Premarital Education and Later Relationship Help-seeking

Abstract

Despite evidence that empirically supported couple therapies improve marital relationships, relatively few couples seek help when they need it. Low-income couples are particularly unlikely to engage in relationship interventions despite being at greater risk for distress and dissolution than their higher-income counterparts. The present study aimed to clarify how premarital education influences couples’ progression through different stages of later help-seeking, as identified in prior research. Using five waves of self-report data from a sample of 431 ethnically diverse newlywed couples living in low-income neighborhoods, analyses revealed that wives who received premarital education later considered seeking therapy at a higher level of relationship satisfaction and lower level of problem severity than those who did not receive premarital education, though this was not true for husbands. Wives who received premarital education were also more likely as newlyweds to say that they would seek therapy if their relationship was in trouble, though husbands were not. Spouses who considered seeking therapy were more likely to follow through with participation if they had received premarital education, whereas if they had not received premarital education they were more likely to consider seeking therapy without following through. Similarly, among couples who received therapy, those who also received premarital education sought therapy earlier than those who did not receive premarital education, though not at a higher level of relationship satisfaction. Taken together, these results suggest that participation in premarital education is linked with later help-seeking by empowering couples to take steps throughout their marriage to maintain their relationship.

Although empirically-supported couple therapies reliably improve relationships (e.g., Baucom, Atkins, Rowe, Doss, & Christensen, 2015), relatively few couples seek help when they need it (Halford, Kelly, & Markman, 1997). Efforts to increase rates of help-seeking among couples are complicated by the fact that both spouses are required to participate, and men in particular appear to be less interested in seeking therapy and slower to pursue treatment once the decision is made (Doss, Atkins, & Christensen, 2003; also see Addis & Mahalik, 2003). The present study aims to understand how couples naturally seek help and how prior experience with premarital education might contribute to this process. We focus specifically on help-seeking among couples living with low incomes — couples who are less likely to participate in relationship interventions than middle-class couples (Halford, O’Donnell, Lizzio, & Wilson, 2006; Sullivan & Bradbury, 1997) despite being at greater risk for distress and dissolution (e.g., Bramlett & Mosher, 2001).

Increasing uptake of couple therapy may pivot on couples’ earlier experiences with premarital education. Although the long-term effectiveness of premarital education remains a topic of debate (Bradbury & Lavner, 2012; Cowan & Cowan, 2014), these programs are widely available and very well-received by couples (Halford & Bodenmann, 2013). To the extent that premarital education does improve relationships, we would predict that couples’ newly established skills and awareness should reduce their need for later treatment. Paradoxically, however, couples who receive premarital education appear to be more likely to seek couple therapy compared those who do not receive it, a possibility suggested by early developers of premarital education programs (Halford, Markman, Kline, & Stanley, 2003; Stanley, 2001) and later demonstrated empirically (Williamson, Trail, Bradbury, & Karney, 2014). Described as the gateway effect, this finding suggests that participation in premarital education induces later help-seeking by empowering couples to maintain their relationship and directing them to resources that enable them to do so. This view implies that increasing participation in premarital education will lead to greater rather than lesser eventual use of couple therapy, perhaps at a time when relationships are still functioning relatively well. We build on this premise by undertaking a replication of the gateway effect and, more critically, by specifying how participation in premarital education might affect the process by which couples later seek therapy.

Drawing from Doss, Atkins, and Christensen’s (2003) model of couple help-seeking, we propose that participation in premarital education will operate upon the progression toward help-seeking in three ways. In the initial stage, partners first recognize and acknowledge friction in the relationship that they cannot readily repair on their own. Here, premarital education might increase couples’ awareness of relationship problems earlier in their marriage, at a time when these problems may be more easily resolved. Consistent with this possibility, premarital education programs appear to heighten awareness of communication deficits targeted specifically within those programs (e.g., couples trained to resolve conflict appear to have greater awareness of unresolved conflict; Rogge, Cobb, Lawrence, Johnson, & Bradbury, 2013). In the second stage, partners consider what to do about their difficulties and whether or not couple therapy could be a solution for them. Couples with prior experience in premarital education should be more likely to consider counseling to be a viable option, compared to couples who had not experienced premarital education. Finally, in Doss et al.’s (2003) third stage, partners actively participate in couple therapy. At this point we might expect that premarital education participants would feel less threatened by therapy, and more inclined to see value in more intensive intervention, and therefore take steps as a couple to seek it out.

