1. Integrative Behavioral Couple Therapy (IBCT)
These IBCT slides are based on a VA training presentation by Andrew Christensen, Ph.D., Professor of Psychology at UCLA, and developer of IBCT (along with the late Neil S. Jacobson of the University of Washington)

2. Acknowledgment
The VA effort to disseminate training on integrative behavioral couples therapy is part of a national project providing clinician training to promote use of evidence-based treatments. We wish to thank Bradley Karlin, Ph.D., National Mental Health Director, Psychotherapy and Psychogeriatrics, VA Office of Mental Health Services and Susan McCutcheon, RN, EdD., Director, Family Services, Women’s Mental Health & Military Sexual Trauma, VA Office of Mental Health Services for their support of this effort.

3. VA Training in Evidence-Based Psychotherapies3

4. Background
In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001)
The VA developed a Mental Health Strategic Plan in response to the President’s New Freedom Commission on Mental Health report (2004)
The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country

5. Goals of VA Training in EBPs
To train VA staff from multiple disciplines in evidence-based psychotherapies
To augment psychotherapies already being offered in VA medical centers

6. VA Dissemination and Training in EBPs
Cognitive Behavioral Therapy (CBT) for Depression and for Insomnia (CBT-I)
Acceptance and Commitment Therapy (ACT) for Depression
Cognitive Processing Therapy (CPT) for PTSD
Prolonged Exposure (PE) for PTSD
Social Skills Training (SST) for Serious Mental Illness (SMI)
Integrative Behavioral Couple Therapy (IBCT)
Family Psychoeducation (FPE) for SMI
Behavioral Family Therapy (BFT)
Multi-Family Group Therapy (MFGT)
Motivational Interviewing
Problem-Solving Therapy

7. Anticipated EBP Trainings
Interpersonal Therapy (IPT) for Depression
Pain Management
Substance Use Disorders
Motivational Enhancement
Contingency Management
Cognitive Behavioral Therapy
Behavioral Couples Therapy

8. EBP Presentations for Interns and Postdoctoral Fellows
VA EBP rollout trainings have been focused on staff
VA Psychology Training Council (VAPTC) developed a workgroup in 2009 to focus on developing EBP didactics for interns and postdoctoral fellows

9. Goals of this EBP Presentation
To provide a basic working knowledge of each of the rollout EBPs
To provide the foundation for trainees to seek out further training and supervision in the EBPs they intend to implement

10. Limitations
This presentation will not provide equivalent training to the EBP rollouts
This presentation will not provide the skills to implement the treatment without further training and supervision

11. Integrative Behavioral Couple Therapy

12. So why did VA choose to disseminate IBCT?
Behavioral foundation made it accessible to many VA clinicians, many of whom have little or no couples experience
Well manualized
Inclusion of “acceptance” paradigm consistent with other EBP roll-outs
Existence of a supporting RCT
Does not require extensive understanding of other family intervention concepts (e.g., attachment theory, family systems)

13. So why did VA choose to disseminate IBCT?
In recent years, health care policy has incorporated evidence-based practice as a central tenet of health care delivery (Institute of Medicine, 2001)
The VA developed a Mental Health Strategic Plan in response to the President’s New Freedom Commission on Mental Health report (2004)
The Mental Health Strategic Plan calls for the implementation of EBPs at every VAMC in the country
PL modified Federal Law 38 USC 1782 to specifically include marriage and family counseling as a service that would be provided to family members of Veterans as necessary in connection with the Veterans treatment plan (October, 2008)

14. Demographics of Couples
About half of first marriages end in divorce
Remarriages fare less well
Those who remain together
Often unhappy
Choice influenced by circumstance
Stable, happy marriage (or happy relationship)
a clear minority of marriages/couples

15. Additional Information on Veteran Couples
Veteran couples tend to have additional stressors impacting their marriage and relationship satisfaction.
More than half of first marriages among veterans who have been exposed to combat end in divorce
 With regards to recently deployed service members, divorce rates have been steadily increasing within the Army and the Marines since the recent conflicts began.
For recently returned veterans, 3 years after deployment approximately 40% report relationship difficulties and 35% report having gone through a separation or divorce. Overall, about ¾ of returning veterans report family adjustment difficulties.

