Preventive Approaches in Couples Therapy

Rony Berger, Mo Therese Hannah

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780876308769
• eBook ISBN: 9781134869893
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Preventive Approaches in Couples Therapy is the first thorough overview of the leading approaches to preventing marital distress and dissolution. Written for professionals, paraprofessionals, and lay people involved in the development and implementation of preventive programs, the editors have created a resource accessible to all those in the field of couples therapy. The volume serves as an important resource for programs that the therapist may already use and as an insightful introduction into new programs that can strengthen and invigorate these existing therapeutic approaches.

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Rony Berger, Psy.D.

Mo Therese Hannah, Ph.D.

Introduction

In this chapter, we will define the arena of preventive approaches to couple distress, illuminating the importance of this field and offering a conceptual framework for comparing the various approaches. We will also outline the guidelines used by the book’s contributors in writing their chapters. Finally, we will end this introduction with the case study that the chapter authors used in applying their particular preventive approaches.

Demarcation of the Field

During the last few decades, there has been a proliferation of new prevention and couple enrichment training programs (Floyd, Markman, Kelly, Blumberg, & Stanley, 1995). Due to the keen interest in such programs among mental health professionals, paraprofessionals, and the general public, we saw the need for an up-to-date, comprehensive summary of current approaches.

In the past, when they were included in volumes on marital and couples therapy, preventive approaches were classified as “emerging models of marital therapy” or “group models” of couples interventions (Jacobson & Gurman, 1986, 1995). But, as will become apparent from what is presented in this volume, preventive approaches have a long history; they began to emerge long before their inclusion in volumes on couples therapy. Nor have all prevention approaches been group oriented. Even more important, as noted by many prominent theoreticians, there are meaningful differences between preventive and remedial approaches to marital and couple distress (e.g., Guerney, Brock, & Coufal, 1986; L’Abate, 1981; Mace, 1983; Markman, Floyd, Stanley, & Lewis, 1986).

In structuring this volume, therefore, one of our main challenges was devising an appropriate title, one that would encompass the diversity of preventive approaches while retaining their distinction from remedial models. We recognized that our choice of a title would reflect a deeper conceptual issue, that is, the demarcation of the field. What, in fact, should be included within the rubric of preventive approaches to couples interventions?

Preventive programs for couples, married or nonmarried, have appeared under different titles throughout the years. They have been termed “family life education” (Groves & Groves, 1947), “marriage enrichment” (Mace & Mace, 1975), “relationship enhancement” (Guerney, 1977), “skill/competence training” (L’Abate, 1986), and, more generically, “psychoeducational programs” (Leveat, 1986). Though there are clearly some differences among these programs (for further discussion, see L’Abate, 1977), they all share one pertinent commonality: They are identified as preventive rather than remedial. However, as L’Abate (1990) noted, marital and couples therapists may also claim to engage in prevention, that is, prevention of “crisis and breakdown” (p. 20).

Thus, our dilemma involves deciding whether remedial approaches should be included among the preventive approaches in the area of marital and couple distress. To make this determination, it is important to illuminate the differences between preventive and therapeutic models.

Preventive Versus Remedial Approaches to Couple Distress

Preventive approaches are geared toward relatively functional couples who have not yet experienced significant relationship problems. Couples therapy models, or remedial interventions, usually target “dysfunctional couples,” that is, couples who have already experienced interactional problems that have comprised relationship satisfaction, relationship stability, or both. Preventive programs are based on psychoeducational, skill-or competence-based models; therefore, such programs focus on the strengths and well-being of the couple. Though these approaches do not ignore risk factors, such as dysfunctional communication styles, destructive interactional patterns, and negative attitudes, they place greater stress on developing positive and mutually satisfying attitudes, communication styles, and intimacy patterns. On the other hand, remedial approaches are often based on the medical model and thus typically underscore the couple’s pathology (Denton, 1986; Guerney et al., 1986).

