Integrative Behavioral Couple Therapy

Abstract

Integrative Behavioral Couple Therapy (IBCT) is based in part on traditional behavioral couple therapy but expands both the conceptualization of couple distress and of intervention. The efficacy of IBCT has been supported in three clinical trials, including one with five year follow-up. Additionally, the effectiveness of IBCT in the real world has been supported through a system-wide dissemination effort in the United States Department of Veteran’s Affairs. The reach of IBCT has also been extended through an online program, www.OurRelationship.com, based on IBCT. A nationwide clinical trial with a representative sample of the US population demonstrated the effectiveness of this program on both relationship and individual variables.

Developed in the 1990s, Integrative Behavioral Couple Therapy (IBCT) [1–2] was based in part on Traditional Behavioral Couple Therapy (TBCT) [3], a couple treatment with the most extensive empirical support at the time [4]. However, IBCT extended the conceptualization of couple distress beyond TBCT’s notions of positive to negative exchange ratios and extended the conceptualization of intervention beyond TBCT’s focus on positive behavior change through communication and problem solving skills. In this piece, we will briefly describe the IBCT conceptualization of couple distress and of couple intervention, review the empirical evidence in support of IBCT, and discuss recent innovations in treatment delivery.

Theoretical Notions in IBCT

IBCT suggests that couples often struggle with one or two broad themes in their relationship, such as a struggle over how interdependent or independent they should be. To understand this theme, IBCT borrows two central ideas from other close relationship research [e.g., 5]: a) the stuff of relationships is the interaction between partners and b) there are three broad factors that influence that interaction: the characteristics each partner brings to the interaction and the context in which that interaction occurs. As they relate to couple distress, IBCT conceptualizes these ideas through a simple mnemonic: the DEEP analysis or DEEP understanding of relationship problems. The D refers to key Differences between partners in personality, interests, goals, etc. The first E refers to emotional sensitivities or vulnerabilities that each partner brings to the relationship that may make the differences particularly problematic. For example, perhaps Bill wants a closer, more interdependent relationship than Sue wants, while she is more comfortable with greater independence than Bill is. This difference could be especially problematic is Bill tends to feel neglected when his partner is not close and interconnected with him. Likewise, this difference could be especially problematic if Sue tends to feel controlled or guilty by efforts to have more connection with her. The second E refers to external circumstances, particularly stressful circumstances, which may exacerbate the problems created by differences and emotional sensitivities. For example, if Sue’s job is very demanding or if Bill and Sue live far away from Bill’s circle of friends and family, these contextual factors may make the differences between Bill and Sue more problematic. Finally, the P refers to the Pattern of Interaction that couples get into as they try to navigate the problem created by the DEE. For example, perhaps Bill frequently complains about how disconnected they are while Sue defends her need to work. Although meant to solve the problem, the pattern of interaction that couples get into often makes the problem worse. Sue finds herself less interested in being with Bill because of all his complaining while Bill finds himself angry at her for her seemingly constant avoidance of contact with him.

The IBCT theory of intervention is based on the fundamental notion that all relationship problems result from the combination of a triggering action or inaction and a sensitive reaction. Therefore, relationship problems can be resolved by altering the triggering action or by altering the vulnerable response but a combination of the two is normally preferable. In contrast to TBCT, which focuses on making change in the triggering action or inaction, IBCT provides equal or greater emphasis on changing the vulnerable response (i.e., emotional acceptance), given that most troublesome actions or inactions in relationships are not egregious acts such as violence or verbal abuse. A second key part of the IBCT theory on intervention is that altering both the triggering events and altering the emotional reactions are best achieved through “contingency shaped processes” rather than “rule governed” processes. Based on original work by Skinner [6] and applied to therapy, rule governed change is deliberate change as a result of specific instruction or training by the therapist. For example, TBCT encourages couples to engage in more positive behavior with each other and teaches them communication and problem solving strategies. In contrast, contingency shaped change comes about spontaneously as a result of a change in the context and the resultant emotional and cognitive reactions. For example, one partner may become less blaming and more supportive when he or she sees that the other is in emotional pain or when he or she understands how they are both caught in a vicious cycle of interaction. Although IBCT employs both strategies, it relies more heavily on the later and assumes it will lead to more lasting change.

Evidence in Support of IBCT

The research on IBCT consists of efficacy research that established IBCT as an evidence-based treatment and effectiveness research that is attempting to extend its reach. The efficacy research includes three randomized clinical trials. In a pilot study of 17 couples, Wimberly [7] showed that a group format of IBCT was superior to a wait list control group. Jacobson, Christensen and colleagues [8] demonstrated that IBCT produced comparable or superior outcomes to TBCT in a study of 21 couples. These two small studies were followed by a two-site clinical trial of 134 seriously and chronically distressed couples randomly assigned to IBCT or TBCT [9] that included 5 year follow-up without additional treatment [10]. This clinical trial showed that IBCT and TBCT produced similar gains in relationship satisfaction by the end of treatment, but couples in IBCT evidenced significantly greater maintenance of gains than their TBCT counterparts during the first two years of follow-up. However, these differences between the conditions disappeared over the last three years of follow-up. Observational data on communication collected at pre, post, and two-year follow-up indicated that TBCT couples made greater gains by treatment termination but IBCT couples showed greater maintenance of their gains at the two year follow-up assessment [11]. Thus, the efficacy research demonstrated that IBCT is comparable or superior to TBCT, particularly in the maintenance of treatment gains.

