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

1. Relationship Rx:An Effective, Brief, Motivational Intervention for Diverse Couples University of Tennessee Department of Psychology Kristina C. Gordon Ph.D.

2. Film clip from Pixar’s UP

3. Why work on your relationship?

6. 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

7. 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

8. 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

10. 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

11. 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

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

13. 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.

15. 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 Keep • Marriage as a capstone, not a cornerstone • CDC report – parental relationship instability is a major problem for low-income children

16. 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 breakdown13. • A mere one percent reduction in rates of family fragmentation would save taxpayers $1.12 billion annually in expenditures related to poverty.

17. 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.

19. 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.

23. 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

24. 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?

25. 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

26. Marriage Checkup • Developed by Dr. James Córdova at Clark University • Consists of two sessions – • Assessment • Feedback • Based on • Integrative Behavioral Couple therapy • Motivational Interviewing

27. 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

28. 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

29. 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

30. MC Timeline TX Assessment + Booster Assessment + Feedback Feedback Time 4 (1 year) Time 2 (2 weeks) Time 5 (1 year FB) Time 1 (Feedback) Time 0 (Baseline) Time 6 (1 year 2wk) Time 3 (6 months)

31. 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

32. Results – Between Group Differences Intimacy scores smoothed profile

33. 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

34. Marital Satisfaction-smoothed profile

35. 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”

36. Implications/ Discussion • Comparable to previous MC studies, with some improvement • Role of the booster visit • Regular checkups

37. 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)

38. What is Different about RX Adapting to the Community and Low-Income populations

39. 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

40. 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

41. Unique challenges for low-income populations • Financial Struggles - poverty • Scarcity hypothesis • Multiple Jobs • Serial relationships – blended families • Homelessness • Discrimination and subtle biases • Substance Abuse

42. Barriers and Benefits • Barriers • Time • Childcare • Stigma • Cultural norms about familial boundaries • Benefits • Tight-knit communities • Value relationships • Responsive and grateful for help

43. 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

44. How to do the Checkup In brief – seems simple but deceptively so….

45. Weird Things Couples Fight About

46. 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

47. Why is communication so hard? • Personality differences and preferences • intensity • approach vs avoid • facts vs. feelings • “flip/flop factor”

48. Why so hard? • Emotions • anger, frustration, irritation, contempt • anxiety and fear • hurt • shame vs. guilt

49. What helps us communicate • Cultivating positive emotions • Joy, contentment, pleasure, connection • gratitude and appreciation • Love and companionship • Empathy

50. What helps us communicate • Seeking Understanding • Practicing Acceptance • Tolerate the discomfort • Learning how to manage disappointment & emotional pain • Seeing problems as “uninvited guest”