Translation of Integrative Behavioral Couple Therapy to a web-based intervention

Abstract

Couple therapy – across a number of different theoretical approaches – has been shown to be an effective treatment for a variety of individual and relationship difficulties. Moreover, recent studies have demonstrated that the effects of several approaches last at least two to five years after the end of treatment. However, couple therapy has a critical limitation: most distressed couples – including those that eventually divorce – do not seek couple therapy. Thus, while we recognize there are notable advances in the treatment approaches described in this special section, we argue that traditional approaches to couple therapy need to be supplemented by alternative interventions before we can make a profound, population-level impact on relationship distress and divorce. To this end, we translated Integrative Behavioral Couple Therapy into a self-help, web-based program - www.OurRelationship.com. Through a combination of tailored feedback, filmed illustrations, and interactive education, the online program first helps couples identify a core problem in their relationship. The program then assists partners in coming to a new and more accurate understanding of the problem they jointly identified and subsequently brings them together in a structured conversation to share their new understandings with each other. Finally, based on this shared conceptualization, the program supports couples in making concrete changes in their relationship. In this article, we discuss the rationale for the program, describe the core components of the website, and illustrate these components with a case example. Relative advantages and disadvantages compared to traditional couple therapy are presented.

Over a third of currently-married individuals are distressed in their relationships and approximately 40–50% of first marriages are likely to end in divorce in the United States (see Whisman, Beach, & Snyder, 2008). The consequences of relationship dissatisfaction are well chronicled as studies indicate increased risk for psychological disorders, physical illness, as well as negative outcomes for children’s psychological well-being and peer relationships. Fortunately, meta-analytic reviews find in-person couple therapy successful in reducing relationship distress (see Snyder, Castellani & Whisman, 2006).

Most recently, Integrative Behavioral Couple Therapy (IBCT) was examined in the largest and longest randomized clinical trial of couple therapy to date (e.g., Christensen, Atkins, Baucom, & Yi, 2010). Results at post-treatment were promising - demonstrating a large effect within-group improvement in relationship satisfaction (d = 0.86). Further, these gains were maintained with 69% of participating couples reporting clinically significant improvements in satisfaction at 2-year follow-up and 50% at 5-year follow-up (Christensen et al., 2010).

IBCT has its roots in traditional behavioral couple therapy’s focus on behavioral exchange (BE) and communication/problem solving (CPT). In the early 1990s, Andrew Christensen and Neil Jacobsen began to integrate strategies for fostering emotional acceptance with the direct change interventions of traditional behavioral couple therapy. The inclusion of emotional acceptance as a key mechanism and change strategy was based upon the recognition that in order for BE and CPT to improve relationships, couples must be collaborative and accommodating with one another. Unfortunately, this collaboration is difficult for couples entering therapy who are typically entrenched in anger or blame. IBCT thus aims to first develop or improve emotional acceptance within the couple and continue with direct change strategies to improve relationship satisfaction (see Doss, Jones, & Christensen, 2002). Our studies investigating mechanisms of change in couple therapy (e.g., Doss, Thum, Sevier, Atkins, & Christensen, 2005) support IBCT’s theoretical model, finding that both acceptance and behavior change are associated with greater improvement in relationship satisfaction during treatment.

The IBCT conceptual model of relationship difficulties holds that relationship distress develops primarily through couples’ repeated and unsuccessful attempts to deal with natural differences or initial localized disagreements that are often emotionally loaded because of partner’s sensitivities or vulnerabilities. These attempts to change the other are met with resistance, fueling greater efforts to change the other and greater forces of resistance. In IBCT this process is called polarization. Couples enter a relationship with common differences, some of which initially drew them together; however, these differences become sources of tension later on in the relationship. Consider the common complaint of financial difficulties in a relationship. The woman is frustrated with her husband because he is more of a spender, while she prefers to save and invest. At the beginning, she may have been attracted to his spending. He always had exciting events planned for them to attend, events she would likely not have attended otherwise. The man, the spender, may have initially enjoyed having someone who reminded him of the importance to save. He appreciated her money-management skills (which freed him from having to do it), and appreciated the comfort of knowing they had a nest egg to fall back on. Now, however, the couple argues constantly about how to use their money. The woman’s position may be emotionally loaded because of her fears about facing retirement destitute, the man’s because of his sensitivity to being controlled. The woman feels more entrenched in her position on saving because of her partner’s spending, and the man feels more and more resistant to saving because he feels controlled by her need to save every penny. Even though the couple likely recognizes that their own positions have reached an unnatural extreme, any changes in the direction of acquiescing to their partner feel like major sacrifices. As the couple continues in this process, their arguments become more heated and intense; they each begin to feel stuck and hopeless in the problem. The couple has entered what IBCT terms the mutual trap.

