Integrative Behavioral Couple Therapy (IBCT)
These IBCT slides are based on a VA training presentation by Andrew Christensen, Ph.D., Professor of Psychology at UCLA, and developer of IBCT (along with the late Neil S. Jacobson of the University of Washington)
Acknowledgment
The VA effort to disseminate training on integrative behavioral couples therapy is part of a national project providing clinician training to promote use of evidence-based treatments. We wish to thank Bradley Karlin, Ph.D., National Mental Health Director, Psychotherapy and Psychogeriatrics, VA Office of Mental Health Services and Susan McCutcheon, RN, EdD., Director, Family Services, Women’s Mental Health & Military Sexual Trauma, VA Office of Mental Health Services for their support of this effort.
VA Training in Evidence-Based Psychotherapies
Background
In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001)
The VA developed a Mental Health Strategic Plan in response to the President’s New Freedom Commission on Mental Health report (2004)
The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country
Goals of VA Training in EBPs
To train VA staff from multiple disciplines in evidence-based psychotherapies
To augment psychotherapies already being offered in VA medical centers
VA Dissemination and Training in EBPs Cognitive Behavioral Therapy (CBT) for Depression and for
Insomnia (CBT-I) Acceptance and Commitment Therapy (ACT) for
Depression Cognitive Processing Therapy (CPT) for PTSD Prolonged Exposure (PE) for PTSD Social Skills Training (SST) for Serious Mental Illness (SMI) Integrative Behavioral Couple Therapy (IBCT) Family Psychoeducation (FPE) for SMI
Behavioral Family Therapy (BFT) Multi-Family Group Therapy (MFGT)
Motivational Interviewing Problem-Solving Therapy
Anticipated EBP Trainings
Interpersonal Therapy (IPT) for Depression Pain Management Substance Use Disorders
Motivational Enhancement Contingency Management Cognitive Behavioral Therapy Behavioral Couples Therapy
EBP Presentations for Interns and Postdoctoral Fellows
VA EBP rollout trainings have been focused on staff
VA Psychology Training Council (VAPTC) developed a workgroup in 2009 to focus on developing EBP didactics for interns and postdoctoral fellows
Goals of this EBP Presentation
To provide a basic working knowledge of each of the rollout EBPs
To provide the foundation for trainees to seek out further training and supervision in the EBPs they intend to implement
Limitations
This presentation will not provide equivalent training to the EBP rollouts
This presentation will not provide the skills to implement the treatment without further training and supervision
INTEGRATIVE BEHAVIORAL COUPLE THERAPY
I
So why did VA choose to disseminate IBCT?
Behavioral foundation made it accessible to many VA clinicians, many of whom have little or no couples experience
Well manualized Inclusion of “acceptance” paradigm consistent
with other EBP roll-outs Existence of a supporting RCT Does not require extensive understanding of
other family intervention concepts (e.g., attachment theory, family systems)
So why did VA choose to disseminate IBCT? In recent years, health care policy has incorporated
evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001)
The VA developed a Mental Health Strategic Plan in response to the President’s New Freedom Commission on Mental Health report (2004)
The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country
PL 110-387 modified Federal Law 38 USC 1782 to specifically include marriage and family counseling as a service that would be provided to family members of Veterans as necessary in connection with the Veterans treatment plan (October, 2008)
Demographics of Couples
About half of first marriages end in divorce Remarriages fare less well Those who remain together
Often unhappy Choice influenced by circumstance
Stable, happy marriage (or happy relationship) a clear minority of marriages/couples
Additional Information on Veteran Couples Veteran couples tend to have additional stressors
impacting their marriage and relationship satisfaction. More than half of first marriages among veterans who
have been exposed to combat end in divorce With regards to recently deployed service members,
divorce rates have been steadily increasing within the Army and the Marines since the recent conflicts began.
For recently returned veterans, 3 years after deployment approximately 40% report relationship difficulties and 35% report having gone through a separation or divorce. Overall, about ¾ of returning veterans report family adjustment difficulties.
