"Couples are often uncertain what to expect from the process of couples therapy. They are not sure of what to expect of the therapist or even if the therapist has any expectations of them.
I have found most couples approach therapy with the notion that each person will describe their distress and somehow the therapist will assist them to create a happier, more functional, relationship. They expect to learn some new or better skills. However, most people hope their partner will do most of the learning in problem areas.
After 30 years of clinical experience and specializing in working with thousands of couples, I have arrived at some guidelines that can make our work more effective. First, I do have some expectations of you. I am not neutral. I have evolved principles and concepts that I believe give us the greatest chance for success.
I believe my primary role is to help you improve your responses to each other without violating your core values or deeply held principles. So that you may know some of my key guiding principles, I have created this document to provide clarity and focus to our work.
Your job is to create your own individual objectives for being in therapy. Like a good coach, my job is to help you reach them. I have many, many tools to help you become a more effective partner - they work best when you are clear about how you aspire to be.
Goals and Objectives of Couples Therapy
The major aim of therapy is increasing your knowledge about yourself, your partner and the patterns of interaction between you. Therapy becomes effective as you apply new knowledge to break ineffective patterns and develop better ones.
The key tasks of couples therapy are increasing your clarity about:
- The kind of life you want to build together
- The kind of partner you aspire to be in order to build the kind of life and relationship you want to create
- Your individual blocks to becoming the kind of partner you aspire to be
- The skills and knowledge necessary to do the above tasks
Tradeoffs and Tough Choices
To create sustained improvement in your relationship you need:
- A vision of the life you want to build together
- To have a life separate from your partner because you are not joined at the hip
- The appropriate attitudes and skills to work as a team
- The motivation to persist
- Time to review progress
To create the relationship you really desire, there will be some difficult tradeoffs and tough choices for each person.
The first tradeoff will be time. It simply takes time to create a relationship that flourishes: time to be together, time to be with family, time to play, coordinate, nurture, relax, hang out and plan. This time will encroach on some other valuable areas – your personal or professional time.
The second compromise is comfort. That means emotional comfort, like going out on a limb to try novel ways of thinking or doing things, listening and being curious instead of butting in, speaking up instead of becoming resentfully compliant or withdrawing. At the beginning, there will be emotional risk taking action, but you will never explore different worlds if you always keep sight of the shoreline. In addition, few people are emotionally comfortable being confronted with how they don't live their values or being confronted with the consequences of their actions.
The other comfort that will be challenged is energy comfort. It simply takes effort to sustain improvement over time: staying conscious of making a difference over time, remembering to be more respectful, more giving, more appreciative etc. It takes effort to remember and act.
The other effort is even more difficult for some people: that is improving their reaction to problems. For example, if one person is hypersensitive to criticism, and his/her partner is hypersensitive to feeling ignored, it will take effort to improve their sensitivity instead of hoping the partner will stop ignoring or criticizing.
In all these areas, there is generally a conflict between short-term gratification and the long-term goal of creating a satisfying relationship. The blunt reality is that, in an interdependent relationship, effort is required on the part of each person to make a sustained improvement. It is like pairs figure skating – one person cannot do most of the work and still create an exceptional team.
How to Maximize the Value from your Couples Therapy Sessions
A common yet unproductive pattern in couple's therapy is making the focus be whatever problem happens to be on someone's mind at the moment. This is a reactive (and mostly ineffective) approach to working things through.
The second unproductive pattern is showing up and saying, "I don't know what to talk about, do you?" While this blank slate approach may open some interesting doors, it is a hit or miss process.
The third common unproductive pattern is discussing whatever fight you are now in or whatever fight you had since the last meeting. Discussing these fights/arguments without a larger context of what you wish to learn from the experience is often an exercise in spinning your wheels.
Over time, repeating these patterns will lead to the plaintive question, "Are we getting anywhere?"
A more powerful approach to your couple's therapy sessions is for each person to do the following before each session:
1. Reflect on your objectives for being in therapy.
2. Think about your next step that supports or relates to your larger objectives for the kind of relationship you wish to create, or the partner you aspire to become.
This reflection takes some effort. Yet few people would call an important meeting and then say, "Well, I don't have anything to bring up, does anyone else have anything on their agenda?" Your preparation will pay high dividends.
Important Concepts for Couples Therapy and Relationships
The following ideas can help identify areas of focus in our work and/or stimulate discussion between you and your partner between meetings. If you periodically review this list, you will discover that your reflections and associations will change over time. So please revisit this list often, it will help you keep focus during our work.
Attitude is Key
When it comes to improving your relationship, your attitude toward change is more important that what action to take.
Identifying what to do and how to do it is often easy to identify. The bigger challenge is why you don't do it.
How to think differently about a problem is often more effective than just trying to figure out what action to take.
Your partner is quite limited in his/her ability to respond to you. You are quite limited in your ability to respond to your partner. Accepting that is a huge step into maturity.
The definite possibility exists that you have some flawed assumptions about your partner's motives. And that he/she has some flawed assumptions about yours. The problem is, most of the time we don't want to believe those assumptions are flawed.
Focus on Changing Yourself Rather than Your Partner
Couples therapy works best if you have more goals for yourself than for your partner. I am at my best when I help you reach objectives you set for yourself.
Problems occur when reality departs sharply from our expectations, hopes, desires and concerns. It's human nature to try and change one's partner instead of adjusting our expectations. This aspect of human nature is what keeps therapists in business.
The hardest part of couples therapy is accepting you will need to improve your response to a problem (how you think about it, feel about it, or what to do about it). Very few people want to focus on improving their response. It's more common to build a strong case for why the other should do the improving.
You can't change your partner. Your partner can't change you. You can influence each other, but that doesn't mean you can change each other. Becoming a more effective partner is the most efficient way to change a relationship.
It's easy to be considerate and loving to your partner when the vistas are magnificent, the sun is shining and breezes are gentle. But when it gets bone chilling cold, you're hungry and tired, and your partner is whining and sniveling about how you got them into this mess, that's when you get tested. Your leadership and your character get tested. You can join the finger pointing or become how you aspire to become.
Nothing is impossible for the person who doesn't have to do it.
Fear lets you know you're not prepared. If you view fear in that mode, it becomes a signal to prepare the best you can.
You can learn a lot about yourself by understanding what annoys you and how you handle it.
The more you believe your partner should be different, the less initiative you will take to change the patterns between you.
Zen Aspects of Couples Therapy (Some Contradictions)
All major goals have built in contradictions, for example, speak up or keep the peace.
