Love in Action: An Integrative Approach to Last Chance Couple Therapy

This article presents an integrative approach to the special challenges of therapy with couples on the brink of dissolution or divorce-who often describe this therapy as their "last chance." In some, one partner is considering ending the relationship, and in others, both partners are considering ending it. Often, these couples have had prior dissatisfying experiences in couple therapy. Four types of last chance couples are described: high-conflict couples; couples in which partners have differing goals for their lives or different timelines for reaching shared goals; couples in which one or both partners have acted in a manner that violates the values, expectations, emotional comfort, or safety of the other; and couples in which there has been a gradual loss of intimacy. The Therapeutic Palette, a multiperspectival, theoretically eclectic integrative approach, is enlisted as a general framework for selecting and sequencing use of particular theories and their associated practices, based on the three "primary colors" of couple therapy: time frame/focus, level of directiveness, and change entry point. An additional complementary framework, the creative relational movement approach, is proposed to provide an integrative frame encompassing both language-based and action-based practices, suggesting that meaning is held and expressed as much through interaction or "relational motion" as it is through language. Principles of change are described. Due to the couple's level of crisis and desire for immediate evidence of possible improvement, priority is given to action-based interventions in early stages of therapy, by engaging couples in "experiments in possibility." Typical action approaches are described. An extended vignette follows.

Applying the creating lasting family connections marriage enhancement program to marriages affected by prison reentry

Divorce proportions are currently high in the US and they are even higher among those who are incarcerated with substance abuse problems. Although much research has examined marital interventions, only two studies have examined marital interventions with prison populations. There is some empirical evidence that incarcerated couples benefit from traditional marital therapy (O'Farrell and Fals-Stewart, 1999, Addictions: A comprehensive guidebook, New York, Oxford University Press). An adaptation of the evidence-based Creating Lasting Family Connections program was implemented with 144 married couples, where one spouse was incarcerated, in a southern state with particularly high divorce and incarceration proportions. Results suggested that married men exposed to the program had larger improvements in some relationship skills relative to a convenience sample of men not so exposed. Both husbands and wives exposed to the program exhibited similar and significant increases in relationship skills. The results were comparable to a Prevention and Relationship Enhancement Program adaptation for inmates. The implications of the findings for prevention practitioners are discussed.

The impact of the within my reach relationship training on relationship skills and outcomes for low-income individuals

A federal grant was awarded to provide the Within My Reach healthy relationships curriculum to low-income, at-risk individuals involved with various social service agencies. The effectiveness of this curriculum was evaluated for 202 participants through measures of training and relationship outcomes pre-, immediately post- and 6 months posttraining. Participants experienced high levels of training satisfaction; significant increases in knowledge, communication/conflict resolution skills, and relationship quality; as well as a trend in the reduction of relationship violence. An important implication of this research is that MFTs may broaden their service delivery to at-risk individuals by collaborating with community agencies to adapt established relationship enhancement programs, evidence-based tools, and principles that complement traditional couples therapy.

A randomized clinical trial of the effectiveness of premarital intervention: moderators of divorce outcomes

This study examined the effects of premarital relationship intervention on divorce during the first 8 years of first marriage. Religious organizations were randomly assigned to have couples marrying through them complete the Prevention and Relationship Education Program (PREP) or their naturally occurring premarital services. Results indicated no differences in overall divorce rates between naturally occurring services (n = 44), PREP delivered by clergy at religious organizations (n = 66), or PREP delivered by professionals at a university (n = 83). Three moderators were also tested. Measured premaritally and before intervention, the level of negativity of couples' interactions moderated effects. Specifically, couples observed to have higher levels of negative communication in a video task were more likely to divorce if they received PREP than if they received naturally occurring services; couples with lower levels of premarital negative communication were more likely to remain married if they received PREP. A history of physical aggression in the current relationship before marriage and before intervention showed a similar pattern as a moderator, but the effect was only marginally significant. Family-of-origin background (parental divorce and/or aggression) was not a significant moderator of prevention effects across the two kinds of services. Implications for defining risk, considering divorce as a positive versus negative outcome, the practice of premarital relationship education, and social policy are discussed.

The role of leaders' working alliance in premarital education

Premarital (and general relationship) education programs, as a prevention method, have been shown to have a positive effect on marital quality and can prevent divorce. However, it is unclear whether these positive effects are consistent across leaders who conduct premarital education programs. Examining the variability in relationship outcomes attributed to the leaders of premarital education programs, and the role of general therapeutic factors such as working alliance in explaining relationship outcomes, may help increase the effectiveness of these programs. Accordingly, this study examined 31 leaders who trained 118 couples (236 attendees) in a randomized clinical trial of the Prevention and Relationship Enhancement Program (PREP), a research-based and empirically supported premarital education program being compared with a treatment as usual track. The results demonstrated that couples' relationship outcomes from pre- to post-training varied on the basis of the leader who provided the premarital education training. Both training in PREP and aggregated leader working alliance quality (as rated by attendees) explained variability between leaders in change in attendees' observed negative and positive communication. Leaders' aggregated working alliance quality also explained change in relationship satisfaction. In addition, attendees' ratings of their leaders' working alliance predicted change in their relationship satisfaction and confidence, and attendees had higher positive communication when they reported better working alliance with their leader.