To extract couples from their mutual trap, IBCT intervenes on two levels: acceptance and direct change. There are two types of acceptance interventions - unified detachment and empathic joining. Unified detachment attempts to move both partners from viewing each other as “bad”, “crazy”, or “disturbed” to understanding that they have co-created their current situation and are both suffering. As a result, the polarization around differences, rather than the differences themselves, becomes the problem. Indeed, unified detachment helps partners see that differences between them are not defects but rather natural and common – perhaps even ones that may have initially drawn them together. The hope of this stage of IBCT is that, with a more accurate understanding of their problem, couples will be less reactive to partner behaviors that were previously experienced as negative. With this greater understanding, partners typically are able to be de-escalate their negative interaction (which was previously experienced as almost automatic and out of their control).

In contrast to the cognitive focus of unified detachment, empathic joining seeks to increase emotional acceptance by creating greater emotional intimacy between partners. In empathic joining, the therapist encourages the couple to share with each other the fears and vulnerabilities that make the conflict so loaded for them. The couple is also asked to reveal to each other their emotional experience during their pattern, with the therapist urging disclosure of the “soft” emotions that are beneath the anger, irritation, and other “hard” surface emotions. In empathic joining, individuals begin to empathize with their partners, realize that their partners are also in emotional pain, and ideally reach out to support their partners. Empathy and increased intimacy with the partner are potent keys to unlocking the mutual trap, because the trap is based on the assumption that “I’m the one suffering in this relationship.” Once the couple extracts themselves from the mutual trap, they can return to seeing themselves as on the same team rather than opponents seeking to cause pain. For many couples, acceptance interventions may be enough to significantly improve their relationship.

However, for other couples, the desired changes do not follow naturally from acceptance interventions. Although acceptance can be helpful to deescalate the conflict and depolarize the partners’ positions, underlying that conflict and polarization may be objectively problematic situations. For example, a therapist may be able to encourage a couple who polarized along their natural differences in saving/ spending to accept those differences through a combination of unified detachment and empathic joining. However, that same couple may face very real budgeting challenges related to a recent job loss; in that case, acceptance is not enough – specific, concrete budgeting changes need to occur. Once the couple develops a collaborative set through their increased acceptance, standard behavioral couple therapy interventions can be successfully utilized in IBCT. Indeed, although they are deemphasized relative to traditional behavioral couple therapy, IBCT includes change-oriented interventions such as behavioral activation, communication training, and problem solving in its repertoire. .

Alternative Interventions for Relationship Distress

While a wealth of research points to the efficacy of in-person IBCT, the reach of couple therapy in general appears to be limited. Although approximately one third of intact couples are distressed, less than 15% of intact couples seek couple therapy. Moreover, studies of divorced couples demonstrate that fewer than 40% sought marital therapy as a means to save the relationship before divorce (see Doss, Rhoades, Stanley, & Markman, 2009). Couples’ hesitancy to seek in-person couple therapy is often due to an unwillingness to share their private life, a lack of recognition that the relationship was in trouble, or thinking it was “too late” for therapy. Lack of health insurance coverage, time, and awareness of resources also keep couples from therapy.

Given that many couples do not seek couple therapy for relationship distress (and many more seek it only as a last resort, after their initial problems have substantially intensified), there is a need for other methods to assist couples with relationship difficulties. One approach is through premarital education (e.g., Prevention and Relationship Enhancement Program; Markman, Renick, Floyd, Stanley, & Clements, 1993); however, research suggests that couples at higher risk for subsequent relationship problems are least likely to attend premarital education (e.g., Stanley, Amato, Johnson, & Markman, 2006).

One notable effort that specifically targets at-risk couples is the Marriage Checkup (e.g., Córdova, Scott, Dorian, Mirgain, Yaeger, & Groot, 2005; Morrill, Eubanks-Gleming, Harp, Sollenberger, Darling, & Córdova, 2011). The Marriage Checkup is a four-hour intervention focused on assessment, feedback, and brief intervention using a blend of IBCT techniques (e.g., unified detachment and empathic joining) and motivational interviewing techniques. While the model of the Marriage Checkup is very appealing, it remains similar to couple therapy in its in-person nature and involvement of a trained therapist/leader. Both similarities ultimately place limitations on the availability and cost of the intervention. Thus, consistent with recent calls to move beyond individual, face-to-face interventions (e.g., Kazdin, 2011), we believe additional models of intervention are indicated for couples who are not willing or able to seek professional, in-person interventions.

It may be that substantially more couples can be helped through a self-help framework. Indeed, rather than seeking couple therapy, substantially more couples read relationship-oriented self-help books (Doss et al., 2009), such as our self-help book for couples experiencing relationship difficulties modeled on IBCT (Christensen, Doss, & Jacobson, in press). Additionally, couples are increasingly seeking help for their relationship online, presenting an exciting new venue for intervention. Intervening with couples via the web presents advantages that are not easily available in a book – a web-based program can present feedback to the couple in a way that can be easily digested (e.g., graphs and tailored text), be responsive to the needs of a specific couple, and more easily engage the couple in a joint process (rather than the typically solitary activity of reading a self-help book).