Correlates of Discord & Divorce
Impact on Partners Mental health: depression, anxiety, loneliness Physical health: variety of stress-related ills Financial health: women particularly suffer
Impact on Children Short-term impact: externalizing &
internalizing problems Long-term impact: divorce, trust
Evidence-based Treatments (EBTs) for Couples
Non-Behavioral Approaches Emotionally Focused Couple Therapy Insight Oriented Couple Therapy
Behavioral Couple Therapy Traditional Behavioral Couple Therapy Cognitive Behavioral Couple Therapy Integrative Behavioral Couple Therapy
“Acceptance Therapy”
Similarities and Differences in EBTs Similarities are great
Dyadic conceptualization Alter destructive interactions Promote constructive communication Build on strengths
Substantial differences exist
Principles of Treatment that Distinguish Behavioral Couple EBTs
Theoretical underpinnings Problem definition:
Molar vs. molecular definitions Types of change
Acceptance vs. change Strategies for inducing change
Structured vs. naturalistic change
Two Ways to Define Problems
Molecular Pinpoint specific behaviors, cognitions Pros: well defined, easily understood Cons: long list, miss forest for trees,
premature definition, solidification Molar
Define response class, broad patterns Pros: breath of coverage, big picture view Cons: less well defined, more messy
Two Types of Changes
Traditional change Modification of the agent or “perpetrator” Increase or decrease in frequency, intensity,
or duration of behavior Acceptance
Modification of the recipient or “victim” Change in emotional reactivity
What is “Acceptance” in IBCT? What it IS NOT:
Resignation, submission, giving in Permission to be abusive
What it IS: Problems as a window into vulnerability Problems as a vehicle for intimacy Letting go of the struggle to change Reducing adversarial relationship
Two Types of Behavior
Rule-governed behavior Follow the rule; “shoulds” Sanctions for violation; reinforcement for compliance E.g., exercise, listen, obligatory compliments When emotions/motives suggest otherwise
Contingency-shaped behavior Situation naturally elicits and reinforced; “Want to’s” Be yourself, let guard down, say what on mind E.g., exercise, listening, genuine compliments When emotions/motives are congruent
Two Strategies of Change
Rule-governed (structured/deliberate) change Suggest/impose new rules (dates, accept, think) Help couples negotiate new rules Dilemma: behaviors versus emotions; compliance;
inauthentic/unnatural, not naturally reinforcing Contingency-shaped (naturalistic/”spontaneous”)
change Elicit/evoke new reactions, experiences Reinforce new responses Dilemma: what will elicit a new experience
Example: “Always” or “Never” Traditional BCT
Communication error Practice correctly
Cognitive Behavior Therapy Look for exceptions Correct cognitive error
Integrative Behavioral Couple Therapy Catch it in session or discuss a recent incident of it Explore what is going on with the one who said it Explore impact on partner
Integrative BehavioralCouple Therapy (IBCT) Functional analytic behavioral views Emphasis on broad, molar themes Emphasis on acceptance Emphasis on contingency shaped behavior
To foster acceptance To foster change
Also includes alternative strategies
Relationship Problems as Defined by Couples in Therapy
Faults lie in the Partner The Verdict: Partner is guilty of selfishness,
inconsideration, etc. The Diagnosis: Partner is mentally ill (neurotic,
afraid to be intimate, mentally or chemically imbalanced)
The Performance Evaluation: Partner is inadequate (does not measure up, unable to communicate/love, needs to improve)
IBCT Formulation ofRelationship Problems DEEP analysis of an issue (content area)
Differences or incompatibilities Emotional sensitivities External circumstances/stressors Patterns of problematic interaction
Patterns of problematic interaction Couple’s efforts to cope with DEE Interaction makes the problem worse
Common Individual Differences: Sources of Incompatibility
Personality differences (Big 5) Differences in levels of sexual interest Differences in link to family of origin Differences in desire for closeness Differences in coping with stress Differences in interests Differences result from genes, social learning
history, gender, socio-economic status, and culture
Emotional Sensitivities
Don’t ever leave me Stand by me
Don’t smother me Give me freedom to be me
Don’t criticize me Accept me, faults and all
Don’t try to control me I’m in charge of myself
Emotional Sensitivities
Don’t treat me like I’m crazy Validate that I’m normal
Don’t ignore me Listen to me
Don’t treat me like a kid Tell me I am competent
Don’t treat me like I’m unattractive Desire me
Origin of Emotional Sensitivities Genes and social learning history Gender: views of masculinity, femininity Socio-economic status: e.g., employment,
financial security Culture: e.g., views of privacy, responsibility
to family, emotional expression
External Stressors Anything outside the couple relationship Common stressors
Children, family of origin Career, finances Illness Friends, neighbors
Patterns of Problematic Interaction Pattern of problematic interaction = repetitious,