All significant growth comes from disagreements, dissatisfaction with the current status, or a striving to make things better. Paradoxically, accepting that conflict produces growth and learning to manage inevitable disagreements is the key to more harmonious relationships.
It's not what you say. It's what they hear.
Solutions, no matter how perfect, set the stage for new problems.
Tough Questions
Asking good questions--of yourself and your partner--helps you uncover causes beneath causes.
In a strong disagreement, do you really believe your partner is entitled to their opinion?
Under duress, do you have the courage and tenacity to seek your partner's reality and the courage to express your reality when the stakes are high?
Why is it important to let your partner know what you think, feel and are concerned about? (Because they really can't appreciate what they don't understand.)
What is the price your partner will have to pay to improve their response to you? How much do you care about the price they will have to pay? (Everything has a price and we always pay it.)
Can you legitimately expect your partner to treat you better than you treat him/her?
If you want your partner to change, do you think about what you can do to make it easier?
When a problem shows up, it's natural to think "What should I do about it?" A much more productive question is. "How do I aspire to be in this situation?"
The Importance of Communication
The three most important qualities for effective communication are respect, openness and persistence.
Good communication is much more difficult than most people want to believe. Effective negotiation is even harder.
A couple's vision emerges from a process of reflection and inquiry. It requires both people to speak from the heart about what really matters to each.
We are all responsible for how we express ourselves, no matter how others treat us.
Communication is the number one presenting problem in couples counseling. Effective communication means you need to pay attention to:
- Managing unruly emotions, such as anger that is too intense
- How you are communicating – whining, blaming, vague, etc.
- What you want from your partner during the discussion
- What the problem symbolizes to you
- The outcome you want from the discussion
- Your partner's major concerns
- How you can help your partner become more responsive to you
- The beliefs and attitudes you have about the problem.
No wonder good communication is so hard.
Some Final Thoughts…
You can't create a flourishing relationship by only fixing what's wrong. But it's a start.
Grace under pressure does not spring full-grown even with the best of intentions - practice, practice and more practice. Practice the right things and you will get there.
Love is destroyed when self-interest dominates.
If you don't know what you feel in important areas of your relationship, it is like playing high stakes poker when you see only half your cards. You will make a lot of dumb plays.
The possibility exists that we choose partners we need but don't necessarily want.
To get to the bottom of a problem often means you first accept how complex it is.
Trust is the foundational building block of a flourishing relationship. You create trust by doing what you say you will do.
It's impossible to be in a highly inter-dependent relationship without ever being judgmental or being judged.
If you strive to always feel emotionally safe in your relationship and get it, you will pay the price by becoming dull.
If neither of you ever rocks boat, you will end up with a dull relationship
Knowledge is not power. Only knowledge that is applied is power.
Most of the ineffective things we do in relationships fall into just a few categories:
- Blame or attempt to dominate
- Disengage/withdraw
- Resentful compliance
- Whine
- Denial or confusion.
These are the normal emotional reactions to feeling a threat or high stress. Improving your relationship means better management of these reactions.
Everything you do works for some part of you, even if other parts of you don't like it.
Three motivations will govern any sustained effort you make. You will seek to:
1. Avoid pain or discomfort
2. Create more benefits
3. Be a better person. It's also true for your partner.
If you are asking your partner to change something, sometimes it's a good idea to ask if the change is consistent with how they aspire to be in that situation.
Businesses and marriages fail for the same three reasons. A failure to:
- Learn from the past
- Adapt to changing conditions
- Predict probable future problems and take action.
Effective change requires insight plus action. Insight without action is passivity. Action without insight is impulsive. Insight plus action leads to clarity and power.
If you want to create a win-win solution, you cannot hold a position that has caused your partner to lose in the past.
"To be a champ you have to believe in yourself when nobody else will." Sugar Ray Robinson –Middleweight boxing champion, considered by many to be the best fighter in history, pound-for-pound.
P.S. please review this document periodically as there is simply too much to absorb in one reading of it. We all will benefit from your efforts."
© Copyright MMIII The Couples Institute
By Michele Weiner Davis, The Divorce Busting Center & DivorceBusting.com Published: November 10, 2004
Married With Problems? Therapy May Not Help By SUSAN GILBERT
Extensive relationship counseling research notes & links, focus on integrative and empirically validated methods & reviews Retrieved from Wikipedia 14/12/09 from Research studies http://ibct.psych.ucla.edu/
Published: April 19, 2005 http://www.nytimes.com/2005/04/19/health/psychology/19coup.html?pagewanted=1&_r=1
With an experimental approach called integrative behavioral couples therapy, for example, 67 percent of couples significantly improved their relationships for two years, according to a study reported in November to the Association for the Advancement of Behavior Therapy.
Instead of teaching couples how to avoid or solve arguments, as traditional counseling techniques do, the integrative therapy aims to make arguments less hurtful by helping partners accept their differences. It is based on a recent finding that it is not whether a couple fights but how they fight that can destroy a relationship. ...
Three types of couples therapy have been found to improve people's satisfaction with their marriage for at least a year after the treatment ends. The oldest approach, developed more than 20 years ago but still widely used, is behavioral marital therapy, in which partners learn to be nicer to each other, communicate better and improve their conflict-resolution skills.
Another, called insight-oriented marital therapy, combines behavioral therapy with techniques for understanding the power struggles, defense mechanisms and other negative behaviors that cause strife in a relationship. With each method, about half of couples improve initially, but many of them relapse after a year.
A relatively new approach that studies have found highly effective is called emotionally focused therapy, with 70 to 73 percent of couples reaching recovery - the point where their satisfaction with their relationship is within normal limits - for up to two years, the length of the studies.
Dr. Johnson, who helped develop emotionally focused therapy in the 1990's, said that it enabled couples to identify and break free of the destructive emotional cycles that they fell into. "A classic one is that one person criticizes, the other withdraws," she said. "The more I push, the more you withdraw. We talk about how both partners are victims of these cycles." As the partners reveal their feelings during these cycles, they build trust and strengthen their connection to each other, she said. Surprisingly, Dr. Johnson said, until emotionally focused therapy came along, therapists were so intent on getting couples to make contracts to change their behavior that they did not delve into the emotional underpinnings of a relationship. "It was like leaving chicken out of chicken soup," she said.