An online intervention, like a self-help book, is likely to be less effective than in-person therapy in terms of the amount of change it creates in couples. However, effectiveness is literally only part of the equation. Within the public health literature (e.g., the RE-AIM framework; Glasgow, Vogt, & Boles, 1999), far more importance is placed on the individual-level impact of the intervention, which has been conceptualized as the product of an intervention’s effectiveness and its reach (i.e., the number of couples who would successfully complete it). As an example, our large-scale trial of in-person IBCT resulted in an average pre-post effect of Cohen’s d = 0.86 (considered a “large” effect) for 134 couples, a total individual-level impact of 115.24. To obtain a similar impact, the web-based version could have a medium effect size (Cohen’s d = 0.50) and reach 230 couples or even a small effect size (Cohen’s d = 0.20) with a reach of 576 couples. To place these numbers in context, between October 2011 and October 2012, there were more than 3.8 million unique visits to the ten most popular self-help relationship websites. Thus, the potential impact of web-based interventions is difficult to overstate.

Encouragingly, there is a growing literature supporting the efficacy of computer-based interventions for individual psychological disorders such as depression and anxiety (e.g., Andersson & Cuijpepers, 2009; Cuijpepers, Marks, Van Straten, Cavanagh, Gega, & Andersson, 2009). Additionally, early investigations of computer-based relationship enhancement programs have yielded promising results. For example, an adapted version of a validated in-person premarital education program has been shown to significantly improve relationship functioning for as long as ten months (Braithwaite & Fincham, 2011). Even short interventions consisting of online feedback about the relationship have been shown to strengthen relationships (Larson, Vatter, Galbraith, Holman, & Stahmann, 2007), although the combination of feedback and intervention is more effective (e.g., Halford, Wilson, Watson, Verner, Larson, Busby, & Holman, 2010). However, these programs have been targeted at relatively happy couples and their efficacy or appropriateness for distressed couples is unclear.

Web-based Version of IBCT

The web-based program based on IBCT, available at www.OurRelationship.com, is a secondary intervention: it is designed to help couples deal with relationship problems after they develop but before those problems escalate and necessitate the involvement of a couple therapist. The program can be completed from any computer that has an internet connection and affords enough privacy to complete the program.

The OurRelationship program is designed so that couples move through the program together (i.e., during the same 4–6 week period) but complete most of the activities separately. The decision to keep partners physically separate during most activities was driven by two considerations. From an intervention standpoint, we wanted to provide individuals time to absorb and reflect on the program material; conjoint completion seemed to invite snide comments from the partner and the possibility that individuals would be more concerned with not losing the argument than with coming to a new, more accepting view of the problem. From a practical standpoint, separate activities mean that partners can complete the program at different times and locations, enhancing the flexibility of the program. Additionally, shared activities present challenges with different reading speeds, sharing the computer mouse, and other considerations that initially seem trivial but likely make significant contributions to program noncompletion. However, couples do complete select activities together, which we describe in more detail below.

The program is structured around the OUR acronym – first Observing the problem through objective feedback, subsequently Understanding the problem through a detailed, objective analysis of the problem, and then beginning to Resolve the problem through efforts to enact specific behavioral changes. Each O, U, and R phase is designed such that partners complete activities together before coming together to have a conversation at the end of each phase to share what they have been working on. In the Observe phase, partners separately view comprehensive feedback on the strength and problem areas in their relationship. The program then helps each partner decide what it is that they consider to be the central or “core” problem in their relationship (e.g., “money,” or “parenting”). During the final activity in the Observe phase, the partners come together in front of the computer to have a shared conversation that is structured by the program. During this conversation, the couple mutually decides on one or two relationship problems they would like to focus on in the program.

In Understand phase, individuals separately progress through a series of chapters designed to encourage them to develop a novel, more accepting view of the relationship problem(s) they selected. Specifically, the online program encourages couples to develop a “DEEP Understanding” of their relationship difficulties. “DEEP” is an acronym that describes the role that natural Differences, surface and hidden Emotions, External stress, and Patterns of communication have played in the development and exacerbation of their core issue. Each partner separately goes through online chapters that focus sequentially on each of the four aspects of a DEEP understanding, seeing filmed examples of other couples and getting online instruction and individualized feedback in how to apply each aspect of DEEP to their own core issue. The couple then comes together at the end of the Understand phase in a conjoint conversation to share their DEEP understandings. Specifically, the program displays key portions of what each individual has written in the previous chapters and encourages the couple to discuss that content in a structured speaker-listener framework.

