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Fami ly Therapy magazi ne

SYSTEMS BRIEF STRATEGIC FAMILY THERAPY INTERGENERATIONAL/TRANSGENERATIONAL FAMILY THERAPY BOWEN FAMILY SY
ntegrative Behavioral Couple Therapy (IBCT)
is a relatively new approach to couple therapy that has
garnered promising empirical support and is current-
ly the focus of a major clinical trial on the outcome
of couple therapy being conducted at UCLA and the
University of Washington. IBCT was developed by
Andrew Christensen of UCLA and the late Neil S.
Jacobson of the University of Washington. Sometimes
referred to as Integrative Couple Therapy, this
approach is integrative in two senses. First, it inte-
grates the twin goals of acceptance and change as pos-
itive outcomes for couple therapy. Also, it integrates
a variety of treatment strategies under a consistent
behavioral theoretical framework.
There are three important clinical features of IBCT.
First, it is driven by a case formulation, which is based
on a thematic analysis. Second, it focuses on emo-
tional acceptance as a basis for concrete change. Third,
it emphasizes evocative rather than prescriptive inter-
ventions. These features will be discussed throughout
the treatment descriptions.
The first three sessions in IBCT are devoted to a
clinical assessment of the couple, which leads to a case
formulation of the couple. An initial conjoint session
focuses on their presenting problems and relationship
history, emphasizing the attractions that brought them
together. The second and third sessions are individ-
ual sessions with each partner. In these sessions, more
information on the presenting complaints and an indi-
vidual history of each spouse is obtained. In these
sessions, IBCT therapists try to specify the most impor-
tant problems the couple is facing, to examine the
theme or themes that underlie these problems, and to
identify the context that makes these problems under-
standable. All of this information leads to a case for-
mulation of the couples problems.
In the fourth session, IBCT therapists share with
the couple a formulation of their problems. One can
think of this formulation as a new story about the
problem. Typically, a couple comes to therapy with
two stories about the problemone generated by each
partner who emphasizes the faults in the other. The
formulation provides a single unified story that takes
into account both partners experiences and puts them
together in a non-blaming framework.
A formulation consists of several components.
First, there is a difference or seeming incompatibility
between partners. As an example, let us consider a
common difference between partnerscloseness.
Joan wants more contact, connection, and communi-
cation with her husband John, who prefers a connec-
tion that involves less contact and leaves more room
for independence. Second, there are vulnerabilities in
one or both partners that provide emotional fuel for
this difference. If Joan is sensitive about abandon-
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A N D R E W C H R I S T E N S E N , P H D
Couple Therapy
IBCT therapists may teach the
couple communication training
or PROBLEM SOLVINGto
help them handle their problems
more effectively and directly.
INTEGRATIVE
BEHAVIORAL
I
YSTEMS PSYCHODYNAMIC OBJECT RELATIONS INSIGHT-ORIENTED COUPLE THERAPY RELATIONAL THERAPIES TODAY GESTA
ment, or if John is vulnerable to being
restricted or constrained in any way,
then this common difference on close-
ness may be uncommonly emotional for
them. These vulnerabilities typically
come from each partners experiences in
their family of origin, but may also come
from more recent experiences, such as
experiences in a previous marriage.
Third, each partner tries to cope with
these differences in ways that seem rea-
sonable, but often unintentionally exac-
erbate the stress and polarize their dif-
ferences. For example, John may
withdraw from Joan in order to achieve
the level of independence with which he
is comfortable. However, this with-
drawal increases Joans anxiety so that
she pursues, criticizes, and makes
demands on John, who, out of anxiety,
withdraws further from Joan. A vicious
cycle of withdrawing and demanding
then develops between the two of them.
Finally, the two may experience a vari-
ety of negative emotions that lead them
to feeling stuck and trapped. The
harder they try, the worse the problem
gets. They feel desperate, but hopeless
to change the situation.
There are other issues assessed dur-
ing the evaluation period and discussed
in the feedback session. For example,
individual diagnoses such as substance
abuse or dependence and depression are
assessed. Relationship problems such as
affairs or violence are assessed. It is
beyond the scope of this short descrip-
tion to discuss these special issues, but
the more detailed references cited below
can provide further information about
these problems.