As part of this efficacy research, there were several additional findings: couples with low-level violence could benefit from treatment without a danger for violence escalating [12]; couples experiencing infidelity could benefit from treatment in the short term and, although these couples are at greater risk for separation over the long-term, those who stay together benefit as much as non-infidelity couples [13–14]; for couples with children, treatment showed benefits for parenting [15]. Prediction studies demonstrated that, out of a number of possible variables, higher relationship commitment and longer length of marriage were independently predictive of long-term positive outcome [16–17]. Examination of mediators of change indicated that changes in frequency of targeted behavior, such as Bill being more affectionate with Sue, as well as acceptance of target behavior, such as Sue being more accepting of Bill’s level of affection, were linked with positive outcome, with frequency more strongly linked early in therapy but acceptance more strongly linked later in therapy with outcome. As expected, TBCT generated greater changes in frequency of behavior while IBCT generated greater changes in acceptance of behavior [18].

There have been two broad efforts to extend and evaluate the effectiveness of IBCT in the “real world,” - an effort to disseminate IBCT throughout the U.S. Department of Veteran’s Affairs and an effort to extend the reach of couple therapy by translating IBCT into an online program for couples. In the VA program, mental health practitioners throughout the VA system, typically social workers and psychologists, are trained in IBCT through an intensive 6-month training program that includes: a) a several day workshop, b) weekly phone supervision while trainees are seeing couples, c) observation of at least 20 audio-recorded sessions of these trainees by IBCT consultants, and d) competence criteria based on ratings of these recorded sessions by IBCT consultants. Approximately 80% of trainees complete the training successfully. Preliminary evaluation of the outcome of couples treated during this training reveals that: a) partners in these couples have far more diagnosed psychopathology than partners in the efficacy trials, b) couples complete an average of about 10 sessions, which is fewer than the average completed in the efficacy trials, c) couples evidence significant improvement even when they have as few as 4 sessions, d) the more sessions couples have, the greater the improvement, and e) effect sizes are in the low to moderate range and less than those found in the efficacy trial [Christensen, Glynn, Fehrenbach, & Lui, Association for Behavioral and Cognitive Therapies, Chicago IL, November 2015].

A second real world effort involved the creation of the OurRelationship program [19], an eight hour self-help program in which couples complete online activities consisting of text, audio, still graphics, animations, and videos. Partners complete the majority of this three phase program on their own and come together at the end of each phase for a key conversation with their partner. In the first phase of the program, “Observe”, partners complete assessments of their relationship and jointly decide on one or two core issues/problems to focus on during the program. The “Understand” phase leads each partner through a DEEP analysis of the problem, including how differences between partners, hidden emotions, external stressors, and patterns of communication might affect their core issue(s). These separate analyses are shared during the subsequent “Understand” conversation. During the “Respond” phase, partners develop a plan for ameliorating the problem by viewing information about acceptance and self-change, communication tips, and suggestions tailored to their presenting problem. During the “Respond” conversation, couples share their strategies to improve their patterns of communication and engage in problem-solving exercises specific to their core issue(s). In addition to the online activities, couples participate in up to four 15-minute calls via phone or videoconference with a staff “coach”. The purposes of these calls is to answer general questions about the program, to tailor the program to the couple’s needs, and to keep couples progressing through the program. The coach calls are carefully scripted and supervised to ensure that these calls do not develop into a therapy session.

In a nationwide randomized-controlled trial of 300 couples [20], the OurRelationship program was well-received, with 86% of couples completing the program and 97% of participants indicating they would recommend it to a friend. Indeed, couples were only slightly less satisfied (Cohen’s d = −0.18) with the program than they were with the in-person couple therapy provided as part of the original trial of IBCT and TBCT [9]. Furthermore, the OurRelationship program created significant improvements in relationship satisfaction (d = 0.69) as well as significant effects on depressive (d = 0.50) and anxiety (d = 0.21) symptoms.

The research on IBCT has clearly established it as a promising evidence based treatment for couples, even for those with serious difficulties. The large clinical trial focused on seriously and chronically distressed couples. The application to VA couples has included couples where almost all have at least one partner with existing diagnosed psychopathology. The exciting new development is the possibility of greater reach through the online program. In a 2015 national survey, 34% of married respondents with at least “some” thoughts of divorce sought to improve their marriage through a self-help website; in contrast, only 25% went to some form of marriage counseling, often with a religious leader [The National Divorce Decision-Making Project, 2015, Provo, UT; URL: https://familycenter.byu.edu/Documents/What are they thinking FINAL digital.pdf]. Additionally, web-based resources – with their greater flexibility, reduced stigma, and lower costs – can reach many couples who would otherwise be unable or unwilling to seek in-person couple therapy. Indeed, of those under 50 years old, 79–98% of Hispanics, African-Americans, and those from lower-income households have either a home computer with broadband access or a smartphone with internet access [21–23]. Importantly, the online clinical trial [20] reached a national sample that was largely representative of the ethnic and income distribution in the country yet there was little variation in outcome based on ethnic or income subsamples. As a result, the promise of effective couple intervention may be open to many people who have in the past been largely overlooked.

Highlights.

• Integrative Behavioral Couple Therapy (IBCT) broadens the traditional behavioral theory of couple distress and of intervention.

• Three clinical trials support the efficacy of IBCT.

• IBCT has been successfully disseminated throughout the VA.

• A large, nationwide clinical trial demonstrated the positive impact of OurRelationship.com, an 8-hour online program based on IBCT.