Dr. Johnson's latest research, completed in January, included 24 of the most at-risk couples, people who were unable to reconcile because their trust in each other had been shattered by extramarital affairs and other serious injuries to their relationship. "These injuries are like a torpedo," she said. "They take a marriage down." The study found that after 8 to 12 sessions, a majority of the couples had healed their injuries and rebuilt their trust. Most important, these gains lasted for three years. "It's very satisfying to know that we can make a difference with these couples and that it sticks," Dr. Johnson said. Alice, a library program coordinator in Honesdale, Pa., credits her couples therapy, which focused on emotional issues, with getting her and her husband to reunite after a yearlong separation. "The marriage counselor brought us back together," she said. Alice, who did not want her last name used out of privacy concerns, said an important catalyst for their reunion was the therapist's asking each to think about the ways that the other person wanted to feel appreciated and loved. Gradually, she said, she has come to see that her husband's needs were different from her own. "Going back to this exercise is one thing that has gotten us through hard times," she said.
Researchers have begun to identify which qualities in a couple make for a lasting relationship.
The findings challenge some common assumptions - that couples who fight a lot are beyond help, for example. Over more than two decades of videotaping and analyzing the behavior of happy and unhappy couples, Dr. Gottman has found that all couples fight and that most fights are never resolved. What is different between happy and unhappy couples is the way they fight.
The happy couples punctuate their arguments with positive interactions, he said, like interjecting humor or smiling in fond recognition of a partner's foibles. The unhappy couples have corrosive arguments, characterized by criticism, defensiveness and other negative words and gestures. Of course, even the happiest of couples can get nasty sometimes. But Dr. Gottman has found that as long as the ratio of positive to negative interactions remains at least five to one, the relationship is sturdy. When the ratio dips below that, he says, he can predict with 94 percent accuracy that a couple will divorce. Dr. Gottman says that couples therapists can use this information to help keep couples together. "You can't just teach a couple to avoid conflict," he said. "You have to build friendship and intimacy into the relationship. If you don't, the relationship gets crusty and mean."
J Consult Clin Psychol. 2000 Apr;68(2):351-5. Integrative behavioral couple therapy: an acceptance-based, promising new treatment for couple discord. Jacobson NS, Christensen A, Prince SE, Cordova J, Eldridge K. Department of Psychology, University of Washington, USA. Although traditional behavioral couple therapy (TBCT) has garnered the most empirical support of any marital treatment, concerns have been raised about both its durability and clinical significance. Integrative behavioral couple therapy (IBCT) was designed to address some of these limitations by combining strategies for fostering emotional acceptance with the change-oriented strategies of TBCT. Results of a preliminary clinical trial, in which 21 couples were randomly assigned to TBCT or IBCT, indicated that therapists could keep the 2 treatments distinct, that both husbands and wives receiving IBCT evidenced greater increases in marital satisfaction than couples receiving TBCT, and that IBCT resulted in a greater percentage of couples who either improved or recovered on the basis of clinical significance data. Although preliminary, these findings suggest that IBCT is a promising new treatment for couple discord. PMID: 10780137 [PubMed - indexed for MEDLINE]
J Consult Clin Psychol. 2004 Apr;72(2):176-91. Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. Christensen A, Atkins DC, Berns S, Wheeler J, Baucom DH, Simpson LE. Department of Psychology, University of California, Los Angeles, Los Angeles, CA 90095-1563, USA. christensen@psych.ucla.edu Comment in: • Evid Based Ment Health. 2004 Nov;7(4):117. A randomized clinical trial compared the effects of traditional behavioral couple therapy (TBCT) and integrative behavioral couple therapy (IBCT) on 134 seriously and chronically distressed married couples, stratified into moderately and severely distressed groups. Couples in IBCT made steady improvements in satisfaction throughout the course of treatment, whereas TBCT couples improved more quickly than IBCT couples early in treatment but then, in contrast to the IBCT group, plateaued later in treatment. Both treatments produced similar levels of clinically significant improvement by the end of treatment (71% of IBCT couples and 59% of TBCT couples were reliably improved or recovered on the Dyadic Adjustment Scale; G. B. Spanier, 1976). Measures of communication also showed improvement for both groups. Measures of individual functioning improved as marital satisfaction improved. PMID: 15065953 [PubMed - indexed for MEDLINE]
J Consult Clin Psychol. 2005 Aug;73(4):624-33. Improving relationships: mechanisms of change in couple therapy. Doss BD, Thum YM, Sevier M, Atkins DC, Christensen A. University of California, Los Angeles, USA. doss@psyc.tamu.edu In a sample of 134 married couples randomly assigned to traditional or integrative behavioral couple therapy (TBCT vs. IBCT), a multivariate hierarchical growth curve analysis using latent variable regression revealed that measures of communication, behavior frequency, and emotional acceptance acted as mechanisms of change. TBCT led to greater changes in frequency of targeted behavior early in therapy, whereas IBCT led to greater changes in acceptance of targeted behavior both early and late in therapy. In addition, change in behavioral frequency was strongly related to improvements in satisfaction early in therapy; however, in the 2nd half of therapy, emotional acceptance was more strongly related to changes in satisfaction. Research and clinical implications are discussed. Copyright 2005 APA, all rights reserved. PMID: 16173850 [PubMed - indexed for MEDLINE]
J Consult Clin Psychol. 2006 Dec;74(6):1180-91. Couple and individual adjustment for 2 years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Christensen A, Atkins DC, Yi J, Baucom DH, George WH. Department of Psychology, University of California, Los Angeles, CA 90095-1563, USA. Christensen@psych.ucla.edu Follow-up data across 2 years were obtained on 130 of 134 couples who were originally part of a randomized clinical trial comparing traditional versus integrative behavioral couple therapy (TBCT vs. IBCT; A. Christensen et al., 2004). Both treatments produced similar levels of clinically significant improvement at 2 years posttreatment (69% of IBCT couples and 60% of TBCT couples). Both treatments showed a "hockey-stick" pattern of change in which satisfaction dropped immediately after treatment termination but then increased for most of follow-up. The break point when couples reversed courses and gained in satisfaction occurred sooner for IBCT than TBCT couples, and those couples who stayed together generally fared better in IBCT than in TBCT. Finally, there was evidence of greater stability during follow-up in IBCT than in TBCT couples. There was little change in individual functioning over follow-up, but when change occurred it was strongly related to change in marital satisfaction. Given that this sample was selected for its significant and chronic distress, the data are encouraging about the long-term impact of behavioral couple therapy. ((c) 2006 APA, all rights reserved). PMID: 17154747 [PubMed - indexed for MEDLINE]
BUT:
