearneffective, as positivecommunication problemand solving skills that help them manageconflict, they treateach othermore gently (evenin conflict) and cometo takepride and haveconfidence in theirjoint capacities and teamwork,which Notarius andYanzetti (1983)termed,,relationship efficacy."Positiveconrmunication pride in and relationship efficacy then serveas protectivefactorsby strengthening couple's the bond.Likewise, as couples build a "bank account"of good feelingthroughfun, friendship, and sensuality, they may be more inclined to approach discussing their inevitable differences more calmly and effectively-without disruptingthe basic sense of "we-ngss." Somehavesuggested preventive that effortsneedto be mountedto address largercontextual variables that affectmaritaloutcomes (Bradbury& Fincham,

suchas & Fincham, Beach,2000;Kelly & Fincham,1999), 1990;Bradbury, (Aubry, Tefft, & Kinsbury, 1990),poverty,racism,and work unemployment pr.rru..i that lead to negativespilloverand time awayfrom family (Fraenkel and We Lower,& Scheldt,1992)- agree, & Wilson,2000; Halford,Gravestock, a one of us (Fraenkel)has developed program in an urban settingto support homelessfamilies and couplesof color as they move from welfare to work 1999)'However, & Fraenkel Shannon, & Hameline, Shannon,2000; (Fraenkel, these efforts or public policy initiativesaddressing short of direct preventive couldincludemodprograms prevention forr.r, existingdistress largersocietal the ulei that help couplesrecognize powerful impact of theseforceson their & levelsand amountof time together(Fraenkel Wilson, 2000)' stress programsalso could do more to recognizethe largercultural belief systems, by degree eachparticularcouple,that inform comor to shared a greater lesser patthe For instance, ubiquitouspursuer-distancer patterns. mon problematic tern, in which womentypically pursueand becomecritical while men withdraw (christensen Heavey,1990),is partly the resultof & and becomedefensive by gender beliefs,reinforced suchpopularbooksasMen Are From stereotyped (Gray, 1992),that women are more suitedby Are From Venus Mars. Women "managers" relationships men are incapable and of natureto be the emotional their feelings.It might assistcouplesto becomemore flexible of expressing and equitablein their interactionsif preventionprogramsincludedmaterial and thesepowerfrrlculturalmessages or that,,deconstructs" closelyexamines "externali thesebeliefs from their own life narze" or separate helps couples rativesand preferredways of being (White & Epston,1990). proare In addition,new challenges emergingas preventionand enrichment amongspecificculturai,ethnic,and relidisseminated gramsare increasingiy Trathen, & Levine,2000; Stanley, !iou, groups(Crohn,Markman,Blumberg, in McCain, & Bryan, 1998;Whitfield" Markman, & Stanley, press),specific social contextsin which couplesshareparticular conditionsand challenges (such as the armed forces),or whole societiesdifferent from the ones from and efficacy were drawn for the basic marital research which participants groups on us studies.It behooves to conductmore research marriagein these the and to reviseprogram formats and contentto address parand societies, more 1998,1999).Likewise, within them (Fraenkel, of ticularneeds marriages known to involve programsshouldtargetcouplesat life-cycle stages preventive (Cowan& Cowan' 1992; risk, such as the transitionto parenthood increased "empty & Jordan,Stanley, Markman,1999; Matese,Shorr,& Jason,1982),the Arp, Markman,& Blumberg,2000),and the transition nest" (Arp, Stanley, marbetween on is More basicresearch needed the relationship to retirement. programs and ital disorderand variousforms of psychopathology, preventive of the and testedto address particularvulnerabilities such must be developed couples,

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to in Informationsuchas that summarized this chaptershouldbe presented thosein positionsto fund programson a broadscale.In addition,marital disand tresspreventionefforts must continueto be empiricallyevaluated extended so that a steadystreamof solid data supportstheir importanceand viability. in has beenmade over the pastthree decades In summary,much progress programsfor preventingmarital disorder.Many developingresearch-based particularlywith regardto promotingprevention remain,however, challenges in the broadersociety.With the evergrowingbody of data documentingthe that skilland divorce,and the mountingevidence negativeimpact of distress we programsfor couplescan make a difference, believe basededucational and couples policy makers, clinicians,communityleaders, socialscientists, would do well to investtime, money,and effort in prevention. themselves

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ACI(NOWLBDGMIINT wasprovideditt of Supportfor the first authorduring prepat'ation this chapter to Foundation the Fanrily grant from the Robert Goclet part by a gellerous StudyCentcL' of Prograrn thc New Yoll<UnivelsityChild Studies