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Dimension II: Intensity—What is the proper dosage?
Proper dosage is an important part of any intervention; too little means ineffective treatment but too much can be wasteful or costly. In the pharmaceutical world, dosage is a constant issue in testing, approving, prescribing, and monitoring drug intervention. In clinical intervention with couples, many therapists are concerned that managed care policies artificially limit a consideration of proper “dosage,” or number of sessions needed to intervene effectively. In policy intervention, intensity of intervention is a critical issue at least because public resources to support policy intervention are scarce and must be allocated efficiently. However, it seems that marriage educators have given less attention to the issue of dosage. Coming from its roots in clinical psychology, most marriage education efforts probably lean to the more intense end of the intervention scale. Moreover, some scholars have expressed concerns that it may be unethical to conduct educational interventions without including a strong clinical diagnostic procedure that can identify and treat serious individual pathology (Gottman, 2002), suggesting the need for educational interventions to be more, not less intense. Others have hypothesized that marriage intervention for disadvantaged, low-income couples will need to be intensive to be effective (Dion et al., 2003. Nevertheless, we believe the question of effective dosage in marriage education is empirically wide open and in need of much more explicit attention in both practice and evaluation research.
Dosage has practical as well as clinical connotations. If a drug-treatment regimen for a specific health problem is too complicated, intrusive, or expensive, it will be less effective because patients will make mistakes or not follow fully the treatment plan or simply will not be able to afford it. This may hold true for marriage education intervention, as well. Another problem with dosage is that, while education is less resource intensive than therapy, it is usually targeted at less distressed couples who may not sense the immediate need for intervention. Indeed, this is one of the biggest problems facing marriage education. Even if it is beneficial for those who submit themselves to its treatment regimen, it reaches only a small proportion of the target population. A common response to this problem is to teach educators more effective marketing. Certainly, marriage educators could stand to learn to be better marketers of their services. But this does not override the need to explore the question of how much treatment is sufficient to produce meaningful learning and that will fall within the resource budgets of a substantial proportion of target “customers.”
In short, we are trying to set the stage for a more critical, creative, and flexible approach to marriage education that varies the dosage along a continuum of intensity. More comprehensive, intensive educational programs will always be a staple of marriage education. Even these staple programs, however, may be sensitive to the dosage issue. Already, several, established marriage programs have confronted the need to become more efficient, modifying their curricula to fit into fewer sessions or distilling the most valuable skills and ideas into a more condensed form. We believe the practice of marriage education needs to address the dosage issue more directly. And intervention researchers regularly need to include dosage as a design feature in their studies. It may be that lower-dosage interventions—especially if they are repeated across the marital life cycle—will yield better, long-term results—and reach more people—than one-time, intensive educational interventions.
Low-level. The field of public health is instructive as we think about intervention intensity. Public health practitioners strive to increase the general health of the population. They do so with educational interventions at many different levels of intensity. They provide intensive educational programs to help motivated individuals facing an immediate problem. But also included in public health efforts to promote healthy living are lower levels of intervention. Public awareness campaigns and public service announcements are cleverly marshaled to teach a basic, helpful strategy to reduce disease or promote well-being. Brief, readable brochures are placed in strategic spots in communities for consumers to read at their leisure. As part of a more comprehensive, population-level intervention plan to address the problem of marital health in our society, marriage educators need to explore the potential of lower-level interventions.
There are some noteworthy efforts beginning to emerge in the area of low-intensity interventions aimed at strengthening marriages. For instance, the organization First Things First (http://www.firstthings.org) of Chattanooga, Tennessee, as part of their community-wide marriage initiative, has used creative, low-level messages in the media and on billboards to teach some basic principles of healthy marriages and to invite further, formal education. They have also produced a pamphlet for wide distribution to young people about popular misconceptions about cohabitation: “What you need to know about living together.” Similarly, the National Marriage Project (http://marriage.rutgers.edu) has produced a short pamphlet, “Ten Things Teens Should Know about Marriage,” that challenges some contemporary, harmful myths about marriage, and gives concrete suggestions of things young adults can do to maximize their chances for a lasting, loving marriage. The impact of these brochures, of course, depends first on their wide circulation. The potential of these kinds of efforts to promote and sustain healthy marriages is, to date, uninvestigated. However, we believe that the documented successes with low-level public health campaigns (Hornik, 2002), such as smoking cessation (Glantz & Goldman, 1998), could be replicated in the marriage education arena.
