Integrated Behavioral Couples Therapy

Traditional Behavioral Couples Therapy (TBCT) is based on a few basic ideas:

Simply talking about how you feel and think about problems is not very helpful; rather, doing something about them is what helps.
TBCT focuses on changing behavior through communication and problem-solving; you negotiate changes and agree to implement them. Studies have shown that inclusion of a “communication skills” module seems to help improve the effect of treatment.
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.

TBCT was shown in over 20 high-quality studies to be an “efficacious and specific” treatment that was very effective (Baucom et al., 1998). 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:

A few smaller studies that showed great results have skewed the opinions of therapists, leading them to think the therapy was more successful.
Jacobson raised doubts about the number of couples who recover versus simply improve, and the number who maintain the gains they make in therapy. Termination studies have showed 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.
Follow-up studies have shown that two years later, 25%-33% of 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 seen in therapy do not appear to last.

Jacobson and Christenson’s Integrated Behavioral Couples Therapy (IBCT) is a newer model designed to improve upon the traditional model. Thus, IBCT is based on a few simple ideas:

Sometimes it is necessary to talk about how you feel and think about problems before you can accept them.
While Jacobson and colleagues note that some problems can be resolved by compromise, some likely can not. Compromise efforts fail, and partners begin to respond to each other in rigid, negative, and reactive ways.
Thus, Jacobson and colleagues have added “emotional acceptance” to the IBCT model.

Andrew Christensen
- When people negotiate change, it means there are externally enforced rules for behavior (“Kiss your partner before they leave for work”). IBCT changes negotiation to be based on internal choices to act in meaningful ways (“Kiss your partner because you want their day to start well”). This reinforces one partner (“I’m a nice person to wish my partner a good day this way”) as well as the other (“My partner loves me and wants me to have a good day”). It also helps with the kinds of problems that don’t have rule-based solutions (“I want him to act enthusiastic”).
- Acceptance does not mean we teach people to become resigned to problems; rather,
  - Putting intense pressure on someone to change creates an intense resistance to change (think about basic systems theory and homeostasis, or how “Every action has an opposite and equal reaction.”).
  - The result is a trap, or a cycle of mutual blame and resentment. Each pressures the other to change, thinking “Things would be better if my partner wuold just…”
  - Partners enter a stage of mutual coercion (“I love you, you’re perfect: Now change”). Each resists, becomes focused on the others’ resistance as the source of all problems, and a pattern of vilification begins. “The Problem Here” is always the other one.
  - Once this happens, both partners become polarized, or unable to see the other accurately, and end up feeling miserable together. By teaching the couple to “tolerate” some problems, and offer and expect minor adjustments to keep it tolerable, the trap is avoided.
  - Part of the way we teach tolerance is to teach couples that they develop problems because the characteristics that at first drew them together later become divisive. There’s a Cathy cartoon where Cathy tells her mother she met an exciting new person. Her mother says that “Mr. Ambition” became a workaholic, “Mr. Sensitive” became a wimp, and “Mr. Free-Spirit” became immature. She asks why she should believe that “Mr. Funny” won’t become obnoxious in a few months. This is a great example of IBCT theory – what initially drew Cathy to these men because something that pushed her away.
- Most partners can change the way they respond to problems, and by changing negative emotional responses they can change what they do that males them, as well as their partners, unhappy.
- As a result, most any couple can be happy and content.

There have been several 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).

Songs for IBCT

Bad Romance by Lady Gaga – In this song, a woman sings about how she wants to have a “bad romance,” full of emotional ups and downs. By the end of the video, the man she desired is literally burned up. Thus, the emotional variability is desired, but in the end destroys the relationship.
The Heel by Eartha Kitt – In this song, the woman describes being in an unhappy relationship, but she cannot leave it because she wants to get even with the man. Thus, she chooses to stay and be miserable.

Quotes for IBCT

Keep your eyes wide open before marriage, half shut afterwards. – Benjamin Franklin

Important Techniques

Therapy begins with an assessment as well as focused interviewing to provide the functional analysis of the behavior, or the thematic meaning and function of the problems. Where TBCT examines the shape and size of the mountain (frequency and duration), IBCT focuses on the impact of the mountain on the surrounding ecology (we don’t need insight, but just enough information for partners to predict how the other will react). They have three appointments (one conjoint, one with each partner separately, and then one conjoint again) and assess a few core issues:
- How distressed are they?
- How committed are they to continuing the relationship?
- What issues divide them?
- Why are these issues so powerful?
- What strengths have kept them together?
- What can treatment do to help?
The first meeting allows them to vent a little, and you might assign some readings to tie them over until the next meeting. The individual meetings allow you to assess each individual’s contribution to the current problems (and how much of their responsibility they own). You also evaluate for things like IPV, affairs, personal pathology… At the third meeting, you offer a conceptualization which makes sense to them (use their language as much as you can), diminishes individual blame, and increases readiness for change. It should include:
- the theme underlying their problems, such as closeness and distance, artist-scientist differences, control and responsibility…
- the polarization process and mutual trap…
- what specific things therapy can do to help, the collaborative process you expect therapy to be, and the goals you think are reasonable
Techniques include
- Acceptance
  - empathic joining (think reframing and empathizing)
  - unified detachment (making the “problem” a third force, so they can talk about it in an intellectual, detached way)
- Tolerance
  - pointing out positive aspects -this is not a Pollyanna intervention, but is designed to note the purpose the symptom serves
  - practicing negative behavior and observing the results – this is exactly what strategic therapists did – if you can control it to make it more dramatic, sarcastic, hurtful… then you can control it to make it less dramatic, sarcastic, hurtful…
  - faking negative behavior – to teach each of the partners how to observe the impact of their behavior when they are calm and cool, kind of like being a scientist and conducting a mini-experiment
  - tolerance through self-care – making needs less demanding and partners less dependent on each other for everything
- Change (classic TBCT techniques)
  - behavior exchange
  - communication and problem-solving training

More…

See Reconcilable Differences – this is a great book for clients, which lays out basic problematic dynamics in relationships and ways to rethink them, written in plain English.

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Integrated Behavioral Couples Therapy