In the Best Interest of the Child:
Relationship Skills Education

Paper presented to the American Academy of Pediatrics Task Force on The Family

October 5, 1998

Janice R. Levine, Ph.D.
with the Coalition for Marriage, Family and Couples Education (CMFCE)

INTRODUCTION

So according to Judith Harris, parents don't much matter?

Then why is it that we see the full range of social, emotional, and academic problems being more prevalent in children of single and divorced parent families than in two parent households?

And why are children of divorce far more likely to themselves grow up and divorce? It isn't a gene; and it isn't their peers.

We may not know the exact mix, but we know that the influence of two parents is healthier than one, and we know that a two parent household in which there is chronically high conflict is even worse for children than a single parent home absent the negative conflict.

So for now, let's work with what we do know to be true, and see whether we can't isolate and support those factors that we know give our children the strongest foundation for overall wellness and happiness.

Race, ethnicity, SES, educational level, geography, genetic endowment -all notwithstanding, we know that: (a) two parents, (b) happily married, are better than one, and this goal is central to the best interest of the child. What could lie more in the province of pediatrics than this?

Focusing on the healthy relationship of parents; on supporting the stability of the two parent household, is fundamental to the overall physical and emotional wellness of a child: It's good preventive medicine. Consider the diathesis stress model. A two parent family creates the kind of environment most conducive to healthy growth and development and can insulate a child against the potential expression of disease -in all arenas of development: cognitive, emotional, and physical; When medical crises do occur, the best possible family resources and supports are available in two parent households to maximize the potential for healing; Long term: Two parent families help offset the chances that children will grow up to replicate the same cycle of divorce and dysfunction. Why? Because as children they will have observed and learned effective ways to handle the inevitable interpersonal stresses that come with marriage and family life: 1) not just because they are recipients of a nurturing environment; 2) not just through parental modeling; but 3) by being active participants their whole lives in a healthy way of interacting with others, thereby providing them with the skills necessary to live with interpersonal differences and to secure satisfying relationships.

I'm proposing that on multiple levels, the long term health and wellness of our children is best served by supporting the two parent household. Our question then becomes, how is this best achieved?

Let me try to answer this question by taking you there the way I arrived myself, and by suggesting that our mutual purpose as helpers and healers of children may not in fact be very different.

BACKGROUND

I am a Developmental Child Psychologist practicing couples therapy and relationship education. My path to Relationship Education is, and has always been driven by an essential commitment to understanding how best to help the children. It's been a journey of continued defection towards the place where I I know I can now truly accomplish this goal most effectively. I began by studying Infant Development at Yale with Bill Kessen and went on to study Early Childhood Development at Harvard with Jerry Kagan. Early in my doctoral training I realized that I'd only have but limited understanding of a child's experience and needs if I limited myself to academic research; i.e. I needed to learn directly from the children themselves. Since Harvard had no clinical degree program, I made my first defection from academia to clinical psychology. I pursued an independent clinical internship at The Judge Baker Guidance Center and became a licensed clinical child psychologist. For about 5 years. But this soon frustrated me greatly, because while I was better able to understand a child's experience of their world through direct interaction, my efforts to help improve their lot often got severely amputated by sending the child home to a non sustaining - if not deleterious - home environment. I found that 50 minutes a week of play therapy barely made a dent in the lives of children who returned to permanent environments that undid our gains. And, I discovered that very few children in fact had independent psychological pathogens that weren't in some way related to their lives at home.