dysfunctional cycle of communication Major types of dysfunctional interaction
Moving against the other Moving away from the other Hanging on to the other (moving toward the other
anxiously)
Moving against the Other
Criticizing, blaming, fault finding, attacking, finger pointing
Demanding, pushing, nagging, pressuring, reminding, correcting
Controlling, competing, showing who is right, allying with others against partner
Arguing, escalating, exaggerating
Moving away from the Other
Withdrawing, escaping, avoiding, distancing, shutting down
Hiding, evading, being secretive, misleading Dismissing, minimizing, or denying other’s
concerns, resisting other’s efforts Defending, justifying, or explaining self
Hanging onto the Other
Pursuing, clinging, hovering, not letting other go
Intruding, invading, being nosey, not letting other have privacy
Questioning, investigating, interrogating, monitoring, keeping watch over other, keeping tabs on other
What Makes these Behaviors Problematic? Context is all – nothing occurs in isolation
Adversarial vs. supportive context – e.g., fault finding, arguments, hanging on: Adversaries
Context of tense distance versus independence – e.g., uncommunicative, withdrawn: Strangers
Short- vs. long-term consequences Short-term gain but long-term pain - editing Short-term pain but long-term gain- editing
Problematic Patterns of Interaction
Asymmetrical patterns Moving against vs. moving away
Discuss/avoid pattern Demand/withdraw pattern
Hanging onto vs. moving away Pursuit/distance pattern Invading/evading pattern
Symmetrical patterns Mutual moving against
Argumentative, bickering pattern Mutual moving away
Mutual avoidance, shutting down pattern
IBCT Formulation: Trust Example
Differences Social skills, views of contact with friends
Emotional reactions/sensitivities Parent’s affair, search for autonomy, early
relationship history External circumstances/stressors
Work contact with colleagues Pattern of interaction
Questioning-checking; evading-hiding
IBCT Formulation: Depression Example
Differences Optimism, outspokenness
Emotional Reactions/Sensitivities Fear of caretaking; sensitivity to criticism
External Circumstances/Stressors Difficulty finding work, doing responsibilities
Patterns of Interaction Demanding criticism/defensive-withdrawal
IBCT Formulation: PTSD Example Differences
Comfort with expression of negative emotion Emotional Reactions/Sensitivities
Fear of strong emotional reactions; fear of PTSD stimuli External Circumstances
Noisy, bad area of town Patterns of Interaction
Avoidant tiptoeing/numbing avoidance followed by explosive reactions
Applications of DEEP Analysis Can be applied to specific problems, such as
trust, money, depression Often the model applies more broadly
Responsibilities – housekeeping, kids, social contacts, job
Closeness – time together, time with friends, time with family, disclosures, privacy
Emotionality – about work, kids, home, each other
Integrative Behavioral Couple Therapy (IBCT): Distress = Content problem/s –theme; can center on diagnosis DEEP Analysis
Differences/incompatibilities Emotional reactions/sensitivities/vulnerabilities External circumstances/stressors Patterns of communication/interaction
Outcome Bigger problem: escalation, polarization, vilification Adversaries or strangers; emotionally trapped –
hopeless/helpless
Inappropriate Couples for IBCT
Exclusionary individual factors Untreated substance abuse/dependence Psychosis, Antisocial Personality Disorder Moderate to severe violence
Injury and/or intimidation Exclusionary couple factors
Not living together regularly One or both not committed to relationship One wants to end relationship
Overview of IBCT Assessment phase
1 joint and 2 individual sessions Clinical formulation and feedback
1 joint session Active treatment
Multiple joint sessions Termination
Spaced joint sessions
Assessment and Feedback:Format Initial session with both partners
Presenting problems and context Relationship history Assign measures, book
Individual interviews with each partner Presenting problems and context Individual history and current social context
Feedback session with both partners Feedback on assessment; outline of treatment
Purpose of Assessment Distress – interview and questionnaires
Couple Satisfaction Inventory (CSI-16) (Funk & Rogge, 2007) http://www.courses.rochester.edu/surveys/funk/
Violence – questionnaires and interview Brief items on violence and intimidation
Commitment & affairs – interview, questionnaires Brief items on commitment
Problematic Issues & Patterns- interview, questionnaires Formulation (Model of distress; DEEP analysis)
Strengths (individual and joint) - interview
Initial Session
Presenting problems and goals Discover issues, interactions, and goals Each speaks, but only for self Therapy neutrality – support both Vague specific; impersonal personal
Relationship history Attractions, early history Development of problem Current situation
Summary, administer measures, assign Reconcilable Differences book
Overview of Measures
Demographic Questionnaire for Couples Age, time together, children, medications, etc.