Behav Ther. 2008 Jun;39(2):137-50. Epub 2007 Nov 19. Observed communication and associations with satisfaction during traditional and integrative behavioral couple therapy. Sevier M, Eldridge K, Jones J, Doss BD, Christensen A. California State University, Fullerton, CA 92834, USA. msevier@exchange.fullerton.edu To investigate changes in couple communication and potential mechanisms of change during treatment, 134 distressed couples, who were randomly assigned to either traditional or integrative behavioral couple therapy (TBCT; IBCT), were observed in relationship and personal problem discussions prior to and near the end of treatment. Analyses were conducted using the Hierarchical Linear Modeling program. Over the time in therapy, during relationship problem discussions, positivity and problem solving increased while negativity decreased. Compared to IBCT, TBCT couples had the largest gains in positivity and reductions in negativity. During personal problem discussions, negativity decreased, while withdrawal increased and positivity decreased. TBCT couples had larger declines in negativity. In both discussion types, increases in marital satisfaction were associated with increases in positivity and problem solving. Declines in marital satisfaction were associated with increased negativity during relationship problem interactions and increased withdrawal during personal problem interactions. However, no treatment differences in these associations were found. Differences in rule-governed and contingency-shaped behavior change strategies between the two therapies and implications of findings are discussed. PMID: 18502247 [PubMed - indexed for MEDLINE]
J Consult Clin Psychol. 2009 Feb;77(1):160-73. Prediction of response to treatment in a randomized clinical trial of couple therapy: a 2-year follow-up. Baucom BR, Atkins DC, Simpson LE, Christensen A. Department of Psychology, University of California, Los Angeles, CA 90095-1563, USA. Many studies have examined pretreatment predictors of immediate posttreatment outcome, but few studies have examined prediction of long-term treatment response to couple therapies. Four groups of predictors (demographic, intrapersonal, communication, and other interpersonal) and 2 moderators (pretreatment severity and type of therapy) were explored as predictors of clinically significant change measured 2 years after treatment termination. Results demonstrated that power processes and expressed emotional arousal were the strongest predictors of 2-year response to treatment. Moderation analyses showed that these variables predicted differential treatment response to traditional versus integrative behavioral couple therapy and that more variables predicted 2-year response for couples who were less distressed when beginning treatment. Findings are discussed with regard to existing work on prediction of treatment response, and directions for further study are offered. PMID: 19170462 [PubMed - indexed for MEDLINE]
J Consult Clin Psychol. 1989 Feb;57(1):39-46. Behavioral versus insight-oriented marital therapy: effects on individual and interspousal functioning. Snyder DK, Wills RM. This study compared the effects of behavioral marital therapy (BMT) and insight-oriented marital therapy (IOMT) on both interspousal and intrapersonal functioning in a controlled outcome study. A total of 79 couples seeking treatment for relationship distress were randomly assigned to BMT, IOMT, or a treatment-on-demand (TOD) waiting-list control group. Results indicated the significance in individual and relationship functioning. Both treatment approaches produced significant effects from intake to termination that were substantially maintained at the 6-month follow-up. Behavioral and insight-oriented therapies resulted in significant improvements in self-reports of global marital accord and, to a lesser extent, in the reduction of overall psychological distress and in the enhancement of self-concept, with no significant differences between treatment conditions. The magnitude of these effects in comparison with those reported in previous marital outcome studies and in more general psychotherapy research is discussed, and possible mechanisms for the equivalence of these technically divergent treatment approaches are explored. PMID: 2925973 [PubMed - indexed for MEDLINE]
http://www.psychpage.com/family/library/ibct.html Integrated Behavioral Couples Therapy Review of Jacobson and Christenson's model of Couples Therapy
Jacobson and Christenson's Integrated Behavioral Couples Therapy (IBCT) is a newer model based on traditional models of behavioral couples therapy. The traditional model is based on a few basic ideas:
• talking about how you feel and think about problems is not very helpful; rather, doing something about them is what helps • most partners can learn ways break bad patterns of behavior that cause problems • most partners can learn new ways to compromise and resolve problems, and thus make each other happier • as a result, most any couple can be happy and content.
When traditional models of behavioral therapy for individuals are applied to couples, therapy tends to produce significant improvements in functioning initially in just over half of couples. While in the past, this treatment appeared to be extremely effective, more recent studies have shown that it is not as effective as previously thought, and a few smaller studies may have made it appear overly effective. Further, other studies have found that at the end of therapy, only about a third of couples recover from their problems well enough to look like happily coupled partners. The rest are still distressed and unhappy. Two years later, a fourth to a third of behavioral therapy couples say they are worse off then when they went to therapy, and after four years over a third are divorced. Thus, the initial improvements do not appear to last. The addition of a "communication skills" module to traditional therapy seems to help improve the lasting effect of treatment to some extent though.
Jacobson and colleagues have done research to improve the effectiveness of behavioral therapy by adding an element of "emotional acceptance." Jacobson and colleagues argue that some problems can be resolved by compromise, but some likely can not. The greatest harm to the couple comes not from the incompatibilities; rather, the greatest harm comes from the rigid, negative, and excessive emotional responses that develop from these unresolved issues. Thus, the IBCT model is based on a few simple ideas:
- talking about how you feel and think about problems sometimes is necessary before you accept them
- most partners can learn ways to alter the negative emotional responses they have to problems, responses that make them, as well as their partners, unhappy
- most partners can learn new ways to resolve problems and the emotions that come with them
- as a result, most any couple can be happy and content.
There have been three promising studies showing the IBCT approach is better than the traditional one. Christenson and colleagues conducted a fourth study though that is especially interesting, in that for this study they purposely took the most distressed couples they could find. They treated 134 couples for an average of 23 sessions over 36 weeks, half with the IBCT approach and half with the traditional approach. They found that about two-thirds of couples reported significant improvements (slightly better than traditional behavioral therapy), half were able to recover from their problems well enough to look like happily coupled partners (again, better than traditional behavioral therapy).
Resources For more information • Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., Baucom, D. H. & Simpson, L. E. (2004). Traditional versus Integrative Behavioral Couple Therapy for Significantly and Chronically Distressed Married Couples, Journal of Consulting and Clinical Psychology, 72, 176–191. • Jacobson, N. S., Christensen, A., Prince, S. E., Cordova, J., and Eldridge, K. (2000). Integrative Behavioral Couple Therapy An Acceptance-Based, Promising New Treatment for Couple Discord, Journal of Consulting and Clinical Psychology, 68, 351-355. • Wimberly, J. & Waltz, J. (1998). An outcome study of Integrative Couples Therapy delivered in a group format. Paper presented at the 32nd annual convention of the Association for Advancement of Behavior Therapy. Washington, D.C. • Shadish, W.R., & Baldwin, S.A. (2005). The effects of behavioral marital therapy: A meta-analysis of randomized controlled trials. Journal of Consulting and Clinical Psychology, 73(1), 6-14.