In this study we test three predictions about how participation in premarital education will covary with couples’ progression through these stages of help-seeking. First, to examine whether premarital education is associated with heightened awareness of relationship problems, we test whether couples who receive premarital education consider seeking therapy when their relationship satisfaction is higher and their levels of relationship problems are lower, compared to couples who did not receive premarital education. Second, to examine whether premarital education is associated with considering treatment, we test whether couples who receive premarital education are more likely as newlyweds to report that they will seek professional help and to report that they have considered seeking therapy after marrying. Third, to examine whether premarital education covaries with help-seeking behaviors, we test whether premarital education receipt is associated with an increased likelihood that couples who consider seeking therapy actually receive it, and whether those who receive premarital education convert from considering to seeking therapy more quickly than couples who did not receive premarital education.

We conduct these tests using five waves of self-report data, collected over the first four-five years of marriage from a sample of 431 ethnically diverse couples living in low-income communities. We focus on this important segment of the population in response to calls for greater diversity in research on couples (e.g., Karney, Kreitz, & Sweeney, 2004; Rogge et al., 2006) and more specifically because enhancing relationships among people living with sociodemographic disadvantage can stabilize the financial status of people who, were they to divorce, would be subject to even more severe forms of poverty and especially poor child outcomes (e.g., Amato, 2000). More pointedly, the gateway effect is especially strong for high-risk populations, including African American couples and couples living with lower incomes and less formal education (Williamson, Trail, Bradbury, & Karney, 2014). Understanding how premarital education may increase use of couple therapy is therefore likely to have greater impact on vulnerable couples than on couples with more economic resources.

Method

Sampling

The sampling procedure was designed to yield first-married newlywed couples in which both partners were of the same ethnicity (Hispanic, African American, or Caucasian), living in neighborhoods with a high proportion of low-income residents in Los Angeles County. Recently married couples were identified through names and addresses on marriage license applications. Addresses were matched with census data to identify applicants living in low-income communities, defined as census block groups wherein the median household income was no more than 160% of the 1999 federal poverty level for a 4-person family. Next, names on the licenses were weighted using data from a Bayesian Census Surname Combination, which integrates census and surname information to produce a multinomial probability of membership in each of four racial/ethnic categories (Hispanic, African American, Asian, and Caucasian/other). Couples were chosen using probabilities proportionate to the ratio of target prevalences to the population prevalences, weighted by the couple’s average estimated probability of being Hispanic, African American, or Caucasian. A total of 3,793 couples were contacted through the addresses they listed on their marriage licenses, and offered the opportunity to participate in a longitudinal study of newlywed development. Of the 3,793 couples contacted, 2,049 could not be reached and 1,522 responded to the mailing and agreed to be screened for eligibility. Of those, 824 couples were screened as eligible, and 658 of them agreed to participate in the study, with 431 couples actually completing the study.

Participants

The sample comprised 862 spouses (431 couples) identified with the above procedures. At baseline, marriages averaged 4.8 months in duration (SD = 2.5); 38.5% of couples had children. Mean ages were 26.3 (SD = 5.0) for women and 27.9 (SD = 5.8) for men. Median household income was $45,000. Twelve percent of couples were African American, 12% were Caucasian, and 76% were Hispanic.