16. Correlates of Discord & Divorce
Impact on Partners
Mental health: depression, anxiety, loneliness
Physical health: variety of stress-related ills
Financial health: women particularly suffer
Impact on Children
Short-term impact: externalizing & internalizing problems
Long-term impact: divorce, trust

17. Evidence-based Treatments (EBTs) for Couples
Non-Behavioral Approaches
Emotionally Focused Couple Therapy
Insight Oriented Couple Therapy
Behavioral Couple Therapy
Traditional Behavioral Couple Therapy
Cognitive Behavioral Couple Therapy
Integrative Behavioral Couple Therapy
“Acceptance Therapy”

18. Similarities and Differences in EBTs
Similarities are great
Dyadic conceptualization
Alter destructive interactions
Promote constructive communication
Build on strengths
Substantial differences exist

19. Principles of Treatment that Distinguish Behavioral Couple EBTs
Theoretical underpinnings
Problem definition:
Molar vs. molecular definitions
Types of change
Acceptance vs. change
Strategies for inducing change
Structured vs. naturalistic change

20. Two Ways to Define Problems
Molecular
Pinpoint specific behaviors, cognitions
Pros: well defined, easily understood
Cons: long list, miss forest for trees, premature definition, solidification
Molar
Define response class, broad patterns
Pros: breath of coverage, big picture view
Cons: less well defined, more messy

21. Two Types of Changes Traditional change Acceptance
Modification of the agent or “perpetrator”
Increase or decrease in frequency, intensity, or duration of behavior
Acceptance
Modification of the recipient or “victim”
Change in emotional reactivity

22. What is “Acceptance” in IBCT?
What it IS NOT:
Resignation, submission, giving in
Permission to be abusive
What it IS:
Problems as a window into vulnerability
Problems as a vehicle for intimacy
Letting go of the struggle to change
Reducing adversarial relationship

23. Two Types of Behavior Rule-governed behavior
Follow the rule; “shoulds”
Sanctions for violation; reinforcement for compliance
E.g., exercise, listen, obligatory compliments
When emotions/motives suggest otherwise
Contingency-shaped behavior
Situation naturally elicits and reinforced; “Want to’s”
Be yourself, let guard down, say what on mind
E.g., exercise, listening, genuine compliments
When emotions/motives are congruent

24. Two Strategies of Change
Rule-governed (structured/deliberate) change
Suggest/impose new rules (dates, accept, think)
Help couples negotiate new rules
Dilemma: behaviors versus emotions; compliance; inauthentic/unnatural, not naturally reinforcing
Contingency-shaped (naturalistic/”spontaneous”) change
Elicit/evoke new reactions, experiences
Reinforce new responses
Dilemma: what will elicit a new experience

25. Example: “Always” or “Never”
Traditional BCT
Communication error
Practice correctly
Cognitive Behavior Therapy
Look for exceptions
Correct cognitive error
Integrative Behavioral Couple Therapy
Catch it in session or discuss a recent incident of it
Explore what is going on with the one who said it
Explore impact on partner

26. Integrative Behavioral Couple Therapy (IBCT)
Functional analytic behavioral views
Emphasis on broad, molar themes
Emphasis on acceptance
Emphasis on contingency shaped behavior
To foster acceptance
To foster change
Also includes alternative strategies

27. Relationship Problems as Defined by Couples in Therapy
Faults lie in the Partner
The Verdict: Partner is guilty of selfishness, inconsideration, etc.
The Diagnosis: Partner is mentally ill (neurotic, afraid to be intimate, mentally or chemically imbalanced)
The Performance Evaluation: Partner is inadequate (does not measure up, unable to communicate/love, needs to improve)

28. IBCT Formulation of Relationship Problems
DEEP analysis of an issue (content area)
Differences or incompatibilities
Emotional sensitivities
External circumstances/stressors
Patterns of problematic interaction
Couple’s efforts to cope with DEE
Interaction makes the problem worse

29. Common Individual Differences: Sources of Incompatibility
Personality differences (Big 5)
Differences in levels of sexual interest
Differences in link to family of origin
Differences in desire for closeness
Differences in coping with stress
Differences in interests
Differences result from genes, social learning history, gender, socio-economic status, and culture

30. Emotional Sensitivities
Don’t ever leave me
Stand by me
Don’t smother me
Give me freedom to be me
Don’t criticize me
Accept me, faults and all
Don’t try to control me
I’m in charge of myself

31. Emotional Sensitivities
Don’t treat me like I’m crazy
Validate that I’m normal
Don’t ignore me
Listen to me
Don’t treat me like a kid
Tell me I am competent
Don’t treat me like I’m unattractive
Desire me

32. Origin of Emotional Sensitivities
Genes and social learning history
Gender: views of masculinity, femininity
Socio-economic status: e.g., employment, financial security
Culture: e.g., views of privacy, responsibility to family, emotional expression 32

33. External Stressors Anything outside the couple relationship
Common stressors
Children, family of origin
Career, finances
Illness
Friends, neighbors

34. Patterns of Problematic Interaction
Pattern of problematic interaction = repetitious, dysfunctional cycle of communication
Major types of dysfunctional interaction
Moving against the other
Moving away from the other
Hanging on to the other (moving toward the other anxiously)

35. Moving against the Other
Criticizing, blaming, fault finding, attacking, finger pointing
Demanding, pushing, nagging, pressuring, reminding, correcting
Controlling, competing, showing who is right, allying with others against partner
Arguing, escalating, exaggerating