Finally, in the Respond phase, individuals work to develop a plan to solve their relationship problem(s) and increase relationship positives. Specifically, individuals learn about when attempts to increase acceptance vs. create direct change are likely to be most effective. They then learn specific strategies to enact direct change in their own behavior – ways to reduce the effect that stress has on their relationship, communication tips tailored to their particular communication pattern, and ways to have more fun with their partner. In the final conversation, the couple comes together to share what they have written in these activities. In addition, during that same conversation, the couple has a chance to problem-solve any remaining aspect of their core issue(s); if they choose to do so, the couple is walked through the standard problem-solving steps of identifying the problem, brainstorming solutions, selecting a solution, and deciding on a date to evaluate progress. Finally, couples receive feedback on their progress in the program. If couples have not experienced much benefit from the program, feedback highlights this fact, hopefully harnessing this information to increase motivation to seek more intensive interventions that they can utilize to address their remaining problems (e.g., couple therapy). However, if couples have made important gains during the program, they receive detailed information about those gains as well as feedback on all the relationship areas that can be considered relationship strengths (in graphical and text formats). Couples are asked to view and discuss this feedback together in the hopes that it will serve as a nice bonding moment for the couple.

To maximize the reach of the program, we kept the core program relatively short (approximately 6 hours) and designed it so that it can be completed without any staff support (to reduce ongoing costs of maintaining the program). However, in an ongoing research study, we are exploring the benefit of individualized staff support through an electronic, asynchronous personal message board. In designing the program, we took care to determine what we did (and did not) want it to be. Driving our decisions was a central goal– to make a tool that would help a couple become “unstuck” in their efforts to resolve a specific core relationship problem.

First, we believe the idea of the program as a tool is critical to both the initial appeal of the program as well as its ability to encourage couples to complete the entire program. Couples are unlikely to be drawn to a program that offers information about relationships in general – or even education about relationship problems similar to ones they are experiencing. Instead, most couples likely seek an online self-help program in order to fix their specific relationship problems. Thus, we were concerned that if we spent too much time focusing on general relationship information or skills, we would be quickly dismissed by most couples as irrelevant. As such, the program focuses on activities designed to help the couple resolve current problems and includes more general relationship information only when it is possible to draw clear connections between that information and a couple’s specific problem.

The second key component of our goal in building the site was to enable couples to target specific problems as they occur in their own relationship. We designed the program to accomplish this goal in two ways. First, the program provides tailored feedback to the individual so he or she can better understand the strengths and weaknesses of the relationship. With this feedback, it is hoped that the individual can better define the central relationship problem. Second, once a core relationship problem is identified, the program is subsequently structured around this problem. Indeed, all the subsequent parts of the program explicitly encourage the individual to explore this core issue in more detail and relate the program content back to that core issue. For example, in illustrating how natural and understandable differences between the partners can play a role in relationship problems in general (a common unified detachment intervention), we first illustrate the general concepts by providing an example of two typical couples through text, audio, and video. However, we move beyond these generic examples by presenting the participant with graphs illustrating how he/she is similar or different from his/her partner on validated measures of personality, alexithymia, and desire for closeness. The graphs are accompanied by tailored text which interprets the results and suggests possible ways the specific combinations of similarities or differences can affect relationships. With this information, the individual is asked to select the difference or similarity that is most related to the core problem he or she selected at the beginning of the program.

The third core component to our overall goal was helping a couple become “unstuck.” As described earlier, many distressed couples repeatedly attempt to solve their relationship problems using maladaptive strategies. These repeated failed attempts often make the initial problem worse and leave the couple polarized, feeling hopeless, and “stuck” in a mutual trap. This program seeks to help couples escape this mutual trap. We decided on “unstuck” as an intermediate point between being informed about a problem and fully resolving that problem. Existing research suggests that simply receiving feedback on your relationship yields only small improvements in relationship functioning (Larson et al., 2007); thus, the program also leads couples through a process which is expected to increase acceptance (though unified detachment and, to a lesser extent, empathic joining) and begin to make concrete changes in their relationship. However, given that our pilot research indicated that couples report being willing to spend only up to six hours on average to complete a program of this nature (Georgia & Doss, in press), we needed to carefully select what aspects to emphasize. Consistent with an IBCT orientation, the majority of the program (the first two phases) focuses on increasing emotional acceptance, with less attention paid to direct change strategies. Additionally, to maximize attention focused on the issues partners identified as central to their relationship difficulties, couples are limited to discussing and solving only two relationship problems (one selected by each partner) within the six hours of the program. However, it is hoped that the couple would begin to generalize the experience of the program to other current (and future) relationship problems. If desired, couples are also able to repeat portions of the program to address additional relationship problem areas.

While we feel confident about our ability to create unified detachment and enact direct behavior change in the web-based program, what is lacking from the web-based program is also notable. Specifically, we found it more difficult to include empathic joining – perhaps the most powerful IBCT intervention – into the program. Empathic joining is often difficult to do successfully even in person; it requires the therapist carefully encouraging each partner to reveal vulnerabilities while simultaneously providing an optimum level of structure. If the intervention is too structured, the couple is unable to experience the powerful experience of rushing to support each other and a sense of reconnection. In contrast, if the therapist is not constantly vigilant, the intervention risks further wounding the couple and driving them further away. However, in the web-based program, there is no therapist present to “catch the bullet”, as Sue Johnson vividly describes it (Johnson, 2004). Therefore, the program does not include activities targeting empathic joining for every couple. However, consistent with in-person IBCT, we do include an opportunity for couples to engage in empathic joining if unified detachment goes well. Specifically, following the sharing of their DEEP Understandings, couples are asked to rate how that conversation went; if it went well, they view a video where Drs. Doss and Christensen encourage the couple to talk about what it meant to each of them that they were able to share these new, non-blaming understandings in a productive manner. It is also possible that couples for whom the conversation is going well will engage in this kind of emotional sharing spontaneously.