Procedure

At baseline (T1), couples were visited in their homes by two interviewers who took spouses to separate areas to describe the IRB approved study, obtain informed consent, and orally administer self-report measures. Interviewers returned at 9 months (T2), 18 months (T3), and 27 months after baseline (T4) and administered the same interview protocol. Couples who reported that they had divorced or separated did not complete the interview. Following each interview couples were debriefed and paid $75 for T1, $100 for T2, $125 for T3 and $150 for T4. At Time 5 (T5), which occurred an average of 22 months after T4, all intact couples and spouses from dissolved couples were contacted via telephone. Each individual was compensated $25 for the T5 interview. Data collection took place between 2009 and 2013 for T1 through T4. Collection of T5 data occurred in February and March 2014.

Over the course of the study, 93 couples (21.6%) were lost to attrition while 55 couples (12.8%) divorced or legally separated. The average number of waves completed was 4.08 out of 5; 241 couples completed all five waves, 89 couples completed four waves, 36 couples completed three waves, 24 couples completed two waves, and 41 couples completed only baseline. Missing data was handled by using all available data for analysis. Thus, if a couple completed fewer than all five waves of assessment their cumulative variables (i.e., consideration of couple therapy, receipt of relationship counseling) were calculated based upon the waves at which they provided data.

Measures

Premarital Education

At T1 participants were asked “Did the two of you receive any sort of relationship education or classes before you got married?” Reponses were coded as 0 = no and 1= yes. Couples were coded as receiving premarital education if either spouse responded yes. In 86% of couples, partners agreed on whether or not they received premarital education. In 7% of couples the husband reported that they received premarital education but the wife did not, and in 7% of couples the wife reported that they received premarital education and the husband did not.

Help-seeking Intentions

Participants’ intentions to seek therapy in the future if they were to experience relationship difficulties were measured with two items administered at T1. Participants were asked; “If you and [SPOUSE NAME] were having marital difficulties, what would you do about it?” Responses to the option “get therapy” were coded as 0 = no and 1 = yes. Next participants were asked; “If you needed to, who would you talk to about your marriage?” Individuals who responded yes to “professional counselor” and/or “other professional (doctor, social worker, etc.)” were coded as 0 = no and 1 = yes.

Consideration of Couple Therapy

Whether participants had considered seeking help for their relationship was assessed by asking “In the last nine months, did you ever consider seeking or receiving counseling for this relationship?” at T2 – T5. Responses were coded 0 = no and 1 = yes at each time point and then collapsed across time points, such that an individual who responded yes at any time point was coded as 1 and individuals who responded no at all time points were coded as 0.

To calculate the level of relationship satisfaction and problem severity at which participants considered seeking therapy, we used the relationship satisfaction and problem severity scores reported at the time point prior to when they reported considering therapy. For example, if an individual reported at T2 that they had considered seeking therapy at some point over the past 9 months, their relationship satisfaction and problem severity scores from T1 would be assigned as the level at which they considered therapy.

Relationship Counseling

At T2 – T5 participants were asked “In the last nine months, have you received counseling for this relationship?” Reponses were coded as 1= yes and 0 = no. Couples were coded as receiving counseling if either spouse responded yes. In 86% of couples, partners agreed on whether or not they received counseling. In 5% of couples the husband reported that they received counseling but the wife did not, and in 9% of couples the wife reported that they received counseling and the husband did not.

To calculate the level of relationship satisfaction and problem severity at which participants sought counseling, we used the relationship satisfaction and problem severity scores reported at the time point prior to when they reported receiving counseling. For example, if an individual reported at T2 that they had received counseling at some point over the past 9 months, their relationship satisfaction and problem severity scores from T1 would be assigned as the level at which they received counseling.

Relationship Satisfaction

Relationship satisfaction at each time point was assessed by summing responses on an eight-item questionnaire. Five items asked how satisfied the respondent was with certain areas of their relationship (e.g., “satisfaction with the amount of time spent together”), and were scored on a 5-point scale (ranging from 1 = Very dissatisfied to 5 = Very satisfied). Three items asked the degree to which the participant agreed with a statement about their relationship, (e.g., “how much do you trust your partner”) and were scored on a 4-point scale (1 = Not at all, 2 = Not that much, 3 = Somewhat, 4 = Completely). Coefficient α exceeded .70 for husbands and wives across all time points.

