Prevention as a Priority
With PREP curricula, it all starts with PREVENTION.
All curricula produced and disseminated by PREP, whether for couples or individuals, servicemembers or civilians have a prevention focus. They are not meant as therapy or counseling, but as relationship education efforts delivered by any of several means. However, this distinction is less about whether or not those being served are low risk, higher risk, or already have significant difficulties in their relationships and more about how they are recruited. After laying a foundation for understanding the broad nature of prevention, we will explain more about why this point matters in decisions about who you serve and effects that might be anticipated.
The entire foundation of PREP and all the adaptations of PREP curricula are based on the goal of prevention. Howard Markman is the founder of program, and his interests go back to the mid-1970s when a burgeoning field of research on couples (by him, John Gottman, and many others) was identifying risks for marital distress and divorce. Markman’s original goal was to develop a program that could prevent marital distress and divorce. By the late 1970s and into the early 1980s, he was joined in this body of research and prevention effort by others such as Frank Floyd and Scott Stanley.
Just how much was prevention baked into PREP from its inception?
Befitting the early motivation, PREP originally stood for the Premarital Relationship Enhancement Program. Markman, Floyd, and Stanley have all published now classic publications on the use of premarital education to strengthen marriages.
Over the years, PREP moved to a wider focus on couples, including married couples, unmarried couples, couples planning marriage, as well as an increasing focus on relationship education for individuals. The acronym has remained but with a new underlying title of “The Prevention and Relationship Education Program.” This name pays homage to our roots in prevention and our focus on an educational model for helping both individuals and couples in their most important relationships.
What do we mean when we say prevention?
By prevention, we mean interventions built around relationship education strategies for the purpose of primary, secondary, and tertiary prevention. Primary prevention efforts are those focused “upstream” on keeping possible risks from developing into problems. It is usually thought of as efforts to help people who have not already developed any problems with a belief that widespread application of an intervention may help reduce the odds for negative outcomes for a broad subset of people. Secondary prevention efforts are those taking place to improve functioning and outcomes for those are already at a higher risk. Such efforts often focus on identifying who is at high risk for some difficulty (e.g., divorce or marital distress) and take steps to lower that risk for the group in questions. Tertiary prevention aims to help those who have already developed a problem to ameliorate and limit damage from it, and/or to reduce the risks for ongoing difficulties that it may cause in other domains.
This framework is largely similar to another well-known schema of prevention--universal, selective, and targeted. However, the first schema (primary, secondary, tertiary) is focused more one the stage of the development and the latter schema (universal, selective, indicated) is focused more on who the target is for the services. Universal prevention efforts serve all who are interested or within a program’s reach. Selective prevention efforts aim to serve those already at higher risk (e.g., for relationship difficulties) because their context or history places them at a higher than typical risk for developing more significant problems. Indicated prevention is when services are targeted to reach people who have already developed some significant problem, such as relationship distress, where the focus of the service is to reduce the ongoing risk of those problems getting worse or affecting other aspects of life. Another example of indicated prevention using PREP would be where couples already have one problem, such as one partner having a serious medical illness, and the goal of the prevention effort is to help the couples cope as a team and protect their relationships.
Most approaches to preventive interventions focus on reducing risk factors and strengthening protective factors. Risk factors are characteristics of peoples’ lives or contexts that put them at greater risk than others. For example, poverty or family history or specific experiences of trauma can all contribute to who is at risk to struggle in their relationships. Protective factors are things that give people a leg up on weathering difficulties in life by either imparting increased resilience or limiting the effects of stress or setbacks. For example, having a supportive social network of friends and family, having access to resources for medical and mental health care, or having training that builds skills for managing difficulties could all be protective factors.
In reality, unless those standing up a service have made efforts to recruit or filter participants based on specific criteria, the “room” of those served by most such workshop efforts will vary from those doing great and wanting to keep it that way to those struggling and looking for a little nudge to those who are already distressed. For many relationship-focused workshops offered on a voluntary basis, the average relationship quality represented in the room will be on the cusp of what researchers would call distressed relationships. Most often, workshop providers do not really know how much the average participant is struggling.
Decisions about whether or not to try to screen in or out who is served are of great importance and should be carefully made. If you try to screen in only those who are distressed, you may find you serve fewer of such couples because word will get around that “that program is for couples having problems.” On the other hand, if you serve only or mostly those who are doing great and seeking pure prevention, you will likely have some preventive effect, but you will be screening out those who would get the most immediate and larger benefits from your program. You can read more about the complex issues regarding who is served in this paper on best practices. Unless there is a resource restriction or other program considerations that lead you to try to screen out participants who are otherwise interested, consider that there are likely advantages of having groups of participants at varying levels of immediate need because doing so can lead to serving groups where people may learn from others who are at a different place in their journeys. Further, this practice conveys the message that what you offer is for all who are interested.
This subject of who to recruit or encourage into your services is even more complex when it comes to research efforts. If your work is being evaluated by a any kind of rigorous evaluation, your choice of where to focus your efforts on the spectrum of prevention will matter a great deal for the effects you are likely to see. It is quite clear that researchers will find the largest effect sizes when those being served are distressed and struggling. Likewise, efforts focused on groups that are more primary prevention in goal, enrolling participants who are generally doing well, will have the smallest effect sizes. Further, the latter focus will likely take longer (more follow-ups) to show effectiveness, because demonstrating primary preventive effects with those functioning well requires a long enough follow up that one could assess the deterioration (or lack thereof) of relationship quality.
Does this mean you are wiser to focus your efforts on those who are struggling the most?
We would argue that this is not the way to think about the question. There is strong merit in preventive efforts all along the spectrum of prevention described above. But if you know you are doing mostly primary prevention and there is an evaluation of your work, you should anticipate small effects (as long as the research is rigorous).