Case Illustration

To illustrate the specific aspects of the program, we present details on a couple who participated in our online pilot study of OurRelationship.com.

Presenting Problem & Client Description

Elizabeth and Alvaro¹ were a married couple in their forties living in the United States. They had been in a relationship for fifteen years, married for twelve, and had two young children. Both partners were Caucasian and English-speaking, but Alvaro was Hispanic, was born in Mexico, and English was his second language. Both were college-educated, and Elizabeth had a graduate degree. At the time of the program, Elizabeth worked outside the home while Alvaro had been recently laid off and cared for their children full time.

Elizabeth initially identified their core issue as “lack of connection,” while Alvaro listed “criticism,”; however, when prompted by the program, both agreed they were referring to the same problem. Elizabeth explained, "my husband is not happy with our life and his role as primary care giver to our children. He wishes that he were 16 again and that he was independent and not part of a family. He has few friends locally and feels isolated. I probably spend too much time at work but wish that our relationship was closer and that he actively liked spending time with me when I am home.” Alvaro also expressed concerns about his role in the family: “I feel criticized and not valued. I think that this problem happens because I don't have a job and I am the primary parent and I think that my wife wants to be the primary parent and have a full time job and she can't have her cake and eat it. I think that she has her own ideas of parenting and feels critical of my parenting choices. I don't feel praised for my good choices but I feel criticized for the choices that she thinks are bad.”

Progression Through the OurRelationship Program

As we have described elsewhere (e.g., Benson, McGinn, & Christensen, 2011; Christensen, 2010), we believe there are five universal principles that are incorporated in all successful couple therapies. These principals also inform the course of treatment in the OurRelationship.com program; therefore, we organize the description of the program below according to these principles. Additionally, because of the lack of in-person contact with a therapist in the online program, we believe a sixth principle – personal contact and accountability – is critical to the program.

Altering views of the relationship

In describing our therapy approach, we have written, “In many ways, the formulation is the core of IBCT …. If a couple leave therapy having incorporated their formulation into their daily understanding of their relationship, then therapy has almost certainly been a success. However, if the therapist and the couple have been unable to derive a formulation that is useful to the couple, therapy will have little effect” (Doss et al, 2002, p. 394). Given the importance we place on the formulation, it was critical to find a way to successfully translate it to the web-based program. To do so, we developed the DEEP (Differences, Emotions, External stress, and Patterns) Understanding acronym that we now also use in training therapists and a revision of the IBCT self-help book (Christensen et al., in press).

Elizabeth and Alvaro progressed through each component of the DEEP understanding, often viewing relevant information from their initial assessments. In the Differences chapter, Elizabeth and Alvaro viewed their own and their partner’s scores in graphical format on the Big-5 personality inventory, desire for closeness, and alexithymia. To facilitate understanding of these graphs, individuals receive text feedback on what the absolute levels (high vs. low) and relative levels (partners’ scores similar or different) on these constructs may mean for their relationship. For instance, Elizabeth’s Desire for Closeness was similar to Alvaro’s, but she was higher in Emotional Expressiveness. Therefore, they received feedback that they may encounter situations when, although they both desired more emotional closeness, Alvaro may have difficulty verbally expressing this desire.

After reviewing and reflecting on this material, they were asked to select the difference or similarity that they believe was most related to their core relationship problem and write a description of the role it played. Elizabeth wrote that she tends to get more “stressed” than Alvaro and he is more “pessimistic,” explaining that this relates to their core issue because they “are both looking towards the other one to reassure each other and becoming frustrated with the fact that [they] both keep getting stuck.” Alvaro stated the trait most related to their core problem is that he and Elizabeth both tend to be “distracted” easily, and they each “want a different type of closeness.” When asked to describe how the other partner’s traits could also be beneficial to the relationship, Elizabeth said Alvaro’s “stoicism is what makes [him] amazing at coping with all the things that life has thrown at [him] and makes [him] a model of acceptance.” Similarly, Alvaro said Elizabeth “avoids disillusionment” through her traits. Asking both partners to identify how these sometimes-helpful personality traits are related to their core issue may have helped them think about the core issue in a more accepting, non-blaming way.

Next, Elizabeth and Alvaro separately developed an understanding of the role emotions played in their core issue. In their daily lives, couples typically respond to their relationship problems with “surface” emotions that often serve to protect the individual (e.g., defensive, suspicious) or push the partner away (e.g., angry, resentful). Therefore, in the “E” or Emotions chapter, Alvaro and Elizabeth were asked to separately reflect on what emotions they typically experience when dealing with their core problem, to reflect on possible reasons from their history why they may be particularly sensitive to this core issue, and to record this information on the website. Alvaro described his surface emotion as “rejection,” behind which he felt “disappointed.” He wrote that this emotion may come from his perceived “lack of achievement/skill,” possibly related to his lack of employment outside the home. For Elizabeth, “anger” hid the more vulnerable feeling of being “unlovable,” which she suggested may have resulted from being “unpopular as a child.”