Relationship Problem Severity

At T1–T5 participants rated how much each of 28 common areas of marital disagreement (e.g., management of money, relationships with in-laws; adapted from Geiss & O’Leary, 1981) was a source of difficulty/disagreement in their relationship on a scale of 0 to 10, such that higher scores reflected issues that caused frequent or intense conflict. To measure the maximum severity of the relationship problems, each participant’s maximum problem rating (possible score 0–10) across the 28 items was assigned as their problem score.

Results

Descriptive Statistics and Preliminary Analyses

Table 1 presents descriptive statistics for the study variables. Roughly 45% of couples received premarital education, which is relatively high in comparison to other studies of premarital education (e.g., 29% reported by Halford and colleagues (2006)). At the time of marriage, 35% of husbands and 41% of wives reported that they intended to “get therapy” if their relationship were to become troubled, whereas only 26% of husbands and 25% of wives reported that they would talk to a “professional counselor.” Over the course of their marriage, 40% of husbands and 51% of wives considered seeking therapy at some point; 27% of couples went on to actually receive therapy.

Table 1.

Base rates of key study variables

	Husband	Wife
Received premarital education	45.2%	45.2%
Intend to get therapy	34.8%	41.3%
Intend to talk to a professional	25.8%	25.1%
Considered seeking therapy	39.7%	51.3%
Received therapy	26.7%	26.7%

Note. N = 431 couples.

Couples who did and did not receive premarital education did not differ in ethnicity (t(429) = −1.47, p = .141). However, they did differ on household income (t(425) = −2.53, p = .012) and religiosity (husbands, t(429) = −6.15, p < .001; wives, t(429) = −6.96, p < .001), with couples who received premarital education reporting higher level of income and religiosity than couples who did not receive premarital education. Additionally, couples who did and did not receive premarital education did not differ in their likelihood of completing all five waves of assessment (χ² = 1.127, p = .289).

Initial levels of relationship satisfaction (husbands: t(429) = 0.88, p = .092; wives: t(429) = −1.30, p = .916) and problem severity (husbands: t(429) = −0.08, p = .762; wives: t(429) = 1.41, p = .982) did not differ between couples who did and did not receive premarital education.

Stage 1: Premarital Education and Awareness of Relationship Problems

Wives who received premarital education reported considering therapy at a higher level of relationship satisfaction (32.4 vs. 31.0; t(206) = −2.53, p = .012), and lower level of relationship problem severity (7.66 vs. 8.22; t(206) = 1.99, p = .047) than those who did not receive premarital education. Husbands, however, considered seeking therapy at the same levels of relationship satisfaction (t(161) = −1.01, p = .313) and relationship problems (t(161) = 0.60, p = .553) regardless of whether or not they received premarital education.

Stage 2: Premarital Education and Intentions to Seek Help

Wives in couples who received premarital education were significantly more likely as newlyweds to say that they would seek therapy if their relationship was in trouble (χ²(1) = 9.24, p = .002), but they were not more likely to say that they would talk to a professional counselor if their relationship was in trouble (wives: χ²(1) = 1.88, p = .171).

Husbands reported that they would seek therapy or talk to a professional counselor if their relationship was in trouble at the same rates, regardless of whether they received premarital education (χ²(1) = 0.53, p = .818 and χ²(1) = 0.38, p = .538, respectively).

Moreover, couples who received premarital education were not more likely to consider seeking therapy over the first 58 months of marriage (husbands: χ²(1) = 1.11, p = .291, wives: χ²(1) = 3.00, p = .083).

Stage 3: Premarital Education and Engagement in Later Help-seeking

Couples who received premarital education were significantly more likely to receive therapy than those who did not receive premarital education (36.3% vs 23.1%, χ² = 8.22, p = .004), thus replicating the gateway effect (Williamson, Trail, Bradbury, & Karney, 2014) that forms the basis for this work.