Low-level interventions are likely to be most effective when communicating specific ideas, principles, or skills, or when addressing a specific problem. Low-level educational interventions need to find creative ways to address issues that attract people’s attention. Marriage educators commonly have professional training in the human behavioral sciences and are trained in a traditional services-provider framework that assumes clients will come to them rather than they go to wherever their clients are (Doherty & Carroll, 2002). Public health educators are more likely to have the experience needed to be effective with low-level interventions, and will need to be recruited to assist with these efforts.
Moderate-level. Providing specific cut-offs that distinguish low-level from moderate-level interventions may be impossible. Intervention dosage is likely a more fluid, or "natural concept" (Hegelson, et al., 1987), in which the boundaries that distinguish categories are relatively fuzzy (Rosch et al., 1976). Hence, categories are more continuous than discrete. We provide, however, some examples of moderate-dosage efforts, as well as some elements that tend to produce higher dosages. For instance, a one-day marriage-enhancement seminar does not demand the on-going time of a programmatic workshop but accommodates more content than low-level efforts. Also, flexible, self-guided interventions may fit well here. “Empowering Couples” (Olson & Olson, 2000) is a book based on the well known “PREPARE/ENRICH” program, and provides individuals who do not want to invest the time and money in formal classroom education a way to learn the material on their own. Larson's (2003) "The Great Marriage Tune-Up Book" shows promise as a self-guided intervention. And a pilot study of the flexible, self-guided "Couple CARE program in Australia (Halford et al., in press, 2004) provides evidence that these kinds of interventions can strengthen couple relationships. With the widespread availability of the Internet, web-based “programs” that capitalize on flexibility and self-guided participation may also fit in a category of modest-level education. For example, Utah State Family Extension Service has built a web-based, marriage preparation course, “Saying ‘I Do’: Consider the Possibilities,” www.utahmarriage.org]. Moderate-dosage interventions may be especially well suited to primary, preventative intervention that can attract individuals and couples who are not experiencing serious relationship problems and thus may lack immediate motivation for extensive program participation. A modest dosage is also more likely to fit into some settings better. Educational programs run through work or healthcare organizations whose primary missions lie elsewhere may match up well with moderate-dosage interventions.
The amount of information dispensed and time required to consume material are probably not the only criteria delineating a moderate-level intervention. Dishion (2003) has shown how shorter, less intensive interventions for parents of adolescents can attract more participants and still be effective. Financial cost to participants also will likely be modest at this level of marriage education. We can envision exceptions to this general rule, but again, it is important that many interventions be affordable to a large proportion of individuals and couples. More disadvantaged couples who otherwise would value participating in programs may not be able to do so unless low-cost or subsidized options are available. And remember that for many couples program participation will involve ancillary costs, such as a child care, transportation, and recommended program materials. Marriage educators should actively seek outside funding support for their programs to provide vouchers or scholarships for disadvantaged families.
Another relevant criterion that may delineate moderate-level marriage education is the amount of professional training required of intervention facilitators. Some scholars have implied that graduate-level, clinical training is essential for educators so that participants with serious problems can be diagnosed and recommended for further, personalized intervention (Gottman, 2002). We would argue, however, that moderate-level intervention try to avoid as much as possible this requirement because the more stringent the “licensing” requirements for instructors, the fewer educators there will be, which rations the amount of the service available and increases cost for clients. And at least one marriage educator-therapist-scholar has suggested that educators who are also therapists can bring clinical baggage as well as insight with them into the educational setting that may diminish their effectiveness (Stahmann, 2000). Moreover, as Stanley and his colleagues (2001) have shown in their research with the PREP program, lay practitioners can be very effective in part because they are well connected to the participants.