So I defected again - to Parent Education. I hosted a Cable TV show called "Perspectives on Parenting" and founded a 4 year Lecture Series in which the likes of Jerry Kagan, Berry Brazelton, David Elkind, Sophie Freud and 40 others came to share their wisdom. But this too was frustrating because, while there was indeed a wealth of good and interesting information to be had, parents were feeling confused and disenfranchised. They felt disempowered, felt they couldn't do it "right", and often felt undermined by the apparently contradictory advice they were hearing: What they learned was good in theory but there was no venue to translate it readily to "real life situations." And, the two parents often disagreed vociferously about parenting decisions, and undermined each other, often with volatile or passive aggressive conflict. So I defected again - to doing Couples Therapy. I began to realize that the essential nugget of family health lay right there inside the couples' relationship itself: that not only were there no parenting panaceas, but there were as many good ways to parent as there were families PROVIDED THAT THE PARENTS HAD AN EFFECTIVE PROCESS FOR HANDLING THEIR DIFFERENCES. Then they would have the skills to make good parenting decisions that reflected both of their values. Then they could nurture their own relationship to longevity; they could create a warm home in which there was acceptance of different points of view and good communication among all members, and ultimately, they could teach their children the most important skills they would ever need to forge healthy relationships in life: whether with their parents, siblings, peers, teachers, or future adult partners. And the cycles of aggression and of divorce could be interrupted. In a word, if the parents' own relationship was strong, the child's environment had all the necessary nutrients to enable them to grow up strong as well.

What was this process couples needed, and how could I provide it best? It seemed to me that at the very core of healthy relationships was the ability for two people to negotiate the inevitable differences that existed between them, in a manner that was conducive to growth rather than to decay. How to resolve conflicts and live with differences. So I developed a conflict-resolution curriculum called The Couples Health Program, that isolated the skills I believed were necessary for effective communication and the resolution of conflicts over time. Very conveniently, I might add as a professional also in the medical field, this model also fit quite nicely into the short-term, solution-focused, managed care environment that required us to cure all ills in 8 sessions or less - without relapse. So, I defected one last time to doing relationship skills education, which in is a form of Behavioral Marital Therapy, or psychoeducation coupled with skills training. Turns out, I stumbled into an emerging new field of relationship educators that included a disparate group of researchers, clergy, clinicians, lawyers, and teachers who all shared an impassioned and sincere commitment to strengthening the two parent family, and improving the lives of our children, in the most effective possible. My hunches had been correct and were shared by all: outcome studies indeed demonstrated that conflict resolution skills, taught behaviorally to couples, could reduce the divorce rate by 50% while improving marital satisfaction.

If our question as pediatric health care providers is where to target our interventions so as to have the most powerful and comprehensive positive impact on our children's lives, then I think we've found our answer. After working in the field for 15 years as a developmental and clinical child psychologist, I have become convinced that to best help our children and responsibly target interventions where they hold the greatest promise, we can no longer focus on the individual child, but instead must look beyond the child to the family, within the family to the parents, and between the parents to the couples' relationship. It is here where the primary locus of our children's health and welfare resides. That is, it is in the couple's relationship - specifically, in their ability to successfully manage conflict - that the greatest potential exists for creating a stable and optimal home environment in which children can develop healthy egos, resiliency, and ultimately, thrive in society.

COUPLES THERAPY AND RELATIONSHIP EDUCATION

What is Relationship Education and how does it differ from the more familiar couples therapy?

1. The overall aim of Couples Therapy is to explore the differences between members of a couple in order to understand why they exist, and then to validate them. Good couples therapists remain neutral and non-directive, allowing the couples to explore their feelings in the safety of the therapist's office. However, this often creates an undue dependency on the therapist for the work to get done.

2. The not-so-good couples therapists practice an extension if individual psychotherapy, only with two people in the room. That is, rather than taking a neutral stance with no overriding agenda, these more classically trained therapists support and promote "individual self interest", in which patients are encouraged to trust their feelings and "if it feels good, do it." There almost exists a "political incorrectness" about supporting marriage outright, and so divorce is often encouraged when one or the other's needs aren't being adequately met.

How did this ethic come to be? Why is marriage politically incorrect? When no-fault divorce laws were instituted some 30 years ago, many feminist advocates hailed it as representing a way for women in oppressive marriages to get out readily and safely. The idea that anyone should be forced to stay in a bad marriage, or subjugate their needs to those of their partner, flew in the face of equal rights. But perhaps the overriding belief that divorce was the only alternative to a bad marriage was promulgated simply because the skills necessary to foster equal rights within a marriage were as yet unknown. Perhaps more to the point, divorce was often encouraged on behalf of the children, because it was believed that if both parents were not feeling personally fulfilled in their marriage, then the children would invariably pick up on it and also suffer the ill effects of their parents' unhappiness. We believed that it was better for the children to have happy parents living in separate homes, than unhappy parents who lived together.

