*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
Volume 42, Issue 07
April 7, 2013
Marriage and relationship education, Heterosexual marriage, Marriage statistics, Communication patterns, Psychotherapy in clinical practice, Marriage tools, Models of marriage education Scott Haltzman, MD,
From The American Psychiatry Association 165th Annual Meeting
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
Psychiatry Program Info Accreditation InfoCultural & Linguistic Competency Resources
From the American Psychiatry Association 165th Annual Meeting
Scott Haltzman, MD, Editor, DrScott.com; Medical Director, NRI Community Services, Woonsocket, RI
The goal of this program is to provide insight into various tools and approaches for preventing and resolving marital strife. After hearing and assimilating this program, the clinician will be better able to:
1. Describe the benefits of preventing divorce to individual couples and society at large.
2. Improve communication between couples through listening and reflection.
3. Recognize key characteristics of healthy relationships and predictors of divorce.
4. Assess the likelihood of a couple remaining together and building a happier relationship.
5. Identify patterns of neurochemical change associated with different stages in relationships.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Haltzman and the planning committee reported nothing to disclose.
Marriage and relationship education (MRE): distinct from individualized psychotherapy; originated as grassroots movement in 1950s; large research grants from Temporary Assistance for Needy Families led to widespread popularity and acceptance; central to addressing relationship problems in many communities; research primarily based on heterosexual marriages (early findings suggest same-sex relationships have similar conflicts and issues, although gay and lesbian couples have fewer problems with communication or “mind reading”); most commonly implemented as structured programs, classes, and workshops provided to groups of couples on voluntary basis at various locations in community; levels of intensity vary (eg, single half-day meeting, weekend retreats, weekly 2-hr meetings that continue for 6-18 wk); provided to general population through, eg, media campaigns, website fact sheets, digital video discs, self-guided internet courses
Benefits of marriage: public — lower rates of poverty; increased likelihood of children raised by 2 parents; decreased dependency on public assistance; private — increased longevity; greater accumulation of wealth; fewer medical conditions; higher rates of happiness; decreased mental health problems, suicidality, and substance abuse (may stem from higher tendency of healthier individuals to marry, but research shows health increased after marriage in patients with preexisting medical conditions; in data from US army, 50% of completed suicides associated with failed relationships)
Effective components of MRE: changing communication patterns, attitudes toward spouses, perceptions of marital roles, general expectations of marriage, and behaviors
MRE vs couples therapy: in Consumer Reports’ comparison of therapeutic modalities targeted at relationships, only couples therapy failed to show efficacy; this led to increased focus on education, and decreased emphasis on encouraging couples to share emotions and addressing how those relate to their connection to one another
Neutrality: may not be necessary in cases of, eg, domestic violence; although some therapists advocate neutrality when discussing divorce, speaker believes marriages can be saved (excluding cases that involve, eg, violence, dangerous substance abuse, repeated infidelity)
Lessons and Techniques
Prevention and Relationship Enhancement Program (PREP): participants only speak while holding symbolic item; during partner’s turn, participants listen attentively and reflect; since efforts to filter responses often interfere with listening, therapists must help patients focus on listening and reflecting; PREP can be extremely powerful and alter how individuals perceive their relationships; however, PREP techniques must be actively applied, and couples frequently revert to more argumentative (“yes, but”) styles of communication
Teaching reflection: couples should reflect specifically what they heard each other say; partners must pay attention to mood when reflecting; differences in communication styles (eg, use of expressive hand gestures) can affect how partners perceive reflections; failure to remain aware of personal communication styles can cause individuals to layer interpretations on ability to reflect; unrealistic expectations, beliefs, or inattention can also act as filters; builds on skills of trained therapists (eg, respond to complaints by encouraging patients to express feelings)
Study (Markman et al, 1993): suggested efficacy of PREP; used highly rigorous testing methods; 1 yr after undergoing PREP, divorce rates decreased by one-third; similar study conducted in 2010 on PREP for military couples showed comparable results