FROM http://christensenresearch.psych.ucla.edu/
Upcoming research presentations:
Acceptance and change in couple therapy. Andrew Christensen. Master Clinician Presentation, World Congress of Behavioral and Cognitive Therapies, Boston, Massachusetts, June, 2010.
Behavior Change in Traditional and Integrative Behavioral Couple Therapy: Examination of Changes Through 2-year Follow up. Katherine J. Williams. Association of Behavioral and Cognitive Therapies. New York, New York.
The Impact of Behavioral Couple Therapy on Attachment in Distressed Couples. Lisa Benson. Association of Behavioral and Cognitive Therapies. New York, New York.
Physical intimacy over the course of couple therapy and follow-up. Meghan McGinn. Association of Behavioral and Cognitive Therapies. New York, New York.
Integrative Behavioral Couple Therapy An Acceptance-Based, Promising New Treatment for Couple Discord
"As Table 4 indicates, 64% of the TBCT couples either improved or recovered by the end of therapy; in contrast, 80% of the IBCT couples either improved or recovered."
Journal of Consulting and Clinical Psychology © 2000 by the American Psychological Association April 2000 Vol. 68, No. 2, 351-355 For personal use only--not for distribution
Neil S. Jacobson Department of Psychology University of Washington Andrew Christensen Department of Psychology University of California, Los Angeles Stacey E. Prince Department of Psychology University of Washington James Cordova Department of Psychology University of Washington Kathleen Eldridge Department of Psychology University of California, Los Angeles ABSTRACT Although traditional behavioral couple therapy (TBCT) has garnered the most empirical support of any marital treatment, concerns have been raised about both its durability and clinical significance. Integrative behavioral couple therapy (IBCT) was designed to address some of these limitations by combining strategies for fostering emotional acceptance with the change-oriented strategies of TBCT. Results of a preliminary clinical trial, in which 21 couples were randomly assigned to TBCT or IBCT, indicated that therapists could keep the 2 treatments distinct, that both husbands and wives receiving IBCT evidenced greater increases in marital satisfaction than couples receiving TBCT, and that IBCT resulted in a greater percentage of couples who either improved or recovered on the basis of clinical significance data. Although preliminary, these findings suggest that IBCT is a promising new treatment for couple discord.
James Cordova is now at the Department of Psychology, University of Illinois at Urbana—Champaign. After the completion of this article, but prior to its revision, Neil S. Jacobson died suddenly and unexpectedly. His untimely departure is a major loss not only for his family and friends but also for the field of marital therapy, to which he contributed so much. This research project was supported by Grant 5 R01 MH499593-02 from the National Institute of Mental Health. We thank Steve Clancy, Peter Fehrenbach, Joan Fiore, Susan Price, and Debra Wilk, who served as therapists for this project. Correspondence may be addressed to Andrew Christensen, Department of Psychology, University of California, Los Angeles, California, 90095. Electronic mail may be sent to Christensen@psych.ucla.edu Received: February 2, 1999 Revised: September 12, 1999 Accepted: September 17, 1999 Traditional behavioral couple therapy (TBCT; also known as behavioral marital therapy) has been the most widely studied approach to treating marital distress, and its efficacy has been repeatedly demonstrated in over 20 randomized clinical trials ( Baucom, Shoham, Meuser, Daiuto, & Stickle, 1998 ; Christensen & Heavey, 1999 ; Jacobson & Addis, 1993 ). Several of these clinical trials were conducted by Jacobson and colleagues using the version of TBCT summarized by Jacobson and Margolin (1979) . In an analysis of the clinical significance of various treatment approaches, Jacobson's version of TBCT yielded higher rates of success than the others examined ( Jacobson et al., 1984 ). This is not to say that TBCT is the only effective approach to couple therapy. In fact, as Baucom et al. (1998) have documented, other treatments, such as emotionally focused couple therapy Greenberg & Johnson, 1988 ), have shown promise. But TBCT is the only couple therapy to receive the highest designation as an "efficacious and specific intervention" ( Baucom et al., 1998 , p. 58).
At the same time, these studies have also revealed significant limitations in both the clinical significance and the durability of TBCT. First, at least one third of the couples studied in randomized clinical trials of TBCT are clear-cut treatment failures, remaining in the maritally distressed range at the conclusion of therapy ( Jacobson & Addis, 1993 ). Second, even among those couples who improve, many do not maintain their improvement over a 2-year period ( Jacobson, Schmaling, & Holtzworth-Munroe, 1987 ).
The purpose of the present study was to provide preliminary data on a new approach to treating marital distress, integrative behavioral couple therapy (IBCT), which was developed by Andrew Christensen and Neil S. Jacobson ( Christensen, Jacobson, & Babcock, 1995 ; Jacobson & Christensen, 1996 ).
Whereas TBCT focuses on helping spouses "change" in light of their partners' complaints and requires active collaboration and compromise between partners, IBCT includes strategies to help spouses accept aspects of their partners that were previously considered unacceptable. However, despite the label, the purpose of "acceptance work" is not to promote resignation to the relationship as it is or mere acceptance. Rather, it is designed to help couples use their unsolvable problems as vehicles to establish greater closeness and intimacy. For couples who have difficulty changing their behavior, acceptance provides a viable alternative for building a closer relationship. For couples who do benefit from the traditional approach, IBCT can facilitate further progress by providing an alternative way to establish a closer relationship, given that there are problems in every relationship that are impervious to change.
Paradoxically, acceptance interventions are also predicted to produce change in addition to acceptance, often more efficiently than the direct change inducing strategies that constitute TBCT, because at times the pressure to change may be the very factor that prevents it from occurring.