That was the theory "du jour." But the data reveals that this, in fact, is not exactly the case. Yes, children living in home environments with chronically hostility and destructive conflict suffer, but this is equally true in one parent and two parent households alike. What is clear from a generation grown up is that the ravages of divorce have undeniable, deep, and enduring negative consequences on children and adult children of divorce, and this finding cuts across all social and economic strata. Encouraging the dissolution of the family unit before every attempt has been made to resuscitate it simply is not in the best interest of the child, from any vantage point. First, we know that nearly every childhood psychological disorder is more prevalent among children of divorce than among children who grow up in intact families. Second, many secondary effects can be traced to conditions of poverty in which children must often live as a result of divorce; and third, children are directly impacted by the ill effects divorce has on their parents, which include higher rates of depression, alchoholism and drug abuse, and many immunilogical, respiratory and G-I related disorders. Did you know that divorced men and women have shorter life expectancies than their married counterparts?

3) Perhaps the most effective of the existing therapeutic options are the strategically oriented family therapies, in which a therapist can make interventions aimed at shifting dysfunctional interaction patterns within the family - often with the goal of releasing the child from the symptomatic role of the Identified Patient (IP).

Marriage and family therapy can indeed be helpful in many cases, however people have to first be willing to seek help. Couples often delay seeking help until approximately 6 years after the first signs of problems, or they wait until they are already in crisis - which often means too little too late. That's if we're lucky! Quite often couples avoid consulting a marriage counselor altogether because they feel stigmatized; they feel that to ask for help pathologizes them. Men are often the more reluctant party because they are uncomfortable with the medium of emotional disclosure and self expression involved, and quite often because it replicates the very experience that produced the schism in the first place!

Marriage therapy misses the boat in at least three essential ways: 1) It runs counter to the ethic of most marital therapists to clearly promote a bias toward marriage; 2) In none of these therapies are specific skills taught that we know to be effective in repairing or preventing marital breakdown; and 3) In the last 30 years, while the numbers of marriage therapists has markedly increased, the divorce rate has not changed.

RELATIONSHIP EDUCATION

The Relationship Education approach is clear about what its objectives are, and pragmatic about its means to achieving them. Its expressed goal is to prevent marital breakdown and improve the quality of relationships by equipping couples with the necessary tools to achieve this on their own. The skills are applicable to couples at any age and stage of relationship, from High School to empty nesters; from premarital counseling to crisis intervention. They can be taught inexpensively and in a classroom, church, or community setting, and consist of very logical, "nuts and bolts" type language and materials. They are NOT therapy groups requiring emotional disclosure, but more resemble classes in drivers education or childbirth. Men and women respond equally positively to the structured, hands-on approach and to the results they can see.

Relationship Education programs are based largely on extensive empirical and clinical research into what differentiates marriages that succeed, from those that don't. Foremost among these researchers are Howard Markman and Scott Stanley at The University of Denver, and John Gottman at University of Washington. Heading the list of factors that differentiate successful from unsuccessful marriages is the couple's ability to manage conflict. What we've discovered is that it's neither the nature of the individual differences, nor the number of disagreements that occur that distinguishes happy from unhappy couples. Rather, it's the way in which the conflicts are handled that can make or break a marriage. What's exciting is that the requisite skills have been isolated, tested, and the results replicated, so we can now offer with confidence programs that promise a significant reduction in divorce rates long term, with commensurately high levels of satisfaction among couples who stay together. Inventories have been developed that can predict with up to 90% accuracy which couples will end up unhappy and divorced. This is indeed very exciting, because it means that couples can learn how to do more of what works to keep their relationships strong, and less of the things shown to predict its breakdown.