After the feedback session, the treat-
ment formally begins, guided by the for-
mulation. The content of the treatment
usually concerns recent, emotionally
salient incidents, both positive and neg-
ative. However, upcoming events that
are of concern, or broader issues of cur-
rent concern, are also common topics.
These incidents and issues that are the
focus of therapy are usually directly or
indirectly related to the formulation. For
example, an incident around Johns leav-
ing for a short business trip would cer-
tainly be a focus for therapy, while an
argument over Joan being late for a
lunch meeting would not be a focus for
therapy, unless it were indirectly relat-
ed to their formulation. However, the
formulation is not a static, conceptual
framework for viewing the couple. As
the therapist and the couple work
together to reach increasingly greater
understanding of their issues, they may
alter and enrich their formulationor
storyof their concerns.
There are three primary treatment
strategies in IBCT that are meant to pro-
mote emotional acceptance: empathic
joining, unified detachment, and toler-
ance building. In the first intervention,
IBCT therapists try to create an empath-
ic connection between the partners
around the very issues that drive them
apart. Partners are liable to first discuss
their problems by expressing hard feel-
ings and thoughts that present the self
as strong, and shower accusations on
the partner (I am tired of being con-
trolled by you, I am resentful of how
you have taken advantage of me).
These accusations usually create sepa-
ration and defensiveness. IBCT thera-
pists look for the softer, more vulnera-
ble feelings and thoughts that may also
exist alongside the harder feelings and
thoughts. IBCT therapists may probe for
feelings of disappointment, neglect, and
hurt that may lie behind the anger and
resentment. However, even these softer
feelings may be presented in an accusa-
tory wayYou always hurt me. So,
it is a challenge for the therapist to cre-
ate a safe environment where partners
can voice their deepest hurts and fears
without fear of attack. For example, the
therapist would want to create an envi-
ronment where Joan could openly dis-
cuss her fears of abandonment and John
could openly discuss his fears of being
controlled. By the therapist modeling an
empathic approach to each partner, they
may begin to take a similar approach to
each other.
The second treatment strategy, aimed
at increasing acceptance, is unified
detachment. Whereas empathic join-
ing focuses on a close, emotional look
at the problems and each partner, uni-
fied detachment takes a more distant,
intellectual, and objective look. IBCT
therapists engage the couple in a
descriptive analyses of their problem
that may emphasize the context in
which the problem develops, the
sequence of actions each partners goes
through, the primary events that trig-
ger escalation, and the efforts at recov-
ery and reconnection that each makes.
For example, the therapist might work
with John and Joan to describe the
context in which a particular problem
arose (an incident of parting, when
John was to leave on a business trip),
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Fami ly Therapy magazi ne
IBCT therapists look for
the softer, more vulnerable feelings and thoughts
that may also exist alongside the harder feelings and
thoughts. IBCT therapists may probe for feelings of
DISAPPOINTMENT, NEGLECT, AND
HURTthat may lie behind the anger and resentment.
AL VIEW RELATIONAL THERAPIES TODAY PROBLEM-CENTERED SYSTEMS BRIEF STRATEGIC FAMILY THERAPY SOCIAL CONSTRU
the triggering events (John failed to tell
Joan of the trip until right before it
happened; Joan blew up at John
about the trip), the sequence of events
that made up the incident (they argued
until John left in a huff), and their
efforts at recovery and reconnection
(e.g., John called later that day and tried
to make nice).
A third strategy for promoting
acceptance is tolerance building. There
are a number of different aspects of tol-
erance building, but one of importance
is to enact negative behavior in the ses-
sion. Since it is impossible for partners
to completely remove negative behavior
that triggers emotional reactions in the
other, it is sometimes helpful to have
partners enact these negative behaviors
in session. For example, Joan may enact
a blow up at John or John might enact
a late notification of an upcoming
trip to Joan. These enactments are
often occasions for empathic joining if
the enactments arouse similar emotions
to the real events (e.g., John gets defen-
sive at Joans reenactment of a blow
up) or are occasions for unified detach-
ment if the enactments lead to a more
detached look at the problem (e.g., Joan
and John both laugh at Johns effort to
stage a late notice). However, the
enactments serve as a reminder for the
couple that these negative actions
will likely occur and give them some
opportunity to experiment with how
they handle them.