Method
Participating Couples and Therapists
Participants in this study were 21 couples requesting therapy for marital distress. To be eligible for the study, couples had to be legally married and living together and both spouses had to be between 21 and 60 years old. In addition, each was required to score above 58 on the Global Distress Scale (GDS) of the Marital Satisfaction Inventory (MSI; Snyder, 1979 ), indicating clinically significant levels of marital distress. Couples were excluded if either spouse was in some concurrent form of psychotherapy ( n = 8), taking psychotropic medication ( n = 8), alcohol dependent ( n = 2), engaging in moderate to severe domestic violence within the past year ( n = 2, using criteria from Jacobson, Gottman, Waltz, Babcock, & Holtzworth-Munroe, 1994 ), or if the sole presenting complaint was sexual dysfunction ( n = 2). We were also prepared to exclude couples if either spouse met the criteria for schizophrenia (current episode), drug dependence, or mania, although no such couples were encountered.
After qualifying for the study, couples were randomly assigned to either TBCT or IBCT. Table 1 presents a summary of pretreatment demographic variables for each spouse (age, education, duration of
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marriage, number of previous marriages, and number of children) as a function of treatment condition.
None of the demographic variables were significantly different in the two treatment conditions.
Cases were assigned to one of five therapists as the therapist was available and as needed to ensure that therapists saw cases in both conditions. Each therapist saw a total of two to six cases and, with the exception of one therapist who saw an extra TBCT case, saw equal numbers of cases in each condition.
The five therapists, who included four licensed psychologists and one master's-level marriage and family therapist, were trained by first attending a didactic workshop presented by Neil S. Jacobson. They were then asked to read both the IBCT ( Christensen et al., 1995 ) and TBCT ( Jacobson & Margolin, 1979 ) treatment manuals. Once they began seeing cases, half were supervised by Andrew Christensen and half were supervised by Neil S. Jacobson, who both supervised cases in each treatment condition.
All of the treatment sessions were audio- or videotaped and mailed to supervisors, and each therapist had weekly 30-min telephone conversations with each supervisor during which the supervisor provided feedback and answered questions regarding the therapist's current cases. In addition to these weekly phone contacts, Andrew Christensen and Neil S. Jacobson met monthly with therapists in Year 1 and bimonthly in Year 2. During these meetings, taped segments illustrating both treatments were viewed, difficult cases were discussed, and any violations of treatment protocol observed by the adherence raters were reviewed. These strategies were successful in preventing drift across supervisors and in revising the IBCT treatment manual so that versions could be published for therapists (Jacobson & Christensen, 1996 ) and for clients ( Christensen & Jacobson, 2000 ).
Treatment Conditions TBCT.
The version of TBCT used in the present study was an adaptation of the one used by Jacobson and Margolin (1979 ), as specified in a companion manual. 1 IBCT ( Christensen et al., 1995 ; Jacobson & Christensen, 1996 ).
This approach includes three interventions designed to promote acceptance between partners: empathic joining, unified detachment, and tolerance building. In IBCT, these acceptance strategies are integrated with the change-oriented strategies of TBCT. The relative emphasis on acceptance versus change depends to some extent on the individual characteristics and needs of the couple.
IBCT treatment began as clinically indicated for each couple in the study on the basis of the case formulation developed during the initial assessment sessions but usually began with acceptance interventions. Subsequently, change techniques were integrated with acceptance strategies as needed.
Treatment length.
All of the couples in both treatment conditions were allowed up to 26 sessions (which included 2 individual sessions during an evaluation phase) and, in fact, received between 13 and 26 sessions. The mean number of sessions for TBCT couples was 20.72 ( SD = 3.55), whereas the mean number of sessions for IBCT couples was 21.00 ( SD = 4.15); the difference between groups was not significant.
Of the 11 couples assigned to TBCT, 1 couple experienced substantial improvement early in treatment and, in agreement with their therapist, terminated after the 14th session. Of the 10 couples assigned to IBCT, 1 couple did not complete treatment, deciding to divorce after 13 sessions.
Therapist adherence and competence.
We constructed an adherence scale that included eight items reflecting change-oriented interventions
Page 3 of 8 11/27/2000 http://spider.apa.org/ftdocs/ccp/2000/april/ccp682351.html Page 4 and nine items reflecting acceptance interventions. Two senior graduate students served as coding trainers and calibrators, and three additional graduate students served as coders. Eight TBCT and eight IBCT cases were coded for adherence. Nine tapes were coded per case (three early, three middle, and three late sessions); within these constraints, the exact tapes to be coded were determined randomly.
Twenty percent of the coded tapes were also coded by a calibrator. Coders were blind as to both treatment condition and which sessions were coded by the calibrator. They rated the degree to which each intervention was observed in that session on a 5-point scale ranging from 1 ( not at all ) to 5 ( extensively ). Reliabilities were calculated based on intraclass correlation coefficients and represent the agreement between each rater and the calibrator. Reliabilities for the three coders ranged from .87 to .95 for change ratings and from .74 to .88 for the acceptance ratings.
In addition, we conducted a second, completely independent manipulation check to ensure that our ratings of adherence were not influenced by rater bias. The adherence ratings described above were conducted by clinical graduate students familiar with TBCT and IBCT and who therefore were often able to discern the treatment condition. Thus, we created a second, simpler system using global codes and trained undergraduate raters who had no previous knowledge of TBCT and IBCT to use this global coding system. This system included a code for "instigate change," which consisted of any of the change interventions defined in the earlier system, and "acceptance," which consisted of any of the acceptance activities defined in the earlier system. After watching an entire session, coders rated the extent to which therapists engaged in these activities on a 9-point scale. Six sessions from each of the 21 cases (two sessions each from the early, middle, and late phases of therapy) were rated by four teams of three or four undergraduate observers who were trained in the global coding system but who were uninformed about TBCT, IBCT, and the nature of the study. In fact, they were not told that two kinds of therapy were being compared but rather that we were examining the correlates of different types of therapist activities. Ratings on these two global scales were reliable (average alpha was .86 for change and .80 for acceptance). Finally, to document that TBCT received a fair test in the present study, we had 120 TBCT tapes coded for competence by Donald H. Baucom, a recognized expert in TBCT. These manipulation checks and their results are described in greater detail below. Outcome Measures We measured pre- to posttreatment changes in marital satisfaction using the GDS of the MSI ( Snyder, 1979 ) and the Dyadic Adjustment Scale (DAS; Spanier, 1976 ). Both are well-validated instruments for assessing satisfaction in marriage.