Couple Satisfaction Index (CSI-16) Measure of relationship quality
Problem Areas Questionnaire Content areas of concerns –issues/theme
Couple Questionnaire CSI-4 (baseline), violence, commitment
Communication During Conflict Questionnaire Pattern of interaction
Individual Session
Confidentiality assurance Issues, interactions, goals
From measures and first session Violence, commitment, affairs
From measures and first session Personal history & current situation
Personal psychiatric history Family of origin (parent’s marriage, relationship with
each parent) Relationship history (e.g., previous marriage) Current situation
Feedback Session Level of distress and commitment Case Formulation
Problematic issues – theme Provide education about disorder as appropriate
Differences or incompatibilities Emotional reactions/sensitivities/vulnerabilities External circumstances/stressors Patterns of communication/interaction Impact – hopeless/helpless, adversaries/strangers
Strengths – individual and couple Treatment – goals, incidents, issues
Go over Weekly Questionnaire as guide
Therapeutic Goals of IBCT:Acceptance and Change Primarily Acceptance for
Differences Emotional sensitivities
Acceptance and change for External stressors
Primarily Change for Patterns of problematic interaction
Therapeutic Methods in IBCT Guiding Formulation – DEEP understanding Focus on emotionally salient, in-vivo experience
Events in therapy that reflect formulation Recent or upcoming incidents that reflect formulation Issues of current concern that reflect formulation
Strategies: Affective change – “Empathic Joining”: New emotional
experience of problem Cognitive change: “Unified Detachment”: New
perspective on the problem Behavioral change: New coping with problem
Three Typical Therapeutic Discussions in IBCT
Compassionate discussions - empathic joining Analytical discussions – unified detachment Practical discussions – making concrete changes
Format for Treatment Sessions
Weekly Questionnaire; check-in Review violent/destructive event, major changes Debrief positive events Set agenda based on client reported incidents/issues
Use of Weekly Questionnaire Use interventions for incidents/issues Shift agenda as problem discussion leads to problem Wind down and summary
Questionnaire, homework
Who Talks to Whom?
Each partner talks to the therapist Therapist has most control Therapist insures hearing and validation for each Therapist can reinforce each appropriately Therapist can transition effectively Less generalization
Couple talks to each other Therapist directs the discussion - enactments Therapist intervenes in the discussion Therapist watches and applauds discussion
Empathic Joining - Purpose
Heart-to-heart discussion of a significant relationship experience
Both partners share feelings, some that they may not have shared before
Partners experience understanding and validation, from therapist & partner
Partners experience greater intimacy and emotional acceptance
Empathic Joining:Therapeutic Strategy Be attentive to emotional reactions
Primary, initial, unrevealed, soft emotions Versus secondary, reactive, hard emotions
Prompt personal disclosure Probe, explore, elicit, suggest emotions Highlight, validate and reflect emotions Prompt disclosure to partner Prompt partner response (e.g., summary,
reaction)
Unified Detachment - Purpose
Intellectual discussion about a significant relationship experience
Partners reveal thoughts, views, perspectives, and observations
Discussion of relationship experience is descriptive, nonjudgmental, dyadic, and mindful versus evaluative, blaming, individually oriented and
responsibility-seeking Partners often feel a sense of common, unified
perspective on a problem and greater acceptance of the problem
Unified Detachment:Therapeutic Strategies Engage couple in a discussion that
Describes sequence and patterns Identifies “triggers” and “buttons” Makes comparisons/contrasts (e.g., ratings) Distinguishes intentions from effects Employs humor, metaphor, and images Treats the problem as an “it” versus a “you”
Direct Change - Purpose
Communicate more effectively Problem solve more effectively Increase positive interactions Increase tolerance of negative events Partners often experience a greater sense of
confidence and control
Direct Change - Strategies
Strategies Prompt existing behavioral repertoires first Teach new communication/problem solving strategies
or suggest new positive events secondarily Interventions
Replay difficult interactions Discuss vexing problems and possible solutions Identify, prompt, & debrief positive actions Teach traditional CT/PST (Communication
Training/Problem Solving Training) Conduct tolerance interventions
How to Intervene in Problematic Interactions Interrupt the process early
Reframe, redirect, and referee interaction Empathic joining:
Identify primary emotional responses Reflect, elaborate, discuss
Discuss functional relationships Enactment, replay
How to Intervene in Improved Interactions Goal – ensure partners are reinforced Leave it alone if partners reinforced If not reinforced sufficiently
Highlight the reactions each had Normalize awkwardness, embarrassment Reinforce directly if partner won’t Help partners understand why
Discuss functional relations
Behavior Exchange:Increasing Positive Behavior
Specification of changes Everyday Small Interpersonal Positive Low cost Action not inaction What do instead of ….