Moderate-dosage intervention should also be identified, we would argue, by some restrictions on the psychic “costs” required of participants. This observation is connected to Doherty’s (1995) levels-of-intervention framework. Levels 4 and 5 in his model involve participants delving into highly personal issues that can be psychologically difficult, either in a group counseling setting or individual therapy. While recognizing that even modest educational interventions can evoke unpredicted, psychological responses in some individuals, they nevertheless should be designed with caution to minimize these responses, and should inform participants of available services for those who desire further help. There are good reasons, we believe, for marriage education to offer a range of services that steer clear of psychic landmines. First, having to tread through dangerous mind fields undoubtedly will scare many potential participants away from participating in what could otherwise be a valuable educational experience. A second, related reason is that psychologically intensive interventions are probably less inviting to men, who already are more suspicious of the value of relationship education, and who are more uncomfortable with public disclosure of their personal and emotional lives. Similarly, some work suggests that disadvantaged, lower-income couples are less comfortable with self-disclosure of the intimate and emotional aspects of their lives (Dion et al., 2003), which is a common pedagogical process in more intensive interventions.
A final criterion relevant to delineating moderate-level intervention may be the scope of the curriculum. Some moderate interventions may try to condense a wide array of topics into “nuggets of truth.” But there is also a need for marriage education that focuses on just one or two topics. For instance, personal financial debt is a rising, serious problem impacting marital quality and stability. Even good communication and problem-solving skills may fray in the face of mounting financial stress. Similarly, such contemporary issues as preventing indulgence in Internet pornography and virtual affairs may be difficult to cover adequately as just one of many topics embedded in a seminar. Interventions aimed at couples with a unique circumstance such as couples who spend considerable time apart due to employment travel or couples who are caring for an elderly parent may be useful as well. Half-day seminars or other formats focused on specific problems would fill an important niche in a comprehensive ecosystem of marriage education offerings. They may also be better attended because they are more likely to hit a concrete problem that many couples can label and may be worrying about in the present moment.
High-level. Educational offerings with a high-level dosage will also be crucial to a comprehensive marriage education strategy. Higher levels of marriage education may allow for in-depth exploration of a fuller range of topics. It is also may allow for individuals and couples to explore personal issues at deeper levels with trained facilitators. A hard and fast delineation of what constitutes a high dosage of marriage education will be somewhat arbitrary. Some relevant factors would include whether participation requires an on-going commitment of significant time, a financial cost that requires budgeting, the depth of personal, psychological exploration, and the amount of professional training required of program leaders. Again, some suggested examples may help to clarify. For instance, the “PAIRS” program (DeMaria & Hannah, in press) requires of participants a commitment of 120 classroom hours and a significant tuition. “Becoming Parents” is a marriage and parenting curriculum adapted from the PREP model targeted specifically to couples going through the transition to parenthood (Jordan, Stanley, & Markman, 1999). The time commitment is considerably less than PAIRS but still more than minor—27 classroom hours plus some “homework”—that probably crosses a resource threshold that feels like “a lot” for most couples. Moreover, the intervention involves extensive coaching of communication and problem-solving skills by licensed instructors who must go through an extensive (and moderately costly) two-day training workshop. Accordingly, we would place this program in the high-dosage category.
Some marriage educators designing interventions explicitly for disadvantaged, lower-income couples have included “family coordinators” to supplement and enhance educators’ efforts. The role of these individuals would be to support program participants by offering encouragement, helping them to meet logistical needs for program involvement, detecting problems that increase family stress (e.g., employment skills, substance abuse), and linking participants to helpful services. In effect, these coordinators work to minimize problems that diminish the potential of the intervention to strengthen couple relationships. While this approach adds to the intensity of the intervention requires additional resources to implement, it likely increases the power of the intervention.
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