Results
Adherence to Treatment Protocols
Table 2 compares the overall change and acceptance ratings for TBCT versus IBCT on our molecular
Adherence scale. The table shows that change-oriented interventions were significantly more likely to be used in TBCT than in IBCT, whereas acceptance interventions were significantly more likely to be used in IBCT than in TBCT. The means reported in Table 2 represent the sum of the ratings for each item in that subscale. Thus, the range for the Change subscale (eight items) is 8 to 40, and the range for the Acceptance subscale (nine items) is 9 to 45. Of particular note is that the mean for Acceptance items in TBCT is very close to the minimum, indicating that there was very little acceptance work going on in TBCT and thus very few protocol violations. On the other hand, because IBCT includes the change-oriented strategies of TBCT, some change work is appropriate. As expected, there were a moderate
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number of change interventions observed in IBCT, but not as many as in TBCT. In addition to the above, we conducted a second manipulation check using naive raters and global codes of instigate change and acceptance described earlier to ensure that our adherence data were not an artifact of the raters' biases. Primary analyses consisting of 2 (treatment group) × 6 (session) repeated measures analyses of variance revealed significant main effects of treatment group.
As predicted, average ratings of acceptance were much higher for IBCT therapists ( M = 6.47) than for TBCT therapists ( M = 4.28), F (1, 17) = 35.61, p < .001, whereas mean ratings for instigate change were much higher for TBCT therapists ( M = 6.08) than for IBCT therapists ( M = 3.32), F (1, 17) = 33.45, p < .001.
Further, when we created a ratio of acceptance to instigate change, we found no overlap in the two distributions: The lowest ratio among IBCT cases was higher than the highest ratio among TBCT cases.
In short, results indicate that these two systems for rating adherence were able to discriminate between TBCT and IBCT and, further, that therapists conducting both treatments were able to keep them distinct: They were successful in avoiding acceptance interventions in TBCT and in incorporating such interventions when conducting IBCT.
Therapist Competence in TBCT One possible explanation for promising results when testing a new treatment approach is the effect of therapist allegiance: Perhaps the therapists' greater enthusiasm for the new treatment and/or their corresponding decreased confidence in the old treatment lead them to provide a less than optimal test of the latter. Therefore, it was important to ensure that TBCT was performed with a high degree of competence and that therapist bias toward IBCT did not influence our results. To this end, we had 120 TBCT tapes coded by an expert in TBCT, Donald H. Baucom from the University of North Carolina.
Baucom had no other connection to the study beyond his role as a consultant who provided competence ratings of TBCT. In collaboration with Baucom, we designed a scale, called the Behavioral Couple Therapy Competence Rating Scale, which is designed to have a maximum score of 66. A score of 40, which indicates an average rating of "good," is considered the cutoff for competent performance of TBCT. Baucom rated up to 16 tapes per couple for 8 couples assigned to TBCT. The first 4 tapes (1st conjoint session, individual assessment sessions with both husband and wife, and feedback session) were viewed for case conceptualization purposes only; competence ratings were completed for Sessions 5—16. Results indicated that TBCT was conducted with a high level of competence. Ratings for individual sessions ranged from 43 to 66, with an overall mean rating of 61.1. These ratings consistently exceeded our established minimum standards of competence and indicated that the TBCT performed in this study was state of the art.
Treatment Outcome Because of the small sample size and inadequate statistical power of the present study, we made a decision to confine our analyses to descriptive statistics reflecting both effect size and clinical significance of the group differences but not to use statistical analyses for hypotheses-testing purposes.
Table 3 presents the results of our primary outcome analyses. The table shows pre- and posttest scores for husbands and wives on the GDS and the DAS, our two primary outcome measures. Results are presented for all 21 couples who participated in the study, including the 1 IBCT couple who did not complete treatment. For the latter couple, because we were unable to obtain posttest scores, their pretest scores on each outcome measure served as the termination score. As the table shows, both husbands and wives experienced greater improvements in their satisfaction following IBCT than they did following TBCT. The effect sizes indicate moderate (based on the DAS) to large (based on the GDS) group differences favoring IBCT.
Finally, we assessed the clinical significance of the observed group differences using the criteria for
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improvement and recovery derived by Jacobson and colleagues (e.g., Jacobson & Truax, 1991 ). Table 4 shows the number and proportion of couples whose increases in marital satisfaction were both statistically and clinically significant using the GDS. Clinical significance referred to both spouses scoring in the nondistressed range at the conclusion of therapy, whereas improvement referred to scores that indicated increased marital satisfaction but were still in the distressed range for 1 or both spouses posttreatment. To ensure that the magnitude of change exceeded that which could reasonably be explained by measurement error, we also required that each partner's magnitude of change had to be statistically reliable on the basis of the modified reliable change index ( Jacobson & Truax, 1991 ). As Table 4 indicates, 64% of the TBCT couples either improved or recovered by the end of therapy; in contrast, 80% of the IBCT couples either improved or recovered.