How do we know what these things are? Marital research labs actually videotape couples living their normal lives - that is, if by normal we include being observed in their daily lives hooked-up to electrodes, having periodic blood and urine samples drawn, and measuring heartrate, blood pressure and respiration to assess stress and arousal levels. The tapes are analyzed along many dimensions of behavioral interactions, and couples are followed for many years to measure long term effects. We now know, for example, that men who are able to accept influence from their wives are in marriages that have a greater chance of surviving; women who approach their husbands with a "softened start-up" also have more successful marriages than those who begin more aggressively; and marriages in which greater numbers of repair attempts are made and honored tend to be more robust. Men's physiological arousal levels rise faster during overt conflict whereas womens' rise faster when they are being stonewalled. We know the three marital styles that seem to survive best, and that regardless of marital style, a 5:1 ratio of positive to negative interactions must exist at a minimum for marriages to survive. We know the four most important danger signs to watch for and target, and the four interactional patterns that are most damaging to marriages over time. We now also know that when clergy deliver programs their success rate increases. And more.

Not all programs have the same focus or teach the same material, and a range of programs having varying designs and applications now exist. What differentiates one program from another are dimensions like:

Psychoeducational content; e.g. whether it covers topics like Parenting, Finances, Fun, Commitment, Sexuality, Friendship, etc.; Structure and format (Design); Teaching methods and applications; Setting and population characteristics; Training and qualifications of leaders.

In general, however, all programs share some basic elements in common, and teach the same basic skill sets, such as: basic communication skills, active listening, learning to speak for oneself, calling time-outs and using other ground rules for safe dialogue, empathy building, conflict resolution and problem-solving skills, including brainstorming, negotiation techniques and contracting, and how to renegotiate and update agreements as families develop and life changes.

Broadly defined, the programs can be broken down into a few overlapping categories based on their different origins and applications:

1) University developed Programs that base their content and materials on their own research and outcome studies; 2) Inventory based Programs that also originate in university settings and focus primarily on assessment; 3) Church and Community Based Programs which involve community leaders and mentor couples actively trying to establish and support a marriage culture; 4) Therapy based Programs that draw from clinical knowledge and techniques and translate them into skills training in classroom settings; and 5) School Programs - perhaps the most exciting application of all - in which the relationship skills are taught to children and teens in their own schools. Talk about primary prevention!

CURRENT INIATIVES, POINTS OF ACCESS, AND POINT PEOPLE

Marriage is, for many, a controversial topic that for a long while has been actively avoided by leaders and policy makers. It can indeed be complicated on many fronts. For example, should we refrain from using the term "Marriage Education" so as to be sensitive and inclusive of gay and lesbian couples, or those who choose not to marry? Does a focus on marriage stigmatize single parent households? Should government agencies not intervene in private matters such as marriage and divorce?

We've skirted the topic for too long, but happily, marriage seems to be re-entering our popular culture and discourse. The M-word, which for so many reasons has been a political "no-no", seems to have been been reinstated not just by the likes of John Gray -whom you might notice speaks to sold out and wildly responsive audiences - but by truly discouraged yet hopeful Generation Xers who want to clean up and prevent some of the havoc our no-fault culture has wreaked. People seem to be ready to ask themselves some hard questions and do the hard work required to insure a good marriage, or to opt not to marry at all.

We have a palette of excellent programs available to us. But we need to find more effective ways of disseminating this resource by working together with the trusted gatekeepers who can reach couples and educate them about how best to avoid repeating the painful mistakes they grew up with. A number of inroads have already been made.

CLERGY

One of our most promising and important resources for reaching couples are the clergy, who still perform 75% of all marriages and who are the trusted advisors to most premarital couples about how to enter marriage and create a loving home. Admittedly, however, clergy lack adequate formal training in how to teach couples what makes marriages work. Clergy of all denominations, however, have proven to be very responsive to supporting marriage education efforts, and to date have already adopted a variety of models from generating simple referral networks to themselves becoming trained leaders.