The association between considering therapy and seeking therapy was also moderated by receipt of premarital education in the predicted manner: when spouses considered seeking therapy, they were more likely to actually do so if they had received premarital education, whereas if they had not received premarital education they were more likely to consider seeking therapy without actually following through (husbands: 61% versus 47%; χ²(1) = 3.79, p = .03, wives: 54% versus 42%; χ²(1) = 3.31, p = .034).

Similarly, among couples who received therapy, those who also received premarital education sought therapy earlier than those who did not receive premarital education (wave 3.3 [~16 months into marriage] vs. wave 3.9 [~22 months into marriage]); t(113) = 2.50, p = .014, d = .48). However, among couples who received therapy, those who did and did not receive premarital education did not differ in the level of relationship satisfaction (husbands: t(108) = −0.003, p = .998; wives: t(109) = −1.42, p = .157) or problem severity (husbands: t(108) = 0.746, p = .746; wives: t(109) = 1.84, p = .069) at which they sought therapy.

Discussion

Couples sometimes turn to couple therapy to improve their relationship, and those who participate in premarital education prior to marriage appear especially inclined to do so (Williamson, Trail, Bradbury, & Karney, 2014). We replicated this gateway effect, while also adopting Doss et al.’s (2003) three stage model in an effort to clarify how participation in premarital education might contribute to couples’ tendencies to consider, seek, and engage in couple therapy. With longitudinal data collected from a relatively large sample of couples living in low-income communities, we demonstrate that premarital education participation covaried with the three stages in the help-seeking process. As we outline below, these findings allow us to highlight specific ways in which premarital education programs might be reconfigured to connect couples with couple therapies as they navigate the early, high-risk years of marriage.

Participation in premarital education was associated, first, with a tendency among wives to consider seeking therapy at higher levels of relationship satisfaction and lower levels of problem severity. This finding is broadly consistent with the view, outlined by Rogge and colleagues (2013), that premarital education may inadvertently sensitize participants to shortcomings in their relationship; the new information added here is that partners may be able to contemplate these shortcomings while the partnership is still relatively strong and see them as a catalyst for efforts to improve their relationship through outside help. This effect, if replicated, underscores the value of premarital education as not simply a gateway to later treatment but as an inducement to healthy relationship maintenance. As others have argued (e.g., Halford, Wilson, Lizzio, & Moore, 2002), a key element in healthy relationships may be an active and intentional willingness to maintain the relationship when it is going reasonably well (as distinct from a global desire for the relationship to persist; see Schoebi, Karney, & Bradbury, 2012), and premarital education modules might be developed to encourage this higher-order capacity.

We find mixed evidence for our second prediction, that participation in premarital education would covary with newlyweds’ intentions to seek treatment or with their subsequent reports of considering treatment. Wives in couples who received premarital education were more likely to say that they would seek therapy, but were not more likely to say that they would talk to a professional counselor (while husbands were no more likely to endorse either). This suggests that wives may define “therapy” to include more than just couple therapy delivered by a professional therapist/counselor, and instead may be seeking counsel from others, such as clergy. This latter possibility is supported by the finding that wives who received premarital education reported a higher level of religiosity than those who did not, suggesting that these couples may have received the premarital education in a religious setting and intend to return to that setting for further counseling if necessary. However, husbands who received premarital education also reported higher levels of religiosity, but were no more likely to say that they would seek therapy for their relationship, suggesting that perhaps they did not see this as a source for future therapy. These are only speculations at this point, as the current study was unable to ascertain the source or type of counseling that couples engaged in. This leaves open the possibility that couples were receiving something other than couple therapy delivered by a therapist, including counseling delivered by a clergy member. Future investigations are needed to determine what types of counseling couples are engaging in, and the effectiveness of these naturally occurring interventions. We suggest that providing couples with information on how to be critical consumers of relationship interventions could be a foundational element in premarital education, capitalizing on premarital education’s ability to facilitate later help-seeking, and steering couples toward resources most likely to be helpful to them.