Next, in the External stress chapter, individuals refine their understanding of how stress affects their core problem. Elizabeth targeted work as a major stressor for her while Alvaro mentioned health issues. They were separately able to identify the differential impact that stress had on them. Specifically, Elizabeth stated she often wanted to share her struggles with Alvaro but he preferred to be by himself and “get on with things”.

Finally, in the Patterns of communication chapter, the program asked Alvaro and Elizabeth to describe the pattern of interaction that typically occurs when they struggle with their core issue. Elizabeth reported that she and Alvaro both tend to “blame/criticize,” while Alvaro similarly reported that he “argues” while Elizabeth “blames/criticizes.” This couple therefore endorsed a mutually argumentative (rather than avoidant) pattern. Elizabeth noted that when Alvaro blames her for problems, “it makes [her] feel more defensive and probably more critical.”

Eliciting avoided private behavior

The core of IBCT is emotional acceptance, which we defined in the program as “Recognizing that there are natural and understandable reasons for the way you, your partner, and your relationship are and, as a result, being more patient and sympathetic when problems arise”. Even if we are successful in facilitating cognitive change (through new information about relationships in general and a new DEEP understanding of their own relationship), creating opportunities for emotional connection is also necessary. However, with distressed couples, emotion is frequently a double-edged sword that can lead to antagonism as well as connection. As a result, it is difficult to strike the right balance in an online program between encouraging opportunities for empathic joining through sharing of vulnerable emotions while at the same time protecting couples from emotional blow-ups. In our in-person work during couple therapy, this is often done by helping one individual develop a softened view of his or her perspective on the problem while attempting to keep the other from jumping in; the therapist directs the discussion, encouraging partners to listen, reflect, and switch roles.

In many respects, we have attempted to replicate this process online. In the “Understand” phase, we encouraged Alvaro and Elizabeth to let go of their blaming attributions and develop their DEEP understanding by completing the program separately with explicit instructions not to share what they wrote with each other. Then, the program brought Elizabeth and Alvaro together at the end of the “Understand” phase and facilitated a sharing of their DEEP understandings by displaying what they have previously written on the screen and asking them to discuss it. This conversation was structured using the speaker/listener model, such that they took turns speaking and reflecting. For example, in the “D” portion of the conversation, Alvaro’s description of the personality differences he selected as being most related to their core issue was displayed on the screen and he was encouraged to describe what he had written to Elizabeth and elaborate on it. Then, Elizabeth was asked to reflect what Alvaro had said and, when done, Alvaro was provided an opportunity to modify anything she had misunderstood. Then, they switched roles: Elizabeth’s description of the natural difference she selected as most related was displayed on the screen and she had a chance to share her views. In this way, the couple began to construct a shared understanding of the difficulties in their relationship. Following the conversation, Elizabeth concluded, “using the structure of the website to slow us down and remind us to keep our ‘turns’ was incredibly helpful.” She strongly endorsed being able to “handle conflicts that come up around the core issue,” “see the core issue in a new way,” and “be more tolerant and accepting of the core issue” because of their DEEP conversation.

IBCT employs empathic joining to facilitate the emotional softening that is the defining feature of emotional acceptance. Some empathic joining may occur during the sharing of the emotions each experiences, particularly the hidden emotions, during the sharing of the DEEP understanding. In addition, after they shared their DEEP analysis with each other, Elizabeth and Alvaro were then asked to rate how this sharing went. Because they both indicated it went “well” (the highest rating), they were provided an opportunity for empathic joining. Specifically, they viewed a video where they were encouraged to “take a moment to share what it was like to have this conversation with each other. As best as you can, try to focus on how you felt. What was it like to open up to your partner? And what was it like for your partner to open up to you – especially about things they felt sensitive or vulnerable about?”

Modifying interfering or unacceptable behavior

Couples with physical violence that results in injury or fear are not appropriate for in person or online interventions that are not specifically focused on aggression and should be referred to appropriate resources. However, for couples with mild or moderate levels of physical aggression (such as pushing and shoving which comprise approximately 50% of couples seeking couple therapy), IBCT can be an effective intervention (Simpson, Atkins, Gattis, & Christensen, 2008). We believe the web-based version of IBCT is also appropriate for these couples as we expect that a DEEP understanding of the underlying issues will serve to defuse the emotions underlying mild violence. Elizabeth reported on the Conflict Tactics Scale that in the last year there had been five occasions of low-level violence such as yelling or shoving, while Alvaro reported two such occasions. As a result, reducing the frequency of these behaviors was a goal of the program. Therefore, just like we would in-person IBCT, the web-based program provided Alvaro and Elizabeth with additional resources, strategies, and referrals for dealing with violence (in a tailored activity that only those with violence receive). In this chapter, they were encouraged to consider how their occasional violence was related to their DEEP understanding (especially their patterns of communication) and identify changes that each of them can make to prevent aggression in the future.