Additionally, most preventive programs have in common the following ingredients: They are didactic, experiential, structured, programmatic, time limited, affirmative, usually economical, and primarily group oriented. In contrast, most remedial models are less structured, nonprogrammatic, minimally didactic, partially affirmative, not time limited, and much more expensive (L’Abate, 1977).

A more detailed differentiation between preventive and remedial interventions was proposed in the report of the Institute of Medicine’s (IOM’s) prevention committee (Mrazek & Haggerty, 1994). The IOM’s committee divided all mental health interventions into three basic categories: prevention, treatment, and maintenance. According to Munoz, Mrazek, and Haggerty (1996), prevention is relegated to “those interventions that occur before the initial onset of a clinically diagnosable disorder” (p. 1118), while treatment (remedial) starts when a diagnosable criterion has been reached. Maintenance, on the other hand, can be either preventive or remedial, though it also occurs after the acute episode of mental disorder. These interventions are geared either toward preventing relapse or recurrence of disorder or toward rehabilitation.

Despite such important differences between prevention and remediation, during the last decade or two, there has been a gradual blurring of these two types of interventions. The influence of psychoeducational models in the medical and mental health fields, the focus by managed care on cost-effective interventions, and the growing prominence of the brief therapy movement have coalesced in the merging of the two classes of interventions. It is now common to see therapeutic models for couples that incorporate preventive ingredients (as an example, see Hendrix & Hunt, chapter 8 of this volume) and preventive models modified for use in the context of couple therapy (see Stanley, Blumberg, & Markman, chapter 13, and L’Abate, chapter 5). Thus, we agree with Guerney and Maxson’s (1990) observation that “sharp demarcation between problem prevention, enrichment, and therapy have not, and perhaps cannot and should not, be made” (p. 1127).

Another way to view the commonalities among preventive and remedial approaches is to view them as falling at different points along a continuum of interventions.

Three Levels of Preventive Programs

Prevention is defined as “the act of anticipating before hindering or preventing” (Webster’s Unabridged Dictionary, 1983). This focus on the temporal aspect (anticipation) rather than on the nature of the intervention or the targeted group was emphasized by many preventionists (Coie et al., 1993; Heller, 1996; Mrazek & Haggerty, 1994; Price, Cowen, Lorion, & Ramos-McKay, 1989; Riess & Price, 1996). The National Institute of Mental Health’s (NIMH) panel, in its report to the National Prevention Conference (Coie et al., 1993), stated that “preventive efforts occur, by definition, before illness is fully manifested” (p. 1013).

L’Abate’s definition is more descriptive: “Prevention consists of any approach, procedure, or method designed to improve interpersonal competence and functioning for people as individuals, as partners in intimate relationships, and as parents” (1990, p. 7).

Historically, preventive approaches have been grouped into one of three levels of intervention: primary, secondary, and tertiary. Primary prevention with couples is considered “true” prevention in that it intervenes with couples before they are experiencing difficulties; it is “prevention before it happens” (L’Abate, 1983). Catalano and Dooley (1980) focused on the proactive nature of such services.

Secondary prevention involves interventions with “at-risk” couples, those who are experiencing some degree of relationship impairment. Secondary prevention thus provides semi-proactive services to intervene with couples “before they get worse,” to borrow L’Abate’s (1983) terminology.

Finally, tertiary prevention applies to couples experiencing significant problems in which the relationship itself is at stake. Here, services are provided “before it is too late,” and are thus considered reactive as opposed to proactive. Couples therapy is a prime example of tertiary prevention.

It is important to note that these distinctions are somewhat artificial. As Mace (1983) indicated, “these preventive processes overlap and cannot be precisely distinguished from each other” (p. 19). Moreover, several authors use similar programs for both primary and secondary prevention, and even, more rarely, for tertiary prevention.

In identifying the preventive nature of the programs presented in this volume, one needs to clarify their primary goals. In other words, what is the program designed to prevent? The following list offers three characteristics of preventive couples therapy.

1. Primary: The program is geared toward helping couples deal with normative problems, such as life transitions (e.g., parenthood, geographical moves, job changes).