Finally, we demonstrate that participation in premarital education is associated with a greater likelihood that couples who had considered seeking treatment would actually follow through to receive it, and would receive it slightly earlier in their relationship, compared to those who did not participate in premarital education. Thus, whereas premarital education may not facilitate consideration of help-seeking directly, experience with premarital education appears to combine with a willingness on the part of couples to consider treatment and thereby convert intentions into actions. This too suggests an elaboration of the gateway effect, in that premarital education may have little bearing on actual treatment uptake if couples see little need for it; however, premarital education may become consequential among those who are beginning to wonder about whether an intervention could help them. Whether couples who have participated in premarital education have more information about who to contact for treatment, or experience less anxiety and discomfort when doing so, cannot be determined from this study. Future investigations into the mechanism through which premarital education helps convert help-seeking intention into action are warranted, as this is a promising area for increasing uptake of couple interventions more broadly.

Results of the current study highlight a possible gender difference in how premarital education is experienced. On individual-level variables, including consideration of therapy and intentions to seek therapy, associations were found only for wives, whereas participation in premarital education was not associated with an increase in any individual-level help-seeking variable for husbands. Husbands, however, did experience an increased likelihood of participating in relationship counseling after receiving premarital education, but given that decisions to pursue relationship counseling are typically dyadic in nature, this effect might be driven primarily by their wives (as women are more likely to be the partner who initiates therapy; see Doss, Atkins, & Christensen, 2003). Additionally, although husbands did not experience an increase in consideration of relationship counseling after attending premarital education, the link between premarital education and relationship counseling was moderated by husbands’ consideration of therapy. Thus, when wives reach the point at which they have decided to initiate therapy, their request may be most effective if their husbands have not only thought that they may need help for their relationship, but have also had prior experience with a relationship intervention.

Several factors affect interpretation of these results. While collecting data from ethnically diverse, first-married, newlywed couples living in low-income communities is a strength of the study, it also limits our ability to generalize our findings to other populations, including established, unmarried, remarried, and same-sex couples. Additionally, the measure of relationship satisfaction used in the current study has not been used in other samples, limiting our ability to compare this sample to others in the literature.

Second, our assessment of premarital education and relationship counseling was crude as it provided no information about the content of those programs or the setting in which they were delivered; thus we have measured all types of naturally occurring premarital education that couples may access in the community. Additionally, because we used a correlational rather than an experimental design, all results should be interpreted with caution. Couples were not randomized and therefore may have self-selected into premarital education because of their desire for a relationship intervention, or may have been required to attend by their religious organization. Couples who self-select into premarital education may differ from couples who choose not to attend on a number of dimensions, including increased comfort with help-seeking in general, prior positive experience with psychological interventions, and being more psychologically-minded. Future investigations into factors that predict participation in various types of premarital education and couples therapy, along with experimental studies of premarital education, will help determine how much these factors may be playing a role in the link between various types of relationship help-seeking.

Third, the present study’s reliance on self-report data might bias the findings we obtained as couples might not have remembered or reported correctly whether they received premarital education or therapy or whether they had considered seeking help over a given wave of the study. More frequent assessments could more accurately capture thoughts about help-seeking, including fluctuations in these thoughts and behaviors that may have occurred during the nine months between assessments.

Finally, the current data do not allow us to tease apart the reasons that may underlie the effects and non-effects of premarital education on the three help-seeking stages. Possible reasons include increased comfort with help-seeking, increased belief that outside intervention could be helpful to their relationship, and increased awareness of how to go about seeking help. Future research may aim to clarify why couples who received premarital education may be more likely to seek therapy.

Notwithstanding these limitations, the present study lends confidence to the gateway effect and adds new perspective on how premarital education may and may not promote later help-seeking and relationship well-being. While premarital education is certainly a heterogeneous enterprise, these results, together with the replicated finding that premarital education is associated with increases in later help-seeking, suggest that increasing access to premarital education and further increasing these programs’ focus on maintaining the relationship in the future may serve to empower more couples to identify problems in their relationships and seek help for them before it is too late.