Creating concrete communication and behavior changes

After a focus on increasing emotional acceptance, IBCT subsequently focuses on helping couples create concrete behavioral and communication improvements. Therefore, in the “Respond” phase, Alvaro and Elizabeth were encouraged to consider areas of their relationship that were appropriate for direct change and then brainstormed things they could do on their own to create that change. Elizabeth wrote she would like to “cut back at work and to reduce the amount of work that [she does]” to reduce stress on the family. She would also like to “make more time to be emotionally available when [Alvaro] has a list of chores for [her] or wants to tell [her] about his day.” She hoped that if she did this, Alvaro “would feel more praised and less criticized,” thus breaking their argumentative pattern of interaction. Alvaro wrote that he would like to “manage [his] own expectations of [himself]” and “be more confident [and] more flexible.” Although he did not specify what he had in mind, it was possible that he was trying to reappraise his role in the family as more valuable so he would feel less frustrated. These ideas suggest that this program helped this couple endorses a new understanding of their relationship, one in which each has the power to alter how they think about and respond to the challenges arising from their personalities and emotional sensitivities.

After brainstorming things that they could do individually to improve their relationship, Elizabeth and Alvaro participated in a conjoint problem solving activity as part of their “Respond” conversation. In this conversation, the program helped them to mutually define the problem, brainstorm solutions, select a solution, and pick a date to evaluate the solution. Alvaro and Elizabeth jointly described their problem area as follows: “Neither of us feel that we get recognition from the other and both of us feel frequently criticized. [Elizabeth is] emotionally exhausted from work and we don't take enough time to talk to each other and to reassure each other when [Elizabeth] gets home. Therefore, [Alvaro] feels criticized and [Elizabeth] feels a lack of connection.” They agreed to identify new ways to handle their post-workday interactions. Elizabeth decided to “be more physically affectionate and to make more efforts to give verbal praise.” Alvaro chose “to slow down and wait for a time that [Elizabeth is] available to speak to [her].” They agreed to try to make these behavioral changes over the next month. After one month, each partner would evaluate whether he or she had made the changes that were agreed upon. Both Elizabeth and Alvaro reported that this conversation had gone “okay” (that is, not poorly but not well). Although this problem-solving exercise would likely to be more successful if the solutions the couple chose were somewhat more behaviorally specific (e.g., determining how long Alvaro is required to wait), the couple’s apparent investment in these solutions they generated and chose themselves is likely to produce helpful changes in their marriage.

Promoting strengths and increasing positives

Couples’ strengths are highlighted throughout the program. In the initial feedback report, individuals see three positive qualities or traits that their partner enjoys about them. For example, both Elizabeth and Alvaro listed their strong commitment to each other and their enjoyment of Alvaro’s humor as positives. Elizabeth also wrote that she likes how well she and Alvaro communicate about their commitment, and Alvaro said he liked Elizabeth’s competence. Additionally, they were each prompted to write about their favorite memories involving their partner; these memories were subsequently shared.

Towards the end of the program, individuals separately generate lists of joint activities that they would like to do with their partners and brainstorm ways to increase the frequency of those activities. Additionally, each individual is asked to identify three things that they could do for themselves that they would really enjoy and things they could do for their partner that they suspect their partner would enjoy. For example, Elizabeth wrote that she would like to “go on a new walk with the family,” “play more board games instead of watching tv,” and “get a babysitter and go out on a date.” For herself, she would enjoy “spending more time in prayer,” “going to a museum,” and “pedicures.” These ideas were displayed to the couple during their conjoint “Respond” conversation so they could discuss them.

Providing personal contact and accountability

Although this component is not one of our five universal principles of in-person couple therapy (e.g., Benson et al., 2011; Christensen, 2010), existing research suggests it is critical for users of web-based interventions to feel a sense of personal contact and accountability. In studies examining the effectiveness of web-based interventions for anxiety and depression, completion rates and effect sizes are generally substantially higher when participants have at least some contact with staff. At the same time, this same literature suggests that personal contact does not need to extensive to be effective; additionally, the effectiveness does not seem to depend on the level of professional training (e.g., Andersson & Cuijpepers, 2009). However, this body of research has focused exclusively on individuals – it is possible that staff contact may be less important when couples are participating in a joint intervention (as each partner can hold the other personally accountable).