These three strategies of empathic
joining, unified detachment, and toler-
ance building are designed to increase
partners emotional understanding and
acceptance of each other. They are not
designed to directly change any of the
offending behaviors that partners may
have listed at the beginning of treatment.
However, emotional understanding and
acceptance often lead to spontaneous
changes in problematic behavior. As John
comes to understand and accept Joans
difficulties with abandonment, he may
alter his behavior in ways that do not
arouse her fears so intensely. Similarly, as
Joan comes to understand and accept
Johns difficulties with control, she may
alter her behavior in ways that do not
arouse his fears so intensely. Thus, impor-
tant changes may follow from the focus
on acceptance.
These three strategies are primarily
evocative rather than prescriptive. That
is, they are designed to evoke a differ-
ent experience of the problem rather
than to prescribe different actions that
the partners should take. The IBCT
therapist does not tell each partner what
he or she should do differently. In fact,
in tolerance building, the therapist may
try to get the partner to enact the very
behavior that is problematic. Even
though the focus is on acceptance, the
IBCT therapist does not tell each part-
ner what should be accepted. The ther-
apist is trying to create conditions that
will lead to greater acceptance.
If these evocative strategies that
focus on greater acceptance are not suf-
ficient to bring about the desired
increase in relationship satisfaction, the
IBCT therapist may also use some of
the well-know, change-oriented, pre-
scriptive strategies of traditional behav-
ior therapy. IBCT therapists may teach
the couple communication training or
problem solving to help them handle
their problems more effectively and
directly. Also, the therapist may have
the partners specify positive events that
each could do to increase the satisfac-
tion of the other and may encourage
them to engage in these positive
actionsthese are familiar strategies of
behavioral approaches of which you are
probably already aware.
Two empirical studies have been
completed on IBCT and a major clini-
cal trial is now in its follow-up stages.
A dissertation by Wimberly in 1997
showed that IBCT administered in
groups was more effective than a wait
list control group. A small study by
Jacobson and colleagues in 2000
showed that IBCT was at least as effec-
tive as traditional behavioral couple
therapy for distressed couples. In the
current, randomized clinical trial, 134
chronically and seriously distressed
couples were treated with either IBCT
or TBCT in Los Angeles or Seattle.
Almost 100 couples wanting treatment
were excluded because they did not
meet the criteria of chronic and serious
distress (they were too happy for the
study). Of this difficult group of 134
couples, 71% of IBCT couples showed
clinically significant improvement or
recovery at the end of treatment com-
pared to 59% for TBCT couples. During
a two-year follow-up period, most cou-
ples in IBCT continued to show greater
improvement than couples in traditional
behavioral couple therapy. This follow-
up data is based on a majority of the cou-
ples, but not all of them, as some have
not reached the 2-year follow-up point.
For more information on IBCT,
consult Jacobson and Christensens
Acceptance and Change in Couple
Therapy (1998), which is the therapists
manual for conducting IBCT, and also
Reconcilable Differences (2000), which
is a book for couples to read as they go
through the treatment.
ANDREW CHRISTENSEN, PHD,
is with the department of
psychology at the University
of California, Los Angeles.
He is the co-developer of
Integrative Behavioral Couple Therapy.
RE F E RE NCE S
CHRISTENSEN, A., & Jacobson, N. S. (2000).
Reconcilable differences. New York:
Guildford.
JACOBSON, N. S. & Christensen, A. (1998).
Acceptance and change in couple therapy: A
therapists guide to transforming relationships.
New York: Norton.
JACOBSON, N. S., Christensen, A., Prince, S. E.,
Cordova, J., & Eldridge, K. (2000). Integrative
behavioral couple therapy: An acceptance-
based, promising new treatment for couple
discord. Journal of Consulting and Clinical
Psychology, 68(2), 351-355.
WIMBERLY, J. D. (1998). An outcome study of
integrative couples therapy delivered in a group
format (Doctoral dissertation, University of
Montana, 1997). Dissertation Abstracts
International: Section B: The Sciences &
Engineering, 58(12-B), 6832.
An earlier version of this article appeared in
Briefings, a news magazine of the California
Psychological Association, Number 160,
April 2003.
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CTIONIST CONSTRUCTIVIST COLLABORATIVE LANGUAGE-BASED MODELS SYMBOLIC EXPERIENTIAL INTERNAL FAMILY SYSTE