Instigation of positive changes Debriefing of positive changes
Communication Training
Expresser skills - no fault communication Non-blaming “I” statements of feeling Partner’s specific behavior in situation “When you do X in Y situation, I feel Z”
Listener Skills Active listening: paraphrase, reflection Check out, summary before change roles
Problem Solving Training
Problem Definition Acknowledge positive Define problem (unilaterally or bilaterally) Acknowledge own role
Problem Solution Brainstorming Pros and Cons Negotiation; Agreement; Experimentation
Tolerance Building Tolerance is on continuum of acceptance:grudging tolerance ------- embracing differences
Goals of tolerance interventions Make partner’s behavior less painful Enhance ability to cope Decrease intensity of conflict Shorten duration of recovery
Types of tolerance interventions: Highlight positive features of negative behavior Rehearsal of negative behavior (desensitization) Faking of negative behavior (relapse prevention) Self-care: Promotion of independence, self-reliance
Ordering of Interventions
Start with Empathic Joining & Unified Detachment, not Direct Change Interventions Partners get heard, understood, and true issues and
feelings exposed May on its own trigger improved functioning
Integrate Empathic Joining and Unified Detachment Debriefing incident in or out of therapy
When doing Direct Change Interventions Prompt existing behaviors before teaching new
behaviors
Ordering of Interventions - Continued
Tolerance interventions are: Done later rather than earlier Are used when couples have some distance
Adapt interventions to the couple Capitalize on their strengths (e.g., humor) Address needed deficits (e.g., difficulty in
expressing emotion, shutting down during difficult communication)
Repeat what works
Termination Phase
When should you begin termination? Significant progress made Couple desires termination Little of emotional significance to discuss Note – 26 sessions maximum in clinical trial
Process of termination Space sessions at longer intervals Allow booster sessions as needed Post measures – feedback to couple
Desired Outcomes
Couples who can not learn from the past are condemned to repeat it (Santayana)
The unexamined relationship is not worth living (Socrates)
Goal: A more accepting and adaptive relationship based on the psychological reality of each partner
Empirical Evidence for IBCT
John Wimberly Dissertation, 1997 17 couples (8 IBCT vs. 9 wait list control) IBCT (group Rx) > wait list control
Jacobson et al., 2000 21 married couples (10 IBCT; 11 TBCT) Clinically significant change by termination
TBCT – 64%; IBCT - 80% reliable improvement or recovery
Christensen et al. (2004; 2006, 2010)
Current On-going Study
NIMH Multi-Site Study of Marital Therapy Los Angeles & Seattle: 134 married couples Comparing Traditional Behavioral Couple
Therapy (TBCT) (68) vs. IBCT (66) 26 sessions of treatment plus 2 year follow-
ups Special Features
Seriously and stably distressed couples High quality therapy
Data on Current Study Termination Data
Couples in TBCT improve quickly but plateau; couples in IBCT improve steadily throughout treatment
Couples showing clinically significant improvement: 60.6% TBCT; 70.3% IBCT
Two year follow-up data Significantly greater maintenance of changes in
relationship satisfaction in IBCT than TBCT through 2 years of follow-up assessments
IBCT showed significantly greater maintenance of gains in observed communication at 2 year follow-up
Couples showing clinically significant improvement: 60% TBCT; 69% IBCT
Separations/divorces (15-20%)
Data on Current Study
5 year follow-up data Separation/divorce: 28% TBCT; 26% IBCT Effect size: 0.92 TBCT; 1.03 IBCT Cl. Sig. Improvement: TBCT – 46%; IBCT – 50%
Conclusions about TBCT and IBCT Similar, substantial improvement during Rx Substantial maintenance for 2 years post treatment Greater maintenance of gains in IBCT for 2 yrs Without booster sessions, some loss of gains from 3-5
years and convergence of treatment effects Seriously distressed couples may need additional
booster sessions post treatment
Treatment manuals
For Therapists Jacobson, N.S., & Christensen, A. (1996).
Acceptance and Change in Couple Therapy: A Therapist’s Guide to Transforming Relationships. New York: Norton.
For Couples and Therapists Christensen, A., & Jacobson, N.S. (2000).
Reconcilable Differences. New York: Guilford.