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Q How does Integrative Behavioural Couple Therapy (IBCT) compare with Traditional Behavioural Couple Therapy (TBCT) for significantly and chronically distressed married couples?
Randomised controlled trial.
Follow up period:
36 weeks (mean length of time until final session).
Community based therapy practices, Los Angeles and Seattle; November 1997 to February 2001.
Seriously and chronically distressed married couples repeatedly reporting substantial relationship distress (n = 134 couples). Inclusion criteria: average score of less than 100 in the Marital Adjustment Test in a phone interview; at least one of the partners with a T score of ⩾59 on the Global Distress Scale at two subsequent screenings by questionnaire and one partner scoring one standard deviation below the population mean (<98) in the Dyadic Adjustment Scale. Participants were 18–65 years, fluent in English, and educated to at least high school level. Exclusions: mildly distressed or unstably distressed couples, people with psychotic disorders, couples in alternative concurrent therapy, and wife reports of violence.
Traditional Behavioral Couple Therapy (TBCT): therapists used three treatment strategies: mutual positive behavioural changes, communication training, and problem solving training. Couples were also given a communication guide to read. Integrative Behavioral Couple Therapy (IBCT): enhanced TBCT using three major strategies: empathic joining (identifying vulnerable feelings underlying response), unified detachment, and tolerance to responses to problems. A maximum of 26 sessions were allowed (mean: 23 sessions).
Relationship satisfaction (Dyadic Adjustment Score and Global Distress Scale) and relationship stability (Marital Status Inventory) determined at intake, and at 13 and 26 weeks. Communication was measured using the Problem Solving Communication and Affective Communication of the Marital Satisfaction Inventory (Revised).
Patient follow up:
94% of couples completed treatment (10+ sessions).
At final assessment, there was no significant difference between IBCT and TBCT (p = 0.34) although both treatments resulted in clinically significant improvement (71% of couples showed reliable improvement or recovery in IBCT v 59% showing improvement in TBCT).
TBCT and IBCT are equally effective for distressed couples. Marital therapy is associated with significant change over time in relationship satisfaction, stability, and communication.
This exceptionally rigorous and well designed study is likely to have a significant impact upon the field of behavioural couple research and therapy because it represents a movement away from a primary focus on skills training to examining more emotional dyadic issues. Similarly, research on issues such as relationship cognitions1 and attachment styles2 both have indicated that the ways in which couples cognitively process their interactions have substantial impact on immediate interactions and on their global perceptions of their relationships. Findings from more psychodynamic interventions such as insight oriented marital therapy3 and emotion focused couple therapy4 also have indicated that interventions targeted toward increasing partners’ understanding of one another and emotional connection appear to have great and potentially lasting impact on the couple’s functioning.
This new study on IBCT fits nicely into this accumulating literature and provides greater impetus in the movement toward integrating emotional and cognitive factors into couple treatments. Indeed, these results suggest that after taking time to help partners understand each other’s positions on the problems and to develop mutual empathy with, and tolerance of, each other’s struggles, problems may resolve and/or decrease in importance, so problem solving skills, when needed, may be put to more effective use. Rather than encouraging couples to parrot the new rules or “skills” without addressing the cognitive and emotional contexts of previously problematic behaviours, the acceptance interventions create a new empathic emotional atmosphere and shared understanding of the problem’s context that automatically promotes change with less need for new skills. It is this importance placed on “contingency shaped” changes rather than rule governed changes that is most eye opening for me.
Finally, the effort to guarantee that these interventions were tested on truly distressed couples ensures that these findings are likely to generalise to most clinic couples. However, the exclusion of the criteria of alcohol abuse and borderline personality disorder does suggest that clinicians should be cautious when extending these results to couples in which these issues are present. Still, overall, this excellent study provides couple therapists with much needed tools to use with couples stuck in seemingly insurmountable and unchangeable distress.
For correspondence: Andrew Christensen, Department of Psychology, University of California, Los Angeles, California, USA;
Sources of funding: the National Institute of Mental Health.
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