36. Moving away from the Other
Withdrawing, escaping, avoiding, distancing, shutting down
Hiding, evading, being secretive, misleading
Dismissing, minimizing, or denying other’s concerns, resisting other’s efforts
Defending, justifying, or explaining self

37. Hanging onto the Other
Pursuing, clinging, hovering, not letting other go
Intruding, invading, being nosey, not letting other have privacy
Questioning, investigating, interrogating, monitoring, keeping watch over other, keeping tabs on other

38. What Makes these Behaviors Problematic?
Context is all – nothing occurs in isolation
Adversarial vs. supportive context – e.g., fault finding, arguments, hanging on: Adversaries
Context of tense distance versus independence – e.g., uncommunicative, withdrawn: Strangers
Short- vs. long-term consequences
Short-term gain but long-term pain - editing
Short-term pain but long-term gain- editing

39. Problematic Patterns of Interaction
Asymmetrical patterns
Moving against vs. moving away
Discuss/avoid pattern
Demand/withdraw pattern
Hanging onto vs. moving away
Pursuit/distance pattern
Invading/evading pattern
Symmetrical patterns
Mutual moving against
Argumentative, bickering pattern
Mutual moving away
Mutual avoidance, shutting down pattern

40. IBCT Formulation: Trust Example
Differences
Social skills, views of contact with friends
Emotional reactions/sensitivities
Parent’s affair, search for autonomy, early relationship history
External circumstances/stressors
Work contact with colleagues
Pattern of interaction
Questioning-checking; evading-hiding

41. IBCT Formulation: Depression Example
Differences
Optimism, outspokenness
Emotional Reactions/Sensitivities
Fear of caretaking; sensitivity to criticism
External Circumstances/Stressors
Difficulty finding work, doing responsibilities
Patterns of Interaction
Demanding criticism/defensive-withdrawal

42. IBCT Formulation: PTSD Example
Differences
Comfort with expression of negative emotion
Emotional Reactions/Sensitivities
Fear of strong emotional reactions; fear of PTSD stimuli
External Circumstances
Noisy, bad area of town
Patterns of Interaction
Avoidant tiptoeing/numbing avoidance followed by explosive reactions

43. Applications of DEEP Analysis
Can be applied to specific problems, such as trust, money, depression
Often the model applies more broadly
Responsibilities – housekeeping, kids, social contacts, job
Closeness – time together, time with friends, time with family, disclosures, privacy
Emotionality – about work, kids, home, each other

44. Integrative Behavioral Couple Therapy (IBCT): Distress =
Content problem/s –theme; can center on diagnosis
DEEP Analysis
Differences/incompatibilities
Emotional reactions/sensitivities/vulnerabilities
External circumstances/stressors
Patterns of communication/interaction
Outcome
Bigger problem: escalation, polarization, vilification
Adversaries or strangers; emotionally trapped – hopeless/helpless

45. Inappropriate Couples for IBCT
Exclusionary individual factors
Untreated substance abuse/dependence
Psychosis, Antisocial Personality Disorder
Moderate to severe violence
Injury and/or intimidation
Exclusionary couple factors
Not living together regularly
One or both not committed to relationship
One wants to end relationship

46. Overview of IBCT Assessment phase Clinical formulation and feedback
1 joint and 2 individual sessions
Clinical formulation and feedback
1 joint session
Active treatment
Multiple joint sessions
Termination
Spaced joint sessions

47. Assessment and Feedback: Format
Initial session with both partners
Presenting problems and context
Relationship history
Assign measures, book
Individual interviews with each partner
Individual history and current social context
Feedback session with both partners
Feedback on assessment; outline of treatment

48. Purpose of Assessment Distress – interview and questionnaires
Couple Satisfaction Inventory (CSI-16) (Funk & Rogge, 2007)
Violence – questionnaires and interview
Brief items on violence and intimidation
Commitment & affairs – interview, questionnaires
Brief items on commitment
Problematic Issues & Patterns- interview, questionnaires
Formulation (Model of distress; DEEP analysis)
Strengths (individual and joint) - interview

49. Initial Session Presenting problems and goals Relationship history
Discover issues, interactions, and goals
Each speaks, but only for self
Therapy neutrality – support both
Vague  specific; impersonal  personal
Relationship history
Attractions, early history
Development of problem
Current situation
Summary, administer measures, assign Reconcilable Differences book

50. Overview of Measures Demographic Questionnaire for Couples
Age, time together, children, medications, etc.
Couple Satisfaction Index (CSI-16)
Measure of relationship quality
Problem Areas Questionnaire
Content areas of concerns –issues/theme
Couple Questionnaire
CSI-4 (baseline), violence, commitment
Communication During Conflict Questionnaire
Pattern of interaction

51. Individual Session Confidentiality assurance
Issