More than One Way to Get There: Pathways of Change in Coparenting Conflict after a Preventive Intervention KENNETH EPSTEIN* MARSHA KLINE PRUETT† PHILIP COWAN‡ CAROLYN COWAN‡ LISA PRADHAN† ELISABETH MAH† KYLE PRUETT§
This study explored pathways of change in the levels of conflict couples experienced after Supporting Father Involvement, an evidence-based, prevention-oriented couples and parenting intervention that included a diverse low-income and working class group of participants. Pathways of change were examined for couples with baseline conflict scores that were initially low, medium, and high. The growth mixture model analysis found that the best-fitting model for change in couples’ conflict was represented by three distinctly different change patterns. The intervention was most successful for High-Conflict couples. This finding contributes to a growing literature examining variations in how relationships change over time and the process of change, especially for couples in distress. This study supports further investigation into the impact and costs associated with universal interventions versus those that target specific groups of higher risk families. Keywords: Couples; Conflict; Marriage; Change; Prevention; Coparenting Fam Proc 54:610–618, 2015
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here is a normative decline in couple relationship quality after partners become parents, with potentially negative consequences for children. This transition presents an optimal time to offer interventions aiming to strengthen parents’ relationships and provide them with resources to deal with disagreements before they escalate out of control. In recent years, preventive interventions for couples early in their relationship (Markman, Stanley, & Blumberg, 2010) or in early parenthood (Feinberg, Jones, Kan, & Goslin, 2010) have attempted to reduce conflict and increase collaboration with the hope that the impact on the coparenting couple would provide benefits for their children. Most of these intervention programs have been “universal” in that recruitment was without regard for demographic or psychological risk status, with more recent attempts to target low-income parents (Cowan, Cowan, & Knox, 2010). Single studies and meta-analyses indicate that universal programs show small but statistically significant effects on the parents *Psychiatry, University of California San Francisco, San Francisco, CA. † School for Social Work, Smith College, Northampton, MA. ‡ Psychology, University of California Berkeley, Berkeley, CA. § School of Medicine, Yale University, New Haven, CT.
Correspondence concerning this article should be addressed to Kenneth Epstein, Psychiatry, University of California San Francisco, 1380 Howard St., San Francisco, CA 94103. E-mail: [email protected]. 610
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(Hawkins, Stanley, Blanchard, & Albright, 2012), although there has been some recent controversy about this conclusion—attributable mostly to disappointing results of a largescale randomized trial with low-income unmarried couples (Cowan & Cowan, 2015). The impact of participation in couples groups has been measured in terms of average pre-postintervention differences between experimental and control groups in relationship satisfaction and self-reported or observed communication patterns, with an emphasis on reductions in parental conflict. Because couples have been recruited without regard to initial conflict levels, the results have been interpreted as if mean differences between experimental and control participants apply to couples who enter the intervention at all points along the conflict continuum. Our aim was to examine this assumption more carefully by tracing pathways of change in conflict from before to after participation in an intervention for couples whose baseline conflict scores were low, medium, or high. The intervention was a third iteration of Supporting Father Involvement (SFI), after two prior intervention trials revealed positive effects. In the first trial (Cowan, Cowan, Pruett, Pruett, & Wong, 2009), 279 Mexican American and European American lowincome couples were randomly assigned to a single informational meeting (low-dose control) or a 16-week group for fathers (mothers attended twice) or for couples, all led by the same clinically trained male–female teams. Fathers and mothers who participated in the one-time meeting showed no positive changes and some negative changes at the 18-month follow-up assessment: Their satisfaction as a couple declined significantly, and they reported increased externalizing and internalizing behaviors in their children. By contrast, participants in both the fathers and couples groups showed significant increases in fathers’ involvement in care of the children and no increase in children’s behavior problems over the course of the study. Relationship satisfaction for control and fathers group participants declined, while mothers and fathers from the couples groups reported no decline in satisfaction as a couple as well as significant reductions in parenting stress. In the second trial (Cowan, Cowan, Pruett, Pruett, & Gillette, 2014), 236 Mexican American, African American, and European American couples participated in 16-week couples groups. The investigators chose not to conduct another RCT because the earlier study had shown that the low-dose control couples and their children declined in adaptation, and the fathers group was not as effective as the couples group. Of 11 measures in this second trial, 10 revealed positive baseline to 18-month follow-up changes in the partners, including a significant reduction in behaviors associated with intimate partner violence (e.g., yelling, throwing things, insulting, slapping, hitting) when discussing issues on which they disagreed. As in other couples interventions, results of SFI to date have been reported in terms of average amounts of change across the sample. Little is known about the different patterns of change for individuals and/or couples as a result of intervention. Until recently, most couples group intervention studies have been limited to middle-class couples not selected on the basis of reported relationship difficulties or exposure to stressful environmental and situational factors that contribute to marital conflict. Understanding varying patterns of change in couple conflict in community samples with varying conflict levels as the intervention begins could contribute to the development of accessible, effective treatment options. The current study focuses on Mexican American, African American, and European American coparents in five diverse low-income and working class communities. The couples were primarily in the first decade of marriage and had young children, which placed them at higher risk for conflict and/or divorce. The study examined patterns of change in conflict levels from before to after participation in the 16-week SFI intervention, to establish whether couples who come to the intervention with low-, mid-level, or highconflict levels traversed similar or different pathways over time. This is an exploratory Fam. Proc., Vol. 54, December, 2015
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study, as to our knowledge there have not been prior studies of preventive interventions for couples with a range of conflict levels examining differential change in conflict as a function of initial conflict levels.
METHOD Supporting Father Involvement is an intervention that takes a group approach to strengthening couple, coparent, and parent–child relationships and increasing fathers’ hands-on involvement in caring for their children. The program was located in Family Resource Centers in five California counties (San Luis Obispo, Santa Cruz, Tulare, Contra Costa, and Yuba). Once both parents agreed to participate, partners were randomly offered either an immediate group or a 6-month delayed one (comparison condition). The curriculum, adapted by Pruett, Ebling, Cowan, and Cowan (2005) based on previous interventions developed by Cowan, Cowan, and Heming (2005), is based on a model of risk and protective factors in five theoretically derived and researched domains of family life, including (a) individual distress and well-being; (b) patterns of couple- and parent–child relationships across three generations; (c) quality of the parents’ relationship as couples or coparents; (d) quality of each parent’s relationship with their child(ren); and (e) the family’s life stressors and social support outside the immediate family (Cowan et al., 2009). Topics pertaining to the domains were explored in a mix of group discussions, structured didactic presentations, role-plays, and exercises to illustrate various principles of effective communication, coparenting, or family relationships. SFI follows a manual with curriculum modules that give group leaders and participants the flexibility and opportunity to explore personal issues that are raised in the moment and appropriate for participants of different cultures. Approximately 42% of families were referred by Child Welfare staff; each set of parents was assessed both by Welfare Department and SFI staff to establish that there was not current violence or abuse in the family and it was deemed safe to include both partners in a couples group setting. For all couples, regardless of referral source, the SFI assessment included a joint couple interview followed by separate interviews of each partner focused on specific questions about whether there was past and/or current intimate partner violence, and whether each partner felt safe to return home after the interview. Of the couples, 20% had been referred for domestic violence, 32% for child neglect, and 48% for different categories of child abuse. Couples with current violence, child abuse, or neglect were referred for other community services. Couples with no current violence or abuse, who felt safe with their partner, were accepted into the study. Parents who reported that they were suffering from a major mental illness or severe substance difficulties that compromised their daily functioning were referred to other services. In addition to their assignment to either immediate or 6-month delayed intervention groups, every family received case management throughout the study, which involved regular contact to help families access and navigate community services, as needed.
Participants Participants were recruited by direct referrals from the county Child Welfare Agency, other community family service agencies, talks at local community organizations, advertisements in local media, and information tables set up at events in the target communities (Pruett, Cowan, Cowan, & Pruett, 2009). Criteria for inclusion were that both parents agreed to participate and had a youngest child between birth and age 11. At least one parent was a biological parent of the child and the two parents planned to raise the child together. www.FamilyProcess.org
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At baseline, 463 participants were randomly assigned to immediate or delayed participation in one of the intervention groups. Of these, 371 participated in either the immediate or delayed intervention and completed the postintervention assessment; 311 completed the follow-up 18 months after entering the study. The missing data problem was accommodated by use of full information maximum likelihood and the expectationmaximization (EM) algorithm (Muth en & Shedden, 1999). This method assumes that the missingness was ignorable (Enders, 2010) and therefore did not bias the results. The majority of fathers and mothers who enrolled identified as Hispanic/Latino (51%), most identifying as Mexican (97%), or European American/White (34%). Over two thirds of the fathers had a high school diploma/GED or less; just under two thirds of the mothers had graduated from high school or less. Another one third of parents had some college or technical school training. A few parents had college degrees. Two thirds (66.4%) of the parents were born in the United States and 33.6% were born in another country, primarily Mexico (97%). All spoke English, although Spanish was the primary language for about one third of the Mexican families, and some assessments and groups were conducted in Spanish. The mean age of fathers and mothers was 33.5 (SD: 8.67) and 31 (SD: 8.01), respectively, and of the families’ youngest child, 3.4 years old (SD: 3.11). Average annual income was less than 18k for fathers and about 11k for mothers.
Procedures Data were collected at: preintervention (baseline), postintervention (2 months after the intervention groups ended), and follow-up (18 months after study entry). Questionnaires with validated instruments were administered orally by the Case Managers in Spanish or English to obtain demographic information and assess each of the five domains (see Cowan et al., 2014, for details). The present study focuses primarily on a measure of conflict between the parents derived from independent reports from each participant.
Measures Couples Communication Questionnaire (CCOM) The 64-item CCOM measures each partner’s perception of conflict and conflict resolution style in the relationship (Cowan, 2005). This study focused on 13 items assessing conflict and disagreement with the partner over the past month on a 0 (“none”) to 6 “a lot” scale. Typical issues generating conflict included household chores, time spent together, financial concerns, and disagreements about parenting. The conflict scale items were highly internally consistent, with alphas ranging between .86 and .90 for fathers and mothers across the three assessments. Three of the 13 items focused on coparenting conflict related to ideas about how to raise children; children’s schooling, and child discipline.
Analytic Strategy We assessed change in reported conflict over three measurement occasions: prior to treatment (baseline), 2 months after the end of treatment/6 months from baseline (postintervention), and 12 months following the end of treatment/18 months from baseline (follow-up). Pathways of change after participation in a couples group intervention were examined first with a traditional analysis of variance. This was followed by an overall growth model describing change in conflict over time, and then with a growth mixture model (GMM; Muth en, 1997), an exploratory measurement model designed to identify latent classes of individuals in categories based on their growth trajectories along the conflict continuum, taking dependency within dyads into account. It was expected that Fam. Proc., Vol. 54, December, 2015
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groups would be identified based on their initial conflict scores, but this was an empirical question determined by the GMM analysis. To evaluate the best-fitting model, the growth trajectories were plotted on a graph comparing observed (actual) against model predicted (estimated) values to see if they followed similar growth patterns. The greater the association between these two patterns, the better the fit in establishing classes of conflict that make sense clinically and theoretically (Muth en, 1997).
RESULTS A GLM analysis (Time of assessment 9 Immediate vs. Delay condition 9 Sex) showed a statistically significant quadratic two-way interaction effect of the intervention on couple conflict, F(1, 459) = 7.39; p < .05. Post hoc analyses showed that conflict declined significantly for the couples who participated in the immediate intervention group condition from baseline to the postintervention assessment, but increased back to baseline by the 18-month follow-up, while the couples in the delay condition did not change in conflict scores. The results of the GLM analysis were supported by findings from the growth trajectory for the complete sample without regard to initial levels of conflict. A model with both linear and quadratic fixed effects fit best (BIC = 4084.186; CFI = 1.0, RMSEA = 0.00, SRMR = 0.016). That is, there was a statistically significant overall decline in conflict, but also a significant upturn in conflict between the first and second postintervention assessments. The GMM revealed a more complex picture. Our focus here is on differential patterns of change in conflict among those who participated in the intervention. Growth trajectories were plotted on a graph comparing observed (actual) against model predicted (estimated) values to evaluate the best-fitting models. Testing for 1-, 2-, and 3-class solutions indicated that a 3-class solution provided the best model fit. Figure 1 shows the trajectory of the growth curves for the 3-class model. As expected, groups were defined by level of self-reported conflict assessed before they entered the study. Figure 1 also shows that the expected and actual growth curves for each latent class were very close together, indicating a very good model fit.
FIGURE 1. Trajectory of Predicted and Observed Growth Curves for the Three-Class Model
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The initially Low-Conflict participants, 47% of the sample (n = 211), began low in conflict and did not change significantly throughout the 18 months. The initially MediumConflict class represented 17.4% of the sample population (n = 77). The Medium-Conflict group experienced increased conflict during the intervention and then decreased significantly but not to baseline levels, in the months following their participation (both linear and quadratic slopes statistically significant, ps < .001). The initially High-Conflict group represented 35.6% of the sample (n = 175 couples). This group decreased in conflict during the intervention and experienced a slight but nonsignificant increase in the year following (both the linear and quadratic slope estimates were significant, p < .001). The three conflict groups identified in the GMM were examined to see whether they differed on age, ethnicity, and referral source. The groups differed by mean age, with the Low-Conflict group being older than both the Moderate- and High-Conflict groups (Bonferroni pairwise p < .017). However, the actual differences in mean age were not large. The variance in age associated with the three-group classification was less than 3% (R2 = .029). The mean age was 33.8 (SD: 9.4) for the Low-Conflict group, 30.7 (SD: 6.9) for the Moderate-Conflict group, and 31.0 (SD: 7.5) for the High-Conflict group. There were no differences among the three conflict groups regarding referral source (v2 = 5.95, 2 df, p > .05) or ethnicity (v2 = 4.45, 4 df, p > .05). Finally, this study provides some information about the connection between conflict couples have about their relationship (money, sex, communication) and about their young children. The median correlations between a scale comprised of the three coparenting conflict items, and a scale comprised of the other 10 conflict items related to child conflict for fathers and mothers were .50 and .57 at baseline, .64 and .64 at the first postintervention, and .70 and .63 at the follow-up. Parents who fought about household chores and money also tended to fight about their children. Both kinds of conflict declined for High-conflict couples after group participation.
DISCUSSION The GLM analysis of change in conflict over the whole sample suggested that the positive intervention effects from baseline to the first postassessment faded over time. The GMM analysis provided a more differentiated account of this finding, based on level of couple conflict assessed before the parents took part in the couples groups. The best-fitting model for change in couples’ conflict was represented by three different change patterns: Conflict for couples with initially Low Conflict remained low over 18 months. Conflict for couples with initially Medium Conflict spiked significantly by the end of the intervention, but returned almost to their preintervention baseline levels after 18 months. Conflict for couples with initially high levels showed a significant decrease at the end of the intervention, followed by a slight, nonsignificant increase over time, still well below their baseline levels. These results indicate that significant baseline to follow-up reduction in conflict was attributable primarily to couples who entered the study with high levels of conflict, whose intervention effects were maintained over 18 months. This finding is noteworthy especially because 20% of the couples had been referred to Child Welfare because of concerns about domestic violence, and these couples are not usually included in couples-based interventions. Initially Low-Conflict couples did not change, and initially Medium-Conflict couples reported increased conflict, reducing the positive intervention effects in conflict for the overall sample. Subgroups in this study were similar to those in other studies that identified Low-, Medium-, and High-Conflict groups (Dush & Taylor, 2012). The Medium-Conflict group (17% of the sample), with accelerating and then decelerating conflict, may be similar to couples who enter therapy for a specific problem and escalate to more generalized conflict, Fam. Proc., Vol. 54, December, 2015
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at least in the short run. This spike occurring soon after the end of the couples group intervention could be attributed to many factors, including the notion that couples were starting to engage about issues they had not been aware of or willing to discuss prior to the intervention. The posttreatment deceleration of reported conflict could be attributed to skills or learning gaining traction and being incorporated into their daily lives, even without group support. The Low-Conflict group poses a challenge for the field of prevention. In postintervention interviews, these couples reported feeling good about the intervention, which seemed to function as an enrichment program for them: valued but not remedial. In any universal intervention in which participants are recruited without regard to their initial level of psychological or relationship adaptation, there will be participants who are well functioning when they begin the intervention and remain so after the intervention is completed. On one hand, they may not “need” what the intervention has to offer. From a public health perspective of program costs, their places could be filled by couples more likely to benefit. On the other hand, couples who have more effective strategies for handling their conflict and disagreement can serve as models to those more challenged, giving hope and positive examples to the higher conflict couples. They can also lead the group discussions to a deeper level, maximizing opportunity for growth and change among higher conflict couples. In addition, the enrichment may serve as a buffer for them during stressful or challenging times encountered subsequently.
Limitations and Future Research The results of this exploratory study contribute to a growing movement examining variations in how couples change over time and to a more nuanced understanding of change in the context of dyads or larger systems (Kazdin & Nock, 2003; Raudenbush, Brennan, & Barnett, 1995). This report is limited to a single, well-established selfreport measure of couple conflict. It should be replicated with observational measures and more differentiated conflict measures, investigating conflict focused specifically on couple relationship versus coparenting issues (see Feinberg et al., 2010; McHale, Waller, & Pearson, 2012), particularly when seeking effects of parents’ participation on their children’s well-being. While the demographics of the couples participating in SFI were generally representative of the California communities in which the intervention took place, the study was comprised primarily of Mexican American and European American low-income heterosexual couples, a majority of whom were married, and therefore the results cannot necessarily be translated to families from other ethnic groups or family structures (Green & Mitchell, 2008). Attempts to investigate the impact of this intervention on diverse samples are now underway.
Implications for Practice Higher conflict couples benefitted most immediately from the 16-week couples group intervention. Perhaps they had the shortest way to go to see any improvement; perhaps their high dudgeon relationships prompted openness to change less distressed couples did not experience. The findings suggest that SFI offered primary and tertiary preventive benefits and a resource for couples that might not choose, access, or be able to afford therapy but can derive benefit from a therapeutic group context that also helps build positive community and identification with local resource centers. Given that a substantial proportion of these families were already identified by the Child Welfare System, SFI provided a safety net to families with children in high need due to risks of abuse, neglect, and violence between their parents. www.FamilyProcess.org
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The High-Conflict group conforms to the couples we have seen who enter therapy in crisis with unremitting conflict. The intensity of the crisis can serve as an impetus to bring the couple together and facilitate their addressing serious issues like marital discord that affect the family. Tang, Luborsky, and Andrusyna (2002) found that sudden gains in therapy were related to the therapeutic alliance, cognitive shifts, and new insights. In the SFI couples groups, the gains could be related not only to parents’ alliance with the group leaders but also with the other group members. The Medium-Conflict group poses a dilemma for both practice and research. If further research replicates the finding that change in conflict increased, at least initially, there are both clinical and ethical issues to be resolved. If the intervention was iatrogenic for these couples, we have the obligation to screen future participants and inform them of the possibility that their conflict may increase in the short run. A further unresolved question, especially if the groups are offered as a universal intervention regardless of couples’ initial levels of distress, is whether the outcomes of offering diagnostic or therapeutic services to low-risk populations justify the costs. We believe that it is too early to make a definitive decision about including Low-Conflict couples in SFI until longer term follow-ups determine whether these couples benefit by reducing risks and enhancing protective factors in the couple and other family domains. One of the major justifications for SFI and other preventive interventions for couples is that reducing conflict will ultimately also benefit children, but few studies actually test this hypothesis empirically. Our reports of the two earlier SFI trials suggest that children of parents who participate in a SFI couples group are less likely to increase in problematic behaviors such as aggressive/acting out or depressed/withdrawn behaviors than children whose parents were not offered the intervention (Cowan et al., 2009, 2014). Further data on outcomes for SFI are forthcoming. In conclusion, this study illustrates the principle that simply examining mean change over time as a result of participating in a preventive intervention may lead to inconclusive or misleading results. Examining patterns of change as a function of participant characteristics may result in a much more differentiated picture of intervention effects, with important implications for the planning and administration of intervention programs. REFERENCES Cowan, P. A. (2005). The family context of parenting in children’s adaptation to elementary school. Mahwah, NJ: Erlbaum Associates. Cowan, P. A., & Cowan, C. P. (2015). Controversies in Couple Relationship Education (CRE): Overlooked evidence and implications for research and policy. Psychology, Public Policy, and the Law, 20(4), 361–383. Cowan, C. P., Cowan, P. A., & Heming, G. (2005). Two variations of a preventive intervention for couples: Effects on parents and children during the transition to elementary school. In P. A. Cowan, C. P. Cowan, J. Ablow, V. K. Johnson, & J. Measelle (Eds.), The family context of parenting in children’s adaptation to elementary school (pp. 277–312). Mahwah, NJ: Lawrence Erlbaum Associates. Cowan, P. A., Cowan, C. P., & Knox, V. (2010). Marriage and fatherhood programs. The Future of Children, 20(2), 205–230. Cowan, P. A., Cowan, C. P., Pruett, M., Pruett, K., & Gillette, P. (2014). Evaluating a couples group to enhance father involvement in low-income families using a benchmark comparison. Family Relations, 63(3), 356–370. Cowan, P. A., Cowan, C. P., Pruett, M. K., Pruett, K., & Wong, J. J. (2009). Promoting fathers’ engagement with children: Preventive interventions for low-income families. Journal of Marriage & the Family, 71, 663–679. Dush, C. M. K., & Taylor, M. G. (2012). Trajectories of marital conflict across the life course predictors and interactions with marital happiness trajectories. Journal of Family Issues, 33(3), 341–368. Enders, C. K. (2010). Applied missing data analysis. New York: Guilford Press. Feinberg, M. E., Jones, D. E., Kan, M. L., & Goslin, M. C. (2010). Effects of Family Foundations on parents and children: 3.5 years after baseline. Journal of Family Psychology, 24, 532–542. Green, R. J., & Mitchell, V. (2008). Gay and lesbian couples in therapy: Minority stress, relational ambiguity, and families of choice. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed., pp. 662–680). New York: Guilford Press.
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Hawkins, A. J., Stanley, S. M., Blanchard, V. L., & Albright, M. (2012). Exploring programmatic moderators of the effectiveness of marriage and relationship education programs: A meta-analytic study. Behavior Therapy, 43(1), 77–87. Kazdin, A. E., & Nock, M. K. (2003). Delineating mechanisms of change in child and adolescent therapy: Methodological issues and research recommendations. Journal of Child Psychology and Psychiatry, 44, 1116–1129. Markman, H., Stanley, S., & Blumberg, S. (2010). Fighting for your marriage. San Francisco, CA: Jossey-Bass. McHale, J., Waller, M., & Pearson, J. (2012). Coparenting interventions for fragile families: What do we know and where do we need to go next? Family Process, 51, 284–306. Muth en, B. O. (1997). Latent variable modeling of longitudinal and multilevel data. Sociological Methodology, 27(1), 453–480. Muth en, B. O., & Shedden, K. (1999). Finite mixture modeling with mixture outcomes using the EM algorithm. Biometrics, 55, 463–469. Pruett, M. K., Cowan, C. P., Cowan, P. A., & Pruett, K. (2009). Lessons learned from the Supporting Father Involvement study: A cross-cultural preventive intervention for low-income families with young children. Journal of Social Service Research, 35, 163–179. Pruett, M. K., Ebling, R., Cowan, P. A., Cowan, C. P., & Pruett, K. D. (2005). Supporting Father Involvement Couples’ Group Intervention Curriculum. Sponsored by the California Department of Social Services, Office of Child Abuse Prevention. Unpublished manuscript. Raudenbush, S. W., Brennan, R. T., & Barnett, R. C. (1995). A multivariate hierarchical model for studying change within married couples. Journal of Family Psychology, 9(2), 161–174. Tang, T. Z., Luborsky, L., & Andrusyna, T. (2002). Sudden gains in recovering from depression: Are they also found in psychotherapies other than cognitive-behavioral therapy? Journal of Consulting and Clinical Psychology, 70(2), 444.
www.FamilyProcess.org
This study explored pathways of change in the levels of conflict couples experienced after Supporting Father Involvement, an evidence-based, prevention-oriented couples and parenting intervention that included a diverse low-income and working class group of participants. Pathways of change were examined for couples with baseline conflict scores that were initially low, medium, and high. The growth mixture model analysis found that the best-fitting model for change in couples’ conflict was represented by three distinctly different change patterns. The intervention was most successful for High-Conflict couples. This finding contributes to a growing literature examining variations in how relationships change over time and the process of change, especially for couples in distress. This study supports further investigation into the impact and costs associated with universal interventions versus those that target specific groups of higher risk families. Keywords: Couples; Conflict; Marriage; Change; Prevention; Coparenting Fam Proc 54:610–618, 2015
T
here is a normative decline in couple relationship quality after partners become parents, with potentially negative consequences for children. This transition presents an optimal time to offer interventions aiming to strengthen parents’ relationships and provide them with resources to deal with disagreements before they escalate out of control. In recent years, preventive interventions for couples early in their relationship (Markman, Stanley, & Blumberg, 2010) or in early parenthood (Feinberg, Jones, Kan, & Goslin, 2010) have attempted to reduce conflict and increase collaboration with the hope that the impact on the coparenting couple would provide benefits for their children. Most of these intervention programs have been “universal” in that recruitment was without regard for demographic or psychological risk status, with more recent attempts to target low-income parents (Cowan, Cowan, & Knox, 2010). Single studies and meta-analyses indicate that universal programs show small but statistically significant effects on the parents *Psychiatry, University of California San Francisco, San Francisco, CA. † School for Social Work, Smith College, Northampton, MA. ‡ Psychology, University of California Berkeley, Berkeley, CA. § School of Medicine, Yale University, New Haven, CT.
Correspondence concerning this article should be addressed to Kenneth Epstein, Psychiatry, University of California San Francisco, 1380 Howard St., San Francisco, CA 94103. E-mail: [email protected]. 610
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(Hawkins, Stanley, Blanchard, & Albright, 2012), although there has been some recent controversy about this conclusion—attributable mostly to disappointing results of a largescale randomized trial with low-income unmarried couples (Cowan & Cowan, 2015). The impact of participation in couples groups has been measured in terms of average pre-postintervention differences between experimental and control groups in relationship satisfaction and self-reported or observed communication patterns, with an emphasis on reductions in parental conflict. Because couples have been recruited without regard to initial conflict levels, the results have been interpreted as if mean differences between experimental and control participants apply to couples who enter the intervention at all points along the conflict continuum. Our aim was to examine this assumption more carefully by tracing pathways of change in conflict from before to after participation in an intervention for couples whose baseline conflict scores were low, medium, or high. The intervention was a third iteration of Supporting Father Involvement (SFI), after two prior intervention trials revealed positive effects. In the first trial (Cowan, Cowan, Pruett, Pruett, & Wong, 2009), 279 Mexican American and European American lowincome couples were randomly assigned to a single informational meeting (low-dose control) or a 16-week group for fathers (mothers attended twice) or for couples, all led by the same clinically trained male–female teams. Fathers and mothers who participated in the one-time meeting showed no positive changes and some negative changes at the 18-month follow-up assessment: Their satisfaction as a couple declined significantly, and they reported increased externalizing and internalizing behaviors in their children. By contrast, participants in both the fathers and couples groups showed significant increases in fathers’ involvement in care of the children and no increase in children’s behavior problems over the course of the study. Relationship satisfaction for control and fathers group participants declined, while mothers and fathers from the couples groups reported no decline in satisfaction as a couple as well as significant reductions in parenting stress. In the second trial (Cowan, Cowan, Pruett, Pruett, & Gillette, 2014), 236 Mexican American, African American, and European American couples participated in 16-week couples groups. The investigators chose not to conduct another RCT because the earlier study had shown that the low-dose control couples and their children declined in adaptation, and the fathers group was not as effective as the couples group. Of 11 measures in this second trial, 10 revealed positive baseline to 18-month follow-up changes in the partners, including a significant reduction in behaviors associated with intimate partner violence (e.g., yelling, throwing things, insulting, slapping, hitting) when discussing issues on which they disagreed. As in other couples interventions, results of SFI to date have been reported in terms of average amounts of change across the sample. Little is known about the different patterns of change for individuals and/or couples as a result of intervention. Until recently, most couples group intervention studies have been limited to middle-class couples not selected on the basis of reported relationship difficulties or exposure to stressful environmental and situational factors that contribute to marital conflict. Understanding varying patterns of change in couple conflict in community samples with varying conflict levels as the intervention begins could contribute to the development of accessible, effective treatment options. The current study focuses on Mexican American, African American, and European American coparents in five diverse low-income and working class communities. The couples were primarily in the first decade of marriage and had young children, which placed them at higher risk for conflict and/or divorce. The study examined patterns of change in conflict levels from before to after participation in the 16-week SFI intervention, to establish whether couples who come to the intervention with low-, mid-level, or highconflict levels traversed similar or different pathways over time. This is an exploratory Fam. Proc., Vol. 54, December, 2015
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study, as to our knowledge there have not been prior studies of preventive interventions for couples with a range of conflict levels examining differential change in conflict as a function of initial conflict levels.
METHOD Supporting Father Involvement is an intervention that takes a group approach to strengthening couple, coparent, and parent–child relationships and increasing fathers’ hands-on involvement in caring for their children. The program was located in Family Resource Centers in five California counties (San Luis Obispo, Santa Cruz, Tulare, Contra Costa, and Yuba). Once both parents agreed to participate, partners were randomly offered either an immediate group or a 6-month delayed one (comparison condition). The curriculum, adapted by Pruett, Ebling, Cowan, and Cowan (2005) based on previous interventions developed by Cowan, Cowan, and Heming (2005), is based on a model of risk and protective factors in five theoretically derived and researched domains of family life, including (a) individual distress and well-being; (b) patterns of couple- and parent–child relationships across three generations; (c) quality of the parents’ relationship as couples or coparents; (d) quality of each parent’s relationship with their child(ren); and (e) the family’s life stressors and social support outside the immediate family (Cowan et al., 2009). Topics pertaining to the domains were explored in a mix of group discussions, structured didactic presentations, role-plays, and exercises to illustrate various principles of effective communication, coparenting, or family relationships. SFI follows a manual with curriculum modules that give group leaders and participants the flexibility and opportunity to explore personal issues that are raised in the moment and appropriate for participants of different cultures. Approximately 42% of families were referred by Child Welfare staff; each set of parents was assessed both by Welfare Department and SFI staff to establish that there was not current violence or abuse in the family and it was deemed safe to include both partners in a couples group setting. For all couples, regardless of referral source, the SFI assessment included a joint couple interview followed by separate interviews of each partner focused on specific questions about whether there was past and/or current intimate partner violence, and whether each partner felt safe to return home after the interview. Of the couples, 20% had been referred for domestic violence, 32% for child neglect, and 48% for different categories of child abuse. Couples with current violence, child abuse, or neglect were referred for other community services. Couples with no current violence or abuse, who felt safe with their partner, were accepted into the study. Parents who reported that they were suffering from a major mental illness or severe substance difficulties that compromised their daily functioning were referred to other services. In addition to their assignment to either immediate or 6-month delayed intervention groups, every family received case management throughout the study, which involved regular contact to help families access and navigate community services, as needed.
Participants Participants were recruited by direct referrals from the county Child Welfare Agency, other community family service agencies, talks at local community organizations, advertisements in local media, and information tables set up at events in the target communities (Pruett, Cowan, Cowan, & Pruett, 2009). Criteria for inclusion were that both parents agreed to participate and had a youngest child between birth and age 11. At least one parent was a biological parent of the child and the two parents planned to raise the child together. www.FamilyProcess.org
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At baseline, 463 participants were randomly assigned to immediate or delayed participation in one of the intervention groups. Of these, 371 participated in either the immediate or delayed intervention and completed the postintervention assessment; 311 completed the follow-up 18 months after entering the study. The missing data problem was accommodated by use of full information maximum likelihood and the expectationmaximization (EM) algorithm (Muth en & Shedden, 1999). This method assumes that the missingness was ignorable (Enders, 2010) and therefore did not bias the results. The majority of fathers and mothers who enrolled identified as Hispanic/Latino (51%), most identifying as Mexican (97%), or European American/White (34%). Over two thirds of the fathers had a high school diploma/GED or less; just under two thirds of the mothers had graduated from high school or less. Another one third of parents had some college or technical school training. A few parents had college degrees. Two thirds (66.4%) of the parents were born in the United States and 33.6% were born in another country, primarily Mexico (97%). All spoke English, although Spanish was the primary language for about one third of the Mexican families, and some assessments and groups were conducted in Spanish. The mean age of fathers and mothers was 33.5 (SD: 8.67) and 31 (SD: 8.01), respectively, and of the families’ youngest child, 3.4 years old (SD: 3.11). Average annual income was less than 18k for fathers and about 11k for mothers.
Procedures Data were collected at: preintervention (baseline), postintervention (2 months after the intervention groups ended), and follow-up (18 months after study entry). Questionnaires with validated instruments were administered orally by the Case Managers in Spanish or English to obtain demographic information and assess each of the five domains (see Cowan et al., 2014, for details). The present study focuses primarily on a measure of conflict between the parents derived from independent reports from each participant.
Measures Couples Communication Questionnaire (CCOM) The 64-item CCOM measures each partner’s perception of conflict and conflict resolution style in the relationship (Cowan, 2005). This study focused on 13 items assessing conflict and disagreement with the partner over the past month on a 0 (“none”) to 6 “a lot” scale. Typical issues generating conflict included household chores, time spent together, financial concerns, and disagreements about parenting. The conflict scale items were highly internally consistent, with alphas ranging between .86 and .90 for fathers and mothers across the three assessments. Three of the 13 items focused on coparenting conflict related to ideas about how to raise children; children’s schooling, and child discipline.
Analytic Strategy We assessed change in reported conflict over three measurement occasions: prior to treatment (baseline), 2 months after the end of treatment/6 months from baseline (postintervention), and 12 months following the end of treatment/18 months from baseline (follow-up). Pathways of change after participation in a couples group intervention were examined first with a traditional analysis of variance. This was followed by an overall growth model describing change in conflict over time, and then with a growth mixture model (GMM; Muth en, 1997), an exploratory measurement model designed to identify latent classes of individuals in categories based on their growth trajectories along the conflict continuum, taking dependency within dyads into account. It was expected that Fam. Proc., Vol. 54, December, 2015
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groups would be identified based on their initial conflict scores, but this was an empirical question determined by the GMM analysis. To evaluate the best-fitting model, the growth trajectories were plotted on a graph comparing observed (actual) against model predicted (estimated) values to see if they followed similar growth patterns. The greater the association between these two patterns, the better the fit in establishing classes of conflict that make sense clinically and theoretically (Muth en, 1997).
RESULTS A GLM analysis (Time of assessment 9 Immediate vs. Delay condition 9 Sex) showed a statistically significant quadratic two-way interaction effect of the intervention on couple conflict, F(1, 459) = 7.39; p < .05. Post hoc analyses showed that conflict declined significantly for the couples who participated in the immediate intervention group condition from baseline to the postintervention assessment, but increased back to baseline by the 18-month follow-up, while the couples in the delay condition did not change in conflict scores. The results of the GLM analysis were supported by findings from the growth trajectory for the complete sample without regard to initial levels of conflict. A model with both linear and quadratic fixed effects fit best (BIC = 4084.186; CFI = 1.0, RMSEA = 0.00, SRMR = 0.016). That is, there was a statistically significant overall decline in conflict, but also a significant upturn in conflict between the first and second postintervention assessments. The GMM revealed a more complex picture. Our focus here is on differential patterns of change in conflict among those who participated in the intervention. Growth trajectories were plotted on a graph comparing observed (actual) against model predicted (estimated) values to evaluate the best-fitting models. Testing for 1-, 2-, and 3-class solutions indicated that a 3-class solution provided the best model fit. Figure 1 shows the trajectory of the growth curves for the 3-class model. As expected, groups were defined by level of self-reported conflict assessed before they entered the study. Figure 1 also shows that the expected and actual growth curves for each latent class were very close together, indicating a very good model fit.
FIGURE 1. Trajectory of Predicted and Observed Growth Curves for the Three-Class Model
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The initially Low-Conflict participants, 47% of the sample (n = 211), began low in conflict and did not change significantly throughout the 18 months. The initially MediumConflict class represented 17.4% of the sample population (n = 77). The Medium-Conflict group experienced increased conflict during the intervention and then decreased significantly but not to baseline levels, in the months following their participation (both linear and quadratic slopes statistically significant, ps < .001). The initially High-Conflict group represented 35.6% of the sample (n = 175 couples). This group decreased in conflict during the intervention and experienced a slight but nonsignificant increase in the year following (both the linear and quadratic slope estimates were significant, p < .001). The three conflict groups identified in the GMM were examined to see whether they differed on age, ethnicity, and referral source. The groups differed by mean age, with the Low-Conflict group being older than both the Moderate- and High-Conflict groups (Bonferroni pairwise p < .017). However, the actual differences in mean age were not large. The variance in age associated with the three-group classification was less than 3% (R2 = .029). The mean age was 33.8 (SD: 9.4) for the Low-Conflict group, 30.7 (SD: 6.9) for the Moderate-Conflict group, and 31.0 (SD: 7.5) for the High-Conflict group. There were no differences among the three conflict groups regarding referral source (v2 = 5.95, 2 df, p > .05) or ethnicity (v2 = 4.45, 4 df, p > .05). Finally, this study provides some information about the connection between conflict couples have about their relationship (money, sex, communication) and about their young children. The median correlations between a scale comprised of the three coparenting conflict items, and a scale comprised of the other 10 conflict items related to child conflict for fathers and mothers were .50 and .57 at baseline, .64 and .64 at the first postintervention, and .70 and .63 at the follow-up. Parents who fought about household chores and money also tended to fight about their children. Both kinds of conflict declined for High-conflict couples after group participation.
DISCUSSION The GLM analysis of change in conflict over the whole sample suggested that the positive intervention effects from baseline to the first postassessment faded over time. The GMM analysis provided a more differentiated account of this finding, based on level of couple conflict assessed before the parents took part in the couples groups. The best-fitting model for change in couples’ conflict was represented by three different change patterns: Conflict for couples with initially Low Conflict remained low over 18 months. Conflict for couples with initially Medium Conflict spiked significantly by the end of the intervention, but returned almost to their preintervention baseline levels after 18 months. Conflict for couples with initially high levels showed a significant decrease at the end of the intervention, followed by a slight, nonsignificant increase over time, still well below their baseline levels. These results indicate that significant baseline to follow-up reduction in conflict was attributable primarily to couples who entered the study with high levels of conflict, whose intervention effects were maintained over 18 months. This finding is noteworthy especially because 20% of the couples had been referred to Child Welfare because of concerns about domestic violence, and these couples are not usually included in couples-based interventions. Initially Low-Conflict couples did not change, and initially Medium-Conflict couples reported increased conflict, reducing the positive intervention effects in conflict for the overall sample. Subgroups in this study were similar to those in other studies that identified Low-, Medium-, and High-Conflict groups (Dush & Taylor, 2012). The Medium-Conflict group (17% of the sample), with accelerating and then decelerating conflict, may be similar to couples who enter therapy for a specific problem and escalate to more generalized conflict, Fam. Proc., Vol. 54, December, 2015
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at least in the short run. This spike occurring soon after the end of the couples group intervention could be attributed to many factors, including the notion that couples were starting to engage about issues they had not been aware of or willing to discuss prior to the intervention. The posttreatment deceleration of reported conflict could be attributed to skills or learning gaining traction and being incorporated into their daily lives, even without group support. The Low-Conflict group poses a challenge for the field of prevention. In postintervention interviews, these couples reported feeling good about the intervention, which seemed to function as an enrichment program for them: valued but not remedial. In any universal intervention in which participants are recruited without regard to their initial level of psychological or relationship adaptation, there will be participants who are well functioning when they begin the intervention and remain so after the intervention is completed. On one hand, they may not “need” what the intervention has to offer. From a public health perspective of program costs, their places could be filled by couples more likely to benefit. On the other hand, couples who have more effective strategies for handling their conflict and disagreement can serve as models to those more challenged, giving hope and positive examples to the higher conflict couples. They can also lead the group discussions to a deeper level, maximizing opportunity for growth and change among higher conflict couples. In addition, the enrichment may serve as a buffer for them during stressful or challenging times encountered subsequently.
Limitations and Future Research The results of this exploratory study contribute to a growing movement examining variations in how couples change over time and to a more nuanced understanding of change in the context of dyads or larger systems (Kazdin & Nock, 2003; Raudenbush, Brennan, & Barnett, 1995). This report is limited to a single, well-established selfreport measure of couple conflict. It should be replicated with observational measures and more differentiated conflict measures, investigating conflict focused specifically on couple relationship versus coparenting issues (see Feinberg et al., 2010; McHale, Waller, & Pearson, 2012), particularly when seeking effects of parents’ participation on their children’s well-being. While the demographics of the couples participating in SFI were generally representative of the California communities in which the intervention took place, the study was comprised primarily of Mexican American and European American low-income heterosexual couples, a majority of whom were married, and therefore the results cannot necessarily be translated to families from other ethnic groups or family structures (Green & Mitchell, 2008). Attempts to investigate the impact of this intervention on diverse samples are now underway.
Implications for Practice Higher conflict couples benefitted most immediately from the 16-week couples group intervention. Perhaps they had the shortest way to go to see any improvement; perhaps their high dudgeon relationships prompted openness to change less distressed couples did not experience. The findings suggest that SFI offered primary and tertiary preventive benefits and a resource for couples that might not choose, access, or be able to afford therapy but can derive benefit from a therapeutic group context that also helps build positive community and identification with local resource centers. Given that a substantial proportion of these families were already identified by the Child Welfare System, SFI provided a safety net to families with children in high need due to risks of abuse, neglect, and violence between their parents. www.FamilyProcess.org
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The High-Conflict group conforms to the couples we have seen who enter therapy in crisis with unremitting conflict. The intensity of the crisis can serve as an impetus to bring the couple together and facilitate their addressing serious issues like marital discord that affect the family. Tang, Luborsky, and Andrusyna (2002) found that sudden gains in therapy were related to the therapeutic alliance, cognitive shifts, and new insights. In the SFI couples groups, the gains could be related not only to parents’ alliance with the group leaders but also with the other group members. The Medium-Conflict group poses a dilemma for both practice and research. If further research replicates the finding that change in conflict increased, at least initially, there are both clinical and ethical issues to be resolved. If the intervention was iatrogenic for these couples, we have the obligation to screen future participants and inform them of the possibility that their conflict may increase in the short run. A further unresolved question, especially if the groups are offered as a universal intervention regardless of couples’ initial levels of distress, is whether the outcomes of offering diagnostic or therapeutic services to low-risk populations justify the costs. We believe that it is too early to make a definitive decision about including Low-Conflict couples in SFI until longer term follow-ups determine whether these couples benefit by reducing risks and enhancing protective factors in the couple and other family domains. One of the major justifications for SFI and other preventive interventions for couples is that reducing conflict will ultimately also benefit children, but few studies actually test this hypothesis empirically. Our reports of the two earlier SFI trials suggest that children of parents who participate in a SFI couples group are less likely to increase in problematic behaviors such as aggressive/acting out or depressed/withdrawn behaviors than children whose parents were not offered the intervention (Cowan et al., 2009, 2014). Further data on outcomes for SFI are forthcoming. In conclusion, this study illustrates the principle that simply examining mean change over time as a result of participating in a preventive intervention may lead to inconclusive or misleading results. Examining patterns of change as a function of participant characteristics may result in a much more differentiated picture of intervention effects, with important implications for the planning and administration of intervention programs. REFERENCES Cowan, P. A. (2005). The family context of parenting in children’s adaptation to elementary school. Mahwah, NJ: Erlbaum Associates. Cowan, P. A., & Cowan, C. P. (2015). Controversies in Couple Relationship Education (CRE): Overlooked evidence and implications for research and policy. Psychology, Public Policy, and the Law, 20(4), 361–383. Cowan, C. P., Cowan, P. A., & Heming, G. (2005). Two variations of a preventive intervention for couples: Effects on parents and children during the transition to elementary school. In P. A. Cowan, C. P. Cowan, J. Ablow, V. K. Johnson, & J. Measelle (Eds.), The family context of parenting in children’s adaptation to elementary school (pp. 277–312). Mahwah, NJ: Lawrence Erlbaum Associates. Cowan, P. A., Cowan, C. P., & Knox, V. (2010). Marriage and fatherhood programs. The Future of Children, 20(2), 205–230. Cowan, P. A., Cowan, C. P., Pruett, M., Pruett, K., & Gillette, P. (2014). Evaluating a couples group to enhance father involvement in low-income families using a benchmark comparison. Family Relations, 63(3), 356–370. Cowan, P. A., Cowan, C. P., Pruett, M. K., Pruett, K., & Wong, J. J. (2009). Promoting fathers’ engagement with children: Preventive interventions for low-income families. Journal of Marriage & the Family, 71, 663–679. Dush, C. M. K., & Taylor, M. G. (2012). Trajectories of marital conflict across the life course predictors and interactions with marital happiness trajectories. Journal of Family Issues, 33(3), 341–368. Enders, C. K. (2010). Applied missing data analysis. New York: Guilford Press. Feinberg, M. E., Jones, D. E., Kan, M. L., & Goslin, M. C. (2010). Effects of Family Foundations on parents and children: 3.5 years after baseline. Journal of Family Psychology, 24, 532–542. Green, R. J., & Mitchell, V. (2008). Gay and lesbian couples in therapy: Minority stress, relational ambiguity, and families of choice. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed., pp. 662–680). New York: Guilford Press.
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Hawkins, A. J., Stanley, S. M., Blanchard, V. L., & Albright, M. (2012). Exploring programmatic moderators of the effectiveness of marriage and relationship education programs: A meta-analytic study. Behavior Therapy, 43(1), 77–87. Kazdin, A. E., & Nock, M. K. (2003). Delineating mechanisms of change in child and adolescent therapy: Methodological issues and research recommendations. Journal of Child Psychology and Psychiatry, 44, 1116–1129. Markman, H., Stanley, S., & Blumberg, S. (2010). Fighting for your marriage. San Francisco, CA: Jossey-Bass. McHale, J., Waller, M., & Pearson, J. (2012). Coparenting interventions for fragile families: What do we know and where do we need to go next? Family Process, 51, 284–306. Muth en, B. O. (1997). Latent variable modeling of longitudinal and multilevel data. Sociological Methodology, 27(1), 453–480. Muth en, B. O., & Shedden, K. (1999). Finite mixture modeling with mixture outcomes using the EM algorithm. Biometrics, 55, 463–469. Pruett, M. K., Cowan, C. P., Cowan, P. A., & Pruett, K. (2009). Lessons learned from the Supporting Father Involvement study: A cross-cultural preventive intervention for low-income families with young children. Journal of Social Service Research, 35, 163–179. Pruett, M. K., Ebling, R., Cowan, P. A., Cowan, C. P., & Pruett, K. D. (2005). Supporting Father Involvement Couples’ Group Intervention Curriculum. Sponsored by the California Department of Social Services, Office of Child Abuse Prevention. Unpublished manuscript. Raudenbush, S. W., Brennan, R. T., & Barnett, R. C. (1995). A multivariate hierarchical model for studying change within married couples. Journal of Family Psychology, 9(2), 161–174. Tang, T. Z., Luborsky, L., & Andrusyna, T. (2002). Sudden gains in recovering from depression: Are they also found in psychotherapies other than cognitive-behavioral therapy? Journal of Consulting and Clinical Psychology, 70(2), 444.
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