Lessons from Gottman: initiate discussion with “soft start-up” (eg, present observations instead of triggering defensiveness with accusations); avoid criticism, defensiveness, stonewalling, and contempt (identified as major predictors of divorce); stonewalling — describes refusal to discuss conflicts (eg, by leaving room) or tendency to immediately end communication; ability to repair — strongest predictor for survival of marriage; involves returning to partner shortly after argument (typically ≈20 min when emotions have subsided) to offer, eg, apologies, reconciliatory gestures, physical contact; reparative acts must be offered with sincerity, accepted by partners, and done when emotions subside
Successful marriage: predicted if man open to wife’s influence; however, if woman shows more openness to her husband’s influence, no improvement in marital quality and happiness, and divorce not prevented
Speaker’s survey on strategies for happy marriage: men typically responded with more utilitarian strategies (eg, nod head regularly, turn off television); women tended to have more global and emotionally based strategies (eg, share mutual connection, foster love)
Role of humor: women who use humor can steer men toward happiness and greater contentment in their relationships; however, men who use humor in their marriages do not typically move women toward greater sense of contentment in their relationships
Positivity: happily married couples maintain 5-to-1 ratio of positive to negative interactions; train couples to maintain this ratio
Reading “love maps”: couples gain understanding and bond through empathic basis; speaker believes more spiritual areas explored (may be problematic for couples seeking solutions to daily problems); Gottman’s techniques share similarities with dialectical behavioral therapy, and involve spirituality in comparable ways; men often have greater difficulties with spiritual components
Solution-focused therapy: popularized in Divorce Busting (Wiener-Davis, 1993); rooted in idea that past not predictive of future; helps partners identify problems, failed strategies, and new solutions which may have better results; encourages individuals to solve their own problems with their partners
Attitudes of men toward relationship problems: although men feel capable of personally solving or repairing many problems, they often feel unable to solve problems with relationships; speaker’s approach directly encourages men to use their own problem-solving skills and have confidence in their ability to manage relationships; in Gottman’s research, actions of men predict whether relationships succeed
Chapman and “love languages”: encourages individuals to learn about types of language their partner may need (eg, positive affirmation, physical touch, acts of service, quality time, gifts); in relationships, partners often mistakenly assume they share the same language; this can lead to situations in which one partner does not respond to communication as expected and creates disappointment
Practical Application of Intimate Relationship Skills (PAIRS): focused on emotional literacy, bonding (specifically physical closeness), emotional openness, fostering sense of safety, and patient’s “daily temperature”
Meta-analysis of MRE: followed 143 studies for 6 mo; found long-term improvements in well-functioning couples and short-term improvements in distressed couples; however, determinations based on self-assessment, and videotapes of distressed couples showed more improvement than their assessments acknowledged
Second meta-analysis of MRE: possible crossover with first meta-analysis; moderate amount of education more effective compared to low amount (eg, 2 hr weekly for 9 wk superior to 1 hr weekly for 4 wk); failed to show any improvements in relationship quality (ie, no effect size)
Study on building strong families: large multisite trial of 5000 participants; intended to assess efficacy on MRE in populations in which divorce typically, eg, leaves individuals dependent on government assistance, causes children to fail in school; provided couples education (including speaker’s methodologies) to unmarried couples with or expecting children at 8 centers across United States; each couple assigned to outreach worker (similar to case manager); average of 14 hr of education; 6 centers used Gottman model (based on, eg, love maps and affect regulation), and 2 centers used PREP model (with integrated parenting skills)
Outcomes: 15-mo follow-up assessed whether couples remained together, quality of relationships, quality of parenting, level of intimate violence, and 10 other parameters; no differences in parameters found at centers located in Baton Rouge, LA; Florida; and Houston and San Angelo, TX; in Atlanta, GA, interventions showed effect size on use of constructive behaviors during conflicts; in Oklahoma City, OK, interventions had positive effect sizes on 9 of 14 parameters (including improved relationships); in Indiana, couples that received interventions less likely to marry (compared to control group); in Baltimore, negative outcomes seen with 7 parameters (including domestic violence); however, interventions improved relationships between African-American individuals
Possible explanations for poor outcomes: individuals with or expecting children may not be particularly happy or receptive (ie, timing of intervention problematic); enrollment limited to impoverished families (so results may not apply to patient populations in many practices); in Baltimore (site with lowest rate of success), only 32% of participants expressed interest in lifelong commitment; speaker suspects problems arose from Gottman model, and prefers more tested and evidence-based approaches; PREP and PREP-based parenting model of Oklahoma site used fewer sessions of longer duration and maintained higher levels of enrollment (included greater number of married couples to act as models for other participants)
Keys to successful MRE: targeting of appropriate couples; flexibility in approach (speaker uses amalgam of tools rather than specific modality, and prefers office-based [ie, nongroup] approach); maintaining hope for salvaging relationship (except in cases presenting genuine safety concerns)
Questions and Answers
Saving marriage vs facilitating amicable divorce: although teaching effective communication skills can provide patients with lifelong benefits, patients who fail to use these skills during their marriages unlikely to use them during divorce; speaker recommends that patients read Covey’s 7 Habits of Highly Effective People for lessons on communication
Data on relationship outcomes: household study of 10,000 adults; 77% of couples who rated their marital happiness as poor remained married for ≥5 yr (86% of those couples revised their scores to reflect average or excellent levels of happiness during that time [with or without couples therapy]); of couples who initially reported lowest levels of happiness, 77% eventually assessed themselves as happy or extremely happy; divorced individuals did not report increased happiness (excluding those in second marriages and victims of domestic violence)
Arranged marriages: associated with lower rates of divorce (possibly due to cultural expectations or lack of initial euphoric love typical of most new marriages); levels of being “in love” tend to start low and increase over time
Arguments and agreement: in Gottman’s research, ≈80% of major arguments between spouses never truly resolve (eg, parties remain in disagreement after 5 yr); therapists should not focus on helping couples to agree, and must instead work on making room for differing points of view
Legacy of marital discord study (Amato et al, 2001): followed 2000 couples over 15 yr; 30% of marriages showed high levels of conflict and expressiveness, or complete breakdowns in communication; children of those 30% of marriages had poor outcomes, but outcomes did not improve in cases of divorce; relevance — although children may wish for divorce when parents conflict, they may not see how circumstances could change (after, eg, education)
Neuroscience of relationships: levels of norepinephrine and dopamine increase during infatuation phase, and levels of serotonin decrease; this leads to increased happiness coupled with increased neuroticism, obsessionality, and chronic anxiety (over, eg, abandonment, infidelity); neurochemical phases — initial attraction (strictly mediated by sex steroids); fluctuations in norepinephrine, dopamine, and serotonin; longer-acting or “mature” love (characterized by increased oxytocin [hormone involved in trust and bonding]); consequences — oxytocin has mellowing effects, and thus may cause perceived lack of excitement in relationships
Influences: social — study found risk for divorce increased by ≈20% for couples that interacted with divorced individuals; economic — rates of divorce decrease during times of economic hardship
Marital expectations and cultural norms: in speaker’s opinion, cultural changes have normalized divorce; in new norm, couples remain together only if happy at all times (absence thereof calls for divorce)
Premarital education: typically viewed as unnecessary by couples, but shows efficacy in studies
Dr. Haltzman spoke at the American Psychiatric Association 165th Annual Meeting, held May 5-9, 2012, in Philadelphia, PA. For information about other meetings presented by the American Psychiatric Association, please visit psych.org. The Audio-Digest Foundation thanks Dr. Haltzman and the American Psychiatric Association for their cooperation in the production of this program.
Allen ES et al: Marriage Education in the Army: Results of a Randomized Clinical Trial. J Couple Relatsh Ther 10:209, 2011; Allen ES et al: The effects of marriage education for army couples with a history of infidelity. J Fam Psychol 26:26, 2012; Amato PR et al: Reconsidering the “Good Divorce.” Fam Relat 60:511, 2011; Cleary Bradley RP, Gottman JM: Reducing situational violence in low-income couples by fostering healthy relationships. J Marital Fam Ther 38:187, 2012; Hawkins AJ et al: Does marriage and relationship education work? A meta-analytic study. J Consult Clin Psychol 76:723, 2008; Hawkins AJ et al: Exploring programmatic moderators of the effectiveness of marriage and relationship education programs: a meta-analytic study. Behav Ther 43:77, 2012; Markman HJ et al: Preventing marital distress through communication and conflict management training: a 4- and 5-year follow-up. J Consult CLin Psychol 61:70, 1993; Markman HJ et al: The premarital communication roots of marital distress and divorce: the first five years of marriage. J Fam Psychol 24:289, 2010; Stanley SM et al: Decreasing Divorce in Army Couples: Results from a Randomized Controlled Trial using PREP for Strong Bonds. J Couple Relatsh Ther 9:149, 2010; Stanley SM et al: Premarital education, marital quality, and marital stability: findings from a large, random household survey. J Fam PSychol 20:117, 2006; Wetzler et al: Marriage education for clinicians. Am J Psychother 65:311, 2011.
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