The Marriage Checkup 1 Running Head: THE MARRIAGE CHECKUP The Marriage Checkup: An Indicated Preventive Intervention for Treatment-Avoidant Couples At-Risk for Marital Deterioration

Prior to dissolution, it is likely that couples that become severely distressed first pass through an at-risk stage in which they experience early symptoms of marital deterioration but have not yet suffered irreversible damage to their marriage. It is during this “at-risk” stage when couples might benefit most from early intervention. In response to this need we have developed an indicated intervention program called the Marriage Checkup (MC) based on the principles of motivational interviewing. The current randomized study provides preliminary evidence for the attractiveness, tolerability, efficacy and mechanisms of change of the MC. The Marriage Checkup 4 The Marriage Checkup: An Indicated Preventive Intervention for Treatment-Avoidant Couples At-Risk for Marital Deterioration Marital deterioration is one of the leading causes of human suffering. Relationship difficulties are among the most common reasons that people seek psychological services (Consumer Reports, 1995). Even so, the vast majority of people suffering from relationship difficulties do not seek the help of mental health professionals and those who do seek help most frequently see clergy or physicians (Doherty, Lester, & Leigh, 1986; Veroff, Douvan, & Kulka, 1981). It has been estimated that at any one time 20% of all marriages in the U.S. are significantly distressed (Beach, Arias, & O’Leary, 1987). Given an estimate of 56 million married-couple family households in 2000 (Fields & Casper, 2001), that is approximately 11.2 million marriages that may be in serious jeopardy of dissolution at any one time. In addition to the suffering inherent in marital deterioration and divorce, these processes have been associated with a number of other sources of human suffering. For example, it has been estimated that the risk of experiencing a major depressive episode is somewhere between 10 and 25 times greater for those experiencing significant relationship distress (Weissman, 1987; Whisman, 2001). It seems likely that, prior to reaching the dissolution stage, couples that become severely distressed and eventually dissolve their marriages first pass through an at-risk stage. During this stage, they experience early symptoms of marital deterioration but have not yet suffered irreversible damage to their marriage (Cordova, Warren, & Gee, 2001). Couples in this at-risk stage are unlikely to seek conventional, tertiary marital therapy either because they have not yet become distressed enough to see the need or because the time, expense, or stigma of therapy present too great a barrier. Such couples are also not likely to seek premarital or newlywed interventions because they are in established marriages and do not perceive themselves as The Marriage Checkup 5 preparing for married life. It is during this “at-risk” stage, however, that couples might benefit most from early intervention. Such indicated early intervention programs have the potential to a fill a niche between the inoculation against marital distress provided by prevention programs and the intensive treatment of severe distress provided by couple therapy. Indicated early intervention with at-risk couples has several goals, each with attendant challenges. The first goal is to reach populations that are at-risk for relationship deterioration. However, involving such couples in an intervention program presents unique challenges. Whereas couples seeking marital therapy and premarital education are motivated to pursue these interventions either by their distress or by their desire to start their married lives on the right foot, at-risk couples in established marriages are motivated by neither. Such couples are unlikely to perceive themselves as distressed enough to seek marital therapy. They may also be suspicious of therapy or may not think of it as a viable or desirable option for economic, time or social reasons. Any successful intervention must overcome these barriers to attract at-risk couples. The second goal is efficient assessment of risk potential, meaning that brief and effective means for identifying the demonstrated predictors and correlates of marital deterioration must be constructed. The attendant challenge involves bridging the gap between the available empirical literature concerning predictors and correlates of marital deterioration and couples presenting from within the community of laypersons. The third goal is to effectively promote marital health in the short run, meaning that the intervention should work to immediately improve the relationship satisfaction of participating couples. The challenge for such interventions is that they must be brief in order to be attractive to at-risk couples, and yet they must also be sufficiently powerful to stimulate quick relationship improvement. This goal is important because a quick boost in marital health and emotional The Marriage Checkup 6 closeness may be a necessary part of motivating partners to work collaboratively toward stable marital health. In response to both the need for early intervention with at-risk couples and the challenges presented by that need, we have developed an intervention program called the Marriage Checkup (MC; Cordova, Warren, & Gee, 2001). The MC is a brief, two-session, assessment and feedback intervention utilizing Miller and Rollnick’s (2002) motivational interviewing strategies and Jacobson and Christensen’s (1998) acceptance promotion strategies. Research on the MC to date has demonstrated that this format is effective at attracting couples that can be considered at-risk for ongoing marital deterioration, but that are otherwise not seeking relationship treatment. In addition, research has demonstrated that the MC is easily tolerated (97% completion rate) and safe for use with at-risk couples (Cordova, Warren, & Gee, 2001). Longitudinal follow-up demonstrated that (1) relationship distress remained significantly improved two-years following the intervention; (2) receiving a treatment recommendation as part of the MC predicted subsequent treatment seeking for wives; and (3) couples’ affective tone following the MC predicted later marital satisfaction (Gee, Scott, Castellani, & Cordova, 2002). The previous studies were uncontrolled, however, so observed improvements could not be confidently attributed to participation in the MC. Therefore, it remains to be demonstrated that the MC is an efficacious indicated intervention for promoting the relationship health of participant couples. In addition, previous research has not addressed the mechanisms by which the MC is theorized to promote relationship health. Theoretically, the MC should improve relationship satisfaction and stability by increasing couples’ motivation to pursue maritally healthy habits and by increasing intimacy and acceptance of common differences. Specifically, the MC is expected to facilitate couples’ progress through The Marriage Checkup 7 the stages of change (Prochaska & DiClemente, 1984), from stages in which they are less motivated to work on improving their marriages to stages in which they are more motivated to pursue and maintain marital health. According to theory (Miller & Rollnick, 2002), motivational feedback facilitates movement through several successive stages of change (Prochaska & DiClemente, 1984). The first is a pre-contemplative stage, in which partners suffering from problem areas in their relationship do not recognize these areas as problematic or subject to change. The second is a contemplation stage in which partners recognize that they have relationship problems but are ambivalent about what, if anything, to do about those problems. The third stage is a determination stage in which partners recognize their relationship problems, are determined to address those problems, but may not know what to do. The fourth stage is an action stage, in which partners recognize their problems and are taking specific steps to address them. At this stage, efforts to change may or may not be effective. The fifth stage is a maintenance stage, in which changes have been made, and partners work to maintain those changes. The sixth stage is either an escape stage, in which the problems are resolved, or a relapse stage, in which the problems recur, and the couple moves back into one of the former stages. In addition, the MC is designed to improve intimacy by facilitating partners’ expressions of emotional vulnerability (Cordova & Scott, 2001). The MC is also designed to facilitate greater acceptance of common differences by highlighting the softer emotions and understandable reasons associated with partners’ behavior (Cordova, Jacobson, & Christensen, 1998). Theoretically, these in turn facilitate partners’ motivation to work collaboratively toward greater marital health. Several hypotheses were tested in the current study. The Marriage Checkup 8 First, it was hypothesized that the MC would attract couples that could be categorized as at-risk for ongoing relationship deterioration. Second, it was hypothesized that participants would tolerate the intervention well and would neither refuse to participate nor drop out of treatment in substantial numbers. Third, it was hypothesized that couples participating in the MC would report increases in relationship satisfaction and that a no-treatment control group would not show comparable improvement. Fourth, it was hypothesized that MC couples would demonstrate increases in intimacy and acceptance, as well as increases in motivation to improve the quality of the relationship, and that no-treatment control couples would not report such increases. Fifth, it was hypothesized that intimacy, acceptance, and increased motivation would mediate the effect of treatment on relationship satisfaction. Method