2. Secondary: The program is designed to prevent future dissatisfaction or the loss of desirable relationship characteristics, such as passion and intimacy.

3. Tertiary: The program aims to keep serious couple problems from leading to further deterioration of the relationship and marital separation.

Items 1 and 2 describe most of the programs in this volume, which therefore could be considered primary or secondary preventive models. However, some contributors suggest that their programs also address couples’ more significant difficulties and can thus be viewed as tertiary models.¹ Others point out that, with some modifications, their interventions can also be used for tertiary prevention.

If couple intervention models are conceptualized as lying along a preventive continuum (L’Abate, 1990), with family education on one side and couples therapy on the other, then we have resolved the polarization between prevention and remediation, thus permitting the application of marital and couple interventions to the varying levels of prevention.

A similar view was reached by the IOM’s prevention committee, which stated: “The committee agreed on the usefulness of viewing treatment and prevention as part of a spectrum of interventions of mental health disorders, instead of seeing them in opposition to each other” (Munoz et al., 1996, p. 1120).

The IOM’s Categorization of Preventive Interventions

Another way to classify the various preventive strategies was suggested by the IOM’s committee (Munoz et al., 1996), which subdivided the field of prevention into universal, selective, and indicated interventions. This categorization is based on the presence and severity of risk factors for developing a mental disorder. Hence, preventive universal strategies are geared toward an entire population group not considered to be at risk. Selective preventive strategies are directed toward individuals or groups who demonstrate relatively significant risk for developing a mental disorder. Finally, indicated preventive strategies address those individuals or groups who have already developed some symptoms (although not a fullblown disorder) or those who manifest a biological predisposition for a mental disorder.

Using the concept of levels of prevention, universal interventions are clearly primary prevention, selective interventions would be considered secondary prevention, and indicated interventions would appear to be either secondary or tertiary prevention.

In using the above strategy to evaluate the programs described in this volume, most would appear to be universal programs geared to the general public. However, the self-selection of participants into such programs could qualify the programs as selective strategies.

Preliminary evidence for this consideration was provided by Hogan, Hunt, Emersson, Hayes, & Ketterer (1996), who showed that highly distressed couples enroll in the Imago Relationship Therapy couples workshop (see Hendrix and Hunt, chap. 8 of this volume). In addition, DeMaria’s (1998) survey of married participants in the PAIRS program (see Gordon and Durana, chapter 10 of this volume) demonstrated that most of these couples were of the highly distressed “devitalized” type, according to the ENRICH typology (see Olson and Olson, chapter 9 of this volume). This phenomenon is believed to apply to participants in other interventions besides those just mentioned, although further research is needed.

Finally, some programs (for example, SE; see L’Abate, chapter 5 of this volume) fall into the category of selective interventions in targeting a particular individual or group at risk. A few programs fit the label of indicated programs, due to their application to specific groups who demonstrate some degree of symptomatology.

Preventing Dysfunction Versus Promoting Wellness

As suggested above, the murky differentiation between prevention and remediation in the field of couples’ distress has not proven helpful in the task of demarcating the field of prevention. Another dilemma relates to the goal of preventive interventions. While some practitioners focus on the narrow objective of preventing psychological disorders, as defined by the DSM-IV (American Psychiatric Association, 1994), others add to it the enhancement of wellness.

This more inclusive definition was articulated in the Prevention Task Panel Report for then-President Carter’s Commission on Mental Health (Albee, 1996). However, this definition has recently been replaced by a more concise definition which maintains that “the goal of prevention science is to prevent or moderate major human dysfunctions” (Coie et al., 1993, p. 1013). The predominance of this definition was demonstrated in the recent IOM and NIMH reports. The IOM report (Mrazek & Haggerty, 1996) went so far as to exclude mental health promotion from its view of prevention, stating that “health promotion is not driven by a focus on illness, but rather a focus o...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• About the Editors
• About the Contributors
• Foreword
• Preface
• Acknowledgments
• Part I Introduction
• Part II Programs
• Part III Research
• Part IV Summary
• Index