LOCAL, STATE, AND FEDERAL GOVERNMENT

Marriage is finally appearing on the public agenda thanks to the efforts of people like Theodora Ooms, Diane Sollee, and others who have joined in the effort to make more large-scale changes in social policy. As you might imagine, this can be a very sticky proposition. Nevertheless, the last two years have witnessed many state and local governments entertaining some form of legislation. Florida, for example, was the first state to sign its landmark Florida Marriage Preparation and Preservation Act into law just this year. This Act provides that couples who are considering divorce attend divorce education classes in order to forestall the decision to divorce when children are involved. Also, Couples who attend a marriage education class before they marry receive a marriage license fee reduction. And most importantly, classes in marriage skills education are now mandated for all 9th and 10th graders. Louisiana's Covenant Marriage offers the option of entering marriage with a deeper level of commitment to the marriage and to actively working on it if it falters; and many cities and counties are instituting "Community Marriage Policies" in which all clergy and civic officials agree to require couples to take a marriage education class before they will perform a wedding ceremony.

EDUCATIONAL INSTITUTIONS

Schools are perhaps the most important agent of preventive skills. High School programs are being widely developed and implemented across the country to educate teens about how to be in healthy relationships, and often include psychoeducational material about relevant topics such as teen pregnancy and teen parenting. My own pet peeve is that these skills need to be taught in elementary school, when a different process of primary learning is available to cast a dye in the psychological fabric of children. I want to see children embrace individual differences and learn healthy conflict-resolution skills before the option of violence and lessons of rugged individualism have a chance to throw our children off course.

PROFESSIONAL POINT PEOPLE

We need to educate and collaborate with those professionals who have meaningful contact with couples when they are most receptive to learning how to have successful marriages and become good parents. Efforts are now being made to reach parents during childbirth classes, such as Pam Jordan's lovely "Becoming Parents Program" (see handout) which combines Parent Education with Relationship Skills training using the PREP model out of the University of Denver. The British have developed an innovative model called "Brief Encounters", which formalizes a specific and time-sensitive protocol for health care providers to follow in order to both assess a couple's need for help, and direct them to the proper resources. A nice element of the Brief Encounters program, implied in its name, is the appreciation and respect for professionals' limited time.

PEDIATRICIANS (and lawyers)

Pediatricians are, really, the next in line, if not the last weigh station before the lawyers and mediators - who by the way are themselves joining the efforts to curtail the rate of divorce. For example, many lawyers are beginning to shift their focus from divorce mediation to "marriage mediation" in response to the many couples who express regret at not having learned the good communication skills they gained while in mediation before it was too late. Many judges and family courts are enforcing mandatory divorce education classes for couples with children. And some divorce lawyers, like Lynne Gold-Bikin, have become so frustrated from "cleaning up the messes," that they are shifting their efforts to teaching preventive skills to teens using a program called "Partners."

Pediatricians, however, are uniquely positioned to catch or family problems before they spread. We know for example that marital stress points exist at certain key junctures during family development; such as: the birth of a first child; during the teenage/adolescent years between 11 and 16; second marriages. These represent some of the most vulnerable times when the seeds of marital breakdown begin to germinate. Who can identify and reach parents at these junctures? Who is the point person? You, the pediatrician. Perhaps this is the "last chance" to catch a positive biopsy; to identify a potential cancer before it spreads and destroys a family. Perhaps with just one or two standard questions that are part of the office protocol or with a simple brochure, you could make a positive diagnosis that would save a family.

If indeed we now know what works to alter or prevent a downward spiral, namely: a) targeting our interventions specifically at the level of the COUPLE in order to maximize the healthiest possible outcomes for the CHILDREN; and b) what, specifically, to teach so that the healthy family can be self sustaining, and reap benefits that are robust, long term, and generalizable, I'd then respectfully suggest that with this knowledge you now have a new responsibility as healers of children to provide this important information to parents. I'd suggest that it's no longer OK to simply refer all family situations to a therapist. What's needed is a new treatment of choice for problems in which the parents are stressed and families are faltering.

So what specifically can the pediatric community do, given the paramenters of its trade and the severely limited time available for patient contact?

I'd like to offer a few suggestions and then open the floor to further discussion.

RECOMMENDATIONS

1. Enlarge role of Pediatrics to include family health. Pediatricians need to consider broadening their role to include caring for the health of the child-in-context. The healthy family is the bedrock of the child's overall wellness, and pathology or stress in the family that eventually erodes its integrity must be caught early to prevent the family from crumbling. The often disguised primary site of family problems is the Couple.

2. Understand what Relationship Education is. The pediatric community needs to be made aware of and educated about the new field of relationship education: to understand what relationship education is, what it accomplishes, and specifically, how it differs from psychotherapy.

3. Dissemination Pediatricians Materials and strategies need to be developed to disseminate this knowledge in a concise and accessible form to the pediatric community at large.

Patients Materials and strategies need to be developed to disseminate this knowledge in a concise and accessible form to the patient community by the pediatricians.

Theodora Ooms, Exec. Director of The Family Impact Seminar, has proposed a collaboration among marital researchers and practitioners to develop waiting room materials. For example, this might include items such as: -Ten Things You Need to Know About Marriage and Divorce -Twelve Things You Can Do To Keep Your Marriage Strong and Help Your Child -Where You Can Get Help to Make Your Marriage Better and Avoid Divorce

4. Early Detection Family-related pathogens need to be detected early, before children manifest them in symptoms and before the parental relationship is beyond repair. Most importantly, attention needs to be paid to the parental relationship at vulnerable developmental pressure points, such as: -the first child -the birth of another child -the years between 11 and 16 -remarriage -blending of families -illness and death of family members.

5. Develop Assessment Protocols Written and/or verbal assessment protocols need to be developed that can a) fit within the parameters of the standard office visit, and b) be sensitive enough to detect early signs of parental distress. This could range from handing out educational materials, to developing a standard set of questions that would ferret out the need for a referral. The Brief Encounters program in Great Britain offers an excellent model for how this can be efficiently integrated into the practices of primary health care professionals to help them provide information and preventive interventions, especially at times of change and crisis.

6. Develop a Relationship with Existing Programs and Resources in the Relationship Education Community The practice of pediatrics is varied and might require more than one standard protocol or approach. The following options should be considered in context of various practice dimensions: -Develop a relationship with, or endorse,one preferred, existing program. -Develop or adapt a program in house, that would be specific to your setting and population needs. -Compile local referral lists of available relationship education programs.

A word here on the economics of time and cost. Relationship Education programs vary significantly in terms of cost and time committment. They range anywhere from 0 to $1000.00 or more, and from a few classes to weekend retreats to 120 hour courses. Some urban communities are rich in access to available programs and some have nothing within their forseeable catchment area.

In terms of cost-effectiveness for their patients, the AAP might want to develop its own program that specifically covers relevant pediatric and parenting psychoeducational material along side the core relationship skills training. Pam Jordan's Becoming Parents Program would be easily adapted to this end.

Alternatively, the AAP might want to find a program that is compatible with managed care and therefore reimburseable through your patients' own health insurance. Janice Levine's The Couples Health Program is one such program specifically designed to comply with, and be reimburseable through managed care. As such it can be a covered benefit through your patients' health insurance.

MAKING A BROADER IMPACT:

7. Medical Role Models Our focus has been on your subspecialty as pediatricians. But as health care professionals the entire medical community needs to be made aware of this resource and eventually expand its charter to include assessment of family dysfunction and referral to relationship education programs. This would not only be in service to the overall health of the adult patient, but would have trickle-down effects on children that would break the cycle of future family breakdown.

8. Advocacy Pediatricians have a unique voice that is both trusted and powerful. The decision to embrace relationship education in service of supporting the two parent household is a statement of commitment that can have broad impact on policy and public awareness. The AAP should consider the influence its unified voice can have in positively affecting local, state, regional, and national governing bodies to support the health of the two parent home on behalf of the children, by demonstrating concretely the steps it is taking to insure healthy parental relationships. ---- The Coalition for Marriage, Family and Couples Education (CMFCE) is an excellent resource and clearinghouse of programs and professionals committed to supporting the two parent family through relationship education. We would be happy to collaborate with the AAP in forging new initiatives that could help advance our mutual goals.

---- The Coalition for Marriage, Family and Couples Education (CMFCE) is an excellent resource and clearinghouse of programs and professionals committed to supporting the two parent family through relationship education. We would be happy to collaborate with the AAP in forging new initiatives that could help advance our mutual goals.

copyright 1998

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