Differential use of premarital education in first and second marriages

Although second marriages are more likely to end in divorce than first marriages, and thus represent an important target for intervention, there have been no detailed examinations of the use of premarital education in second marriages. Using random-digit dialing methods, 398 individuals currently in a second marriage and 1,342 individuals currently in a first marriage participated. Compared with those in first marriages, individuals in second marriages were significantly less likely to receive premarital education for their current marriage. This difference was fully mediated by differences between individuals in first and second marriages in pre-engagement cohabitation, education level, having children from a previous relationship, and being married by a religious leader. In both first and second marriages, those couples at most risk for subsequent marital distress and divorce were less likely to receive premarital education. Results suggest that more needs to be done to understand the barriers to the use of premarital education for second marriages.

A randomized clinical trial of a computer based preventive intervention: replication and extension of ePREP

This randomized clinical trial replicated the efficacy of the ePREP preventive intervention for mental health and relationship relevant outcomes in a sample of 77 college students. It extended previous research by demonstrating efficacy at a 10-month follow up. Participants in the ePREP condition experienced improved mental health and relationship relevant outcomes relative to those who received a placebo intervention. The impact of the ePREP intervention on these outcomes was durable to relationship dissolution with and without repartnering. The flexibility of this intervention empowers it to overcome key obstacles in the dissemination of relationship education.

Premarital education, marital quality, and marital stability: findings from a large, random household survey

One of the limitations of experimental studies on the effectiveness of premarital education is the reliance on samples of mostly White, middle-class couples. In contrast, although survey methods allow only weak inferences about causal relations, representative surveys can yield important information about use and estimated effects across a diverse population. Using a large random survey of 4 middle American states, the authors found that participation in premarital education was associated with higher levels of satisfaction and commitment in marriage and lower levels of conflict-and also reduced odds of divorce. These estimated effects were robust across race, income (including among the poor), and education levels, which suggests that participation in premarital education is generally beneficial for a wide range of couples.

The impact of family formation change on the cognitive, social, and emotional well-being of the next generation

How have recent changes in U.S. family structure affected the cognitive, social, and emotional well-being of the nation's children? Paul Amato examines the effects of family formation on children and evaluates whether current marriage-promotion programs are likely to meet children's needs. Amato begins by investigating how children in households with both biological parents differ from children in households with only one biological parent. He shows that children growing up with two continuously married parents are less likely to experience a wide range of cognitive, emotional, and social problems, not only during childhood but also in adulthood. Although it is not possible to demonstrate that family structure causes these differences, studies using a variety of sophisticated statistical methods suggest that this is the case. Amato then asks what accounts for the differences between these two groups of children. He shows that compared with other children, those who grow up in stable, two-parent families have a higher standard of living, receive more effective parenting, experience more cooperative co-parenting, are emotionally closer to both parents, and are subjected to fewer stressful events and circumstances. Finally, Amato assesses how current marriage-promotion policies will affect the well-being of children. He finds that interventions that increase the share of children who grow up with both parents would improve the overall well-being of U.S. children only modestly, because children's social or emotional problems have many causes, of which family structure is but one. But interventions that lower only modestly the overall share of U.S. children experiencing various problems could nevertheless lower substantially the number of children experiencing them. Even a small decline in percentages, when multiplied by the many children in the population, is a substantial social benefit.

Predicting participation in premarital prevention programs: the health belief model and social norms

The development of effective programs to prevent marital dysfunction has been a recent focus for marital researchers, but the effective dissemination of these programs to engaged couples has received relatively little attention. The purpose of this study is to determine which factors predict couples' participation in premarital counseling. Predictive factors were derived from the health prevention literature, with a particular focus on the health belief model (HBM). Couples' beliefs and attitudes about premarital counseling were assessed at least six months before their wedding, and participation was assessed after their wedding. Results indicate that the strongest predictors of couples' participation were couples' perceptions of barriers to counseling and whether they had counseling recommended to them. These variables predicted participation even after controlling for important demographic variables. Recommendations for recruiting engaged couples for premarital counseling are made based on the findings.

Promoting marriage as welfare policy: looking at a public role in private lives

This paper discusses the interest in and politics surrounding government's using welfare reform legislation to carve out a stronger role in promoting marriage. It examines trends in family formation, their impact on society, and the effect of single parenting, divorce, and step-parenting on child well-being. The paper also looks at the treatment of marriage in current government programs, new state activities to promote marriage, proposals for a stronger government role, and marriage experts' expectations for the success of marriage education programs.

The social consequences of psychiatric disorders, III: probability of marital stability

OBJECTIVE

The associations of prior DSM-III-R disorders with probability and timing of subsequent divorce were examined.

METHOD

The data came from the part II subsample (N=5,877) of the National Comorbidity Survey. The respondents completed a structured diagnostic interview that retrospectively dated age at onset of each of 14 lifetime DSM-III-R disorders and recorded ages at first marriage and divorce. These data were used to estimate survival models describing the relationships between prior disorders and subsequent divorce. In addition, simulations were used to estimate the number of years spent out of marriage because of these causal relationships in the total U.S. population.

RESULTS

Prior psychiatric disorders were associated with a substantially higher risk of divorce. The simulations suggested that the effects of these associations in the U.S. population in the survey's age range are approximately 23 million lost years of marriage among men and 48 million lost years of marriage among women.

CONCLUSIONS

Psychiatric disorders have a number of adverse consequences for those who suffer from them and for their families and communities. The results reported here suggest that an increase in the number of people who divorce and a decrease in the number of years of marriage in the population may be among them. The debate over whether society can afford to provide universal treatment for psychiatric disorders needs to take these costs into consideration.