Discussion The results of our treatment development study suggest that IBCT may be a promising alternative to TBCT. First, through our adherence ratings, we demonstrated that IBCT was a distinct treatment from TBCT. Second, we showed that the therapists in this study were able to successfully implement our independent variable by confining acceptance-focused interventions to IBCT and by providing an intensive, state-of-the-art test of change-oriented interventions in TBCT. Third, and most importantly, IBCT, performed by therapists with no prior experience with the treatment, obtained results that were impressive both in an absolute sense and relative to TBCT. Besides these outcome results, there are several additional findings that support the future study of IBCT. Christensen and Jacobson (1996) reported that IBCT produced as much or more change in some areas of the relationship than TBCT, despite the emphasis on acceptance, rather than change, in IBCT. Consistent with the theory of change underlying IBCT ( Jacobson & Christensen, 1996 ), the contextual shifts following successful acceptance work can be a more effective way of shifting the contingencies of reinforcement in a way that supports spontaneous change. Acceptance may not only be conducive to an improved relationship in its own right but may also at times be a more efficient way of producing behavior change than the direct attempts to induce it, which characterize TBCT. Furthermore, evidence of differential processes occurring in the two treatments was found in an examination of couples' in-session verbal behavior ( Cordova, Jacobson, & Christensen, 1998 ). Using a system designed to rate husband—wife interaction, coders were trained to rate early, middle, and late therapy sessions on the occurrence of spouse behaviors expected to discriminate between the two treatments. Results indicated different kinds of interactional changes in the two treatments that were in accord with the theories of change underlying the two treatments. For example, two categories of spouse behavior, empathic joining and unified detachment, behaviors that are encouraged in IBCT but not in TBCT, were indeed more common in IBCT sessions, especially toward the end of therapy. This study provides further evidence that the types of interactional change targeted by the two treatments are actually reflected in couples' in-session behavior, especially in middle and later sessions. Since we conducted this original trial, two additional unpublished studies, summarized by Christensen and Heavey (1999) , have provided further preliminary evidence as to the scope of IBCT. Not only does it appear to be possible to successfully apply IBCT in a couples—group format, but the treatment may also be a viable alternative to individual therapy when depression in 1 spouse coexists with marital discord. Although these results, taken together, warrant further exploration, they must be interpreted in the preliminary spirit in which the data were collected. The next step is a randomized clinical trial with sufficient statistical power to establish both the replicability and the reliability of group differences Page 6 of 8 11/27/2000 http://spider.apa.org/ftdocs/ccp/2000/april/ccp682351.html
Page 7 between IBCT and TBCT. In fact, we have begun such a trial at two sites–the University of California, Los Angeles, and the University of Washington–where 150 couples are being randomly assigned to IBCT or TBCT in what will be the largest study of marital therapy efficacy ever undertaken. Only after such a trial has been completed will we know if the early promise demonstrated in the present study can be confirmed. The study currently under way will also address a question that is crucial to the value of a marital treatment but beyond the scope of the present treatment development study: the durability of acceptance and change produced by the two treatments under study. Not only do we need to know about the immediate benefits of IBCT, but a major reason for its development was also the hope that an integrative treatment would lead to permanent improvement, a goal that has not yet been tested, even in a preliminary way. References Baucom, D. H., Shoham, V., Meuser, K. T., Daiuto, A. D. & Stickle, T. R. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology, 66, 53-88. Christensen, A. & Heavey, C. L. (1999). Interventions for couples. Annual Review of Psychology, 50, 165-190. Christensen, A. & Jacobson, N. S. (1996, November). The measurement of acceptance and change in integrative versus traditional behavioral couple therapy. (Paper presented at the annual meeting of the Association for the Advancement of Behavior Therapy, New York, NY) Christensen, A. & Jacobson, N. S. (2000). Reconcilable differences. (New York: Guilford Press) Christensen, A., Jacobson, N. S. & Babcock, J. C. (1995). Integrative behavioral couple therapy.(In N. S. Jacobson, & A. S. Gurman (Eds.), Clinical handbook of couples therapy (pp. 31—64). New York: Guilford Press.) Cordova, J. V., Jacobson, N. S. & Christensen, A. (1998). Acceptance versus change interventions in behavioral couples therapy: Impact on couples' in-session communication. Journal of Marriage and Family Counseling, 24, 437-455. Greenberg, L. S. & Johnson, S. M. (1988). Emotionally focused couples therapy. (New York: Guilford Press) Jacobson, N. S. & Addis, M. E. (1993). Research on couples and couple therapy: What do we know? Where are we going? Journal of Consulting and Clinical Psychology, 61, 85-93. Jacobson, N. S. & Christensen, A. (1996). Acceptance and change in couple therapy: A therapist's guide to transforming relationships. (New York: Norton) Jacobson, N. S., Follette, W. C., Revenstorf, D., Baucom, D. H., Hahlweg, K. & Margolin, G. (1984). Variability in outcome and clinical significance of behavioral marital therapy: A reanalysis of outcome data. Journal of Consulting and Clinical Psychology, 52, 497-504. Jacobson, N. S., Gottman, J. M., Waltz, J., Babcock, J. & Holtzworth-Munroe, A. (1994). Affect, verbal content and psychophysiology in the arguments of couples with a violent husband. Journal of Consulting and Clinical Psychology, 62, 982-988. Jacobson, N. S. & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. (New York: Brunner/Mazel) Jacobson, N. S., Schmaling, K. B. & Holtzworth-Munroe, A. (1987). A component analysis of behavioral marital therapy: Two-year follow-up and prediction of relapse. Journal of Marital and Family Therapy, 13, 187-195. Jacobson, N. S. & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19. Snyder, D. K. (1979). Multidimensional assessment of marital satisfaction. Journal of Marriage and the Family, 11, 813-823. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage Page 7 of 8 11/27/2000 http://spider.apa.org/ftdocs/ccp/2000/april/ccp682351.html
Page 8 and similar dyads. Journal of Marriage and the Family, 38, 15-28. 1 The TBCT manual can be obtained from Andrew Christensen by written request. Pretreatment Demographic Variables Overall Adherence Ratings Pre- to Posttreatment Improvement by Treatment Condition Clinical Significance Data Page 8 of 8 11/27/2000
The history of couple therapy: a millennial review. Family Process, 07/22/2002, Vol. 41 No. 2 Pg. 199 By: Alan S. Gurman; Peter Fraenkel
In this article, we review the major conceptual and clinical influences and trends in the history of couple therapy to date, and also chronicle the history of research on couple therapy. The evolving patterns in theory and practice are reviewed as having progressed through four distinctive phases: Phase I—A theoretical Marriage Counseling Formation (1930-1963); Phase II--Psychoanalytic Experimentation (1931-1966); Phase III--Family Therapy Incorporation (1963-1985); and Phase IV--Refinement, Extension, Diversification, and Integration (1986-present). The history of research in the field is described as having passed through three phases: Phase I--A Technique in Search of Some Data (1930-1974), Phase II--Irrational(?) Exuberance (1975-1992), and Phase III-- Caution and Extension (1993-present). The article concludes with the identification of Four Great Historical Ironies in the History of Couple Therapy.
...
What is the relative effectiveness of different couple therapies? To borrow a borrowed phrase from Luborsky, Singer, and Luborsky's (1975) discussion of the comparative efficacy of individual psychotherapies, "Everybody has won, and all must have prizes" (p. 995). More accurately, all those couple therapies that have been reasonably well put to the empirical test to data have won, i.e., have proven superior to no treatment. These methods are Behavioral (including cognitive-behavioral) Therapy, Emotionally Focused Therapy, and Insight-Oriented Marital Therapy. Thus far, there is no strong evidence that any one of these approaches is more effective than the others, or any other. To date, there have been very few head-to-head comparative studies in clinical trials, so that the occasional differences that have been found may be quite unreliable, and, in any case, have not been replicated.
At the same time, not all influential approaches to systems-oriented therapy even deserve consideration for "prizes" to date for their treatment of couples, e.g., Structural, Strategic, Bowen Family Systems, Solution-Focused, and Narrative methods with couples have essentially never been tested empirically. This fact should certainly not lead us to dismiss outright treatments that have not yet been tested empirically. Nonetheless, the proponents of such untested methods have a collective obligation to provide more than anecdotal evidence of their efficacy and effectiveness.