Thus, we are currently conducting a randomized trial to determine whether couples in web-based IBCT benefit from several opportunities to interact with staff and other couples throughout the program. The first type of contact with staff occurs at certain pre-defined points in the program. For example, after viewing their initial feedback, couples receive an e-mail from staff offering to answer any questions they had and providing encouragement. In another example, after the couple shares their DEEP understandings, couples receive e-mails tailored to the couple’s ratings of how those conversations went. A second type of staff contact occurs based on couples’ progress through the program. For example, if a couple does not complete certain activities in a timeframe they selected, they are contacted via e-mail; if the couple continues to be delayed, staff contact them by phone. Additionally, if a user enters blaming text that will later be displayed to their partner in a conversation, staff will contact the user and encourage him or her to consider revising the text. Finally, the third type of contact couples can have with staff is through an asynchronous message board called “My Coach”. In the “My Coach” interface, a user can type a confidential message (that will not be seen by his or her partner) and receive a response by his or her dedicated “coach” within one business day. Users can send messages with questions about program content or how that content applies to their relationship. However, program staff do not act as therapists; users with critically-important questions that are outside of the scope of the program are referred to an individual or couples therapist.

Outcome and Prognosis

At the end of the program, couples are able to view the progress they have made during the program. Alvaro and Elizabeth’s responses on multiple measures suggested that their relationship improved substantially over the course of the program. Alvaro’s marital satisfaction notably increased (Cohen’s d = 0.85, a “large” effect), crossing from the distressed to the non-distressed range. Elizabeth, who began the program in the non-distressed range, saw somewhat smaller gains in marital satisfaction (Cohen’s d = 0.43, a “small” effect). Additionally, both Elizabeth and Alvaro reported increased confidence that they could handle conflicts related to the core issue; at the start of the program, both had “slightly agreed” they could do this, while at the end of the program both “strongly agreed.” Both partners’ negative feelings about the relationship also decreased substantially, with Elizabeth showing somewhat larger decreases (d = −1.22, a “large” effect) than did Alvaro (d = −0.41, a “small” effect). Findings for positive feelings about the relationship and communication patterns were more mixed. Alvaro’s positive feelings did not change, and Elizabeth’s decreased by one point. By Alvaro’s report, the couple’s communication notably improved during the program (d = 1.45, a “large” effect), but surprisingly Elizabeth reported their communication worsened by four points, a small effect (d = −0.34). However, the overall effect of the intervention on the couple’s relationship appears to have been positive. Both partners reported that the program helped them “a great deal” to handle their relationship problems. These results suggest that despite their distress and the self-directed nature of the program, this couple was able to change their understanding of the relationship and make concrete behavioral improvements as a result of completing the intervention.

Summary and Future Directions

As with couples, where attractions can also be sources of discord, the strengths of the program are also its weakness. Specifically, the primary strength of the OurRelationship program is its ability to help couples independently work though their relationship problems – in their own time and in their own homes. As Elizabeth and Alvaro illustrated, the program can assist couples in developing an individualized and thorough understanding of their core issue, communicate those separate understandings with each other, and develop some possible changes from that analysis. However, maximal success in the program requires an ability to independently apply the content and exercises in the program to one’s own relationship. Thus, while Elizabeth and Alvaro had the motivation to look closely and nondefensively at their problems, there were also places in the program that we suspect we could have been more helpful to them if we could have provided additional guidance. Thus, in future versions of the program, we may need to build in additional supports and resources in certain parts of the program.

Additionally, although both partners reported gains in relationship satisfaction and tended in the “nondistressed” range, they both continued to report problems in their relationship. Therefore, it is likely that they would benefit from additional self-help resources or even in-person couple therapy. Indeed, we have begun to explore whether the OurRelationship program can be used before, or as an adjunct to, couple therapy. For example, feedback from Elizabeth and Alvaro as well as our other pilot couples suggested that they were very satisfied with the way the program helps them develop and share their DEEP understandings. Given that much of the work in the initial stages of in-person IBCT consists of assessment, conceptualization, and feedback, it is possible that the program could assist in this process. Indeed, if couples could present with a more comprehensive and accepting understanding of their relationship, therapy could begin to address remaining issues more rapidly. While we do not believe that web-based resources should replace in-person couple therapy, the potential for synergism between the two is exciting to us.

Another direction we are currently exploring is the development of a web-based program that can be completed by individuals. Programs targeted at individuals have been identified as filling important gaps in relationship education (e.g., Rhoades & Stanley, 2009). The individual version of www.OurRelationship.com can be utilized in two ways. First, our early pilot work suggested that, in a substantial minority of couples, only one of the partners will be willing or interested in completing a web-based program. Thus, individuals will be able to start and finish the program on their own, with guidance on whether or not to share what they have learned with their partner. Second, even after agreeing to complete a couple-based programs, some partners will later change their mind; therefore, we wanted to provide a “back-up” program that could be completed by the remaining user so that his or her work in the program would not be for naught.

In summary, our preliminary results, as illustrated by the case of Alvaro and Elizabeth, suggest that OurRelationship.com can be a useful resource for couples struggling with important relationship difficulties. The program combines a proven couple therapy approach with interactive and tailored web-based exercises. Although we will continue to revise and improve the program, based on the ongoing data we get from couples who go through the program, we are encouraged that we are closing in on our goal of developing an online tool that can be utilized by thousands of couples to better understand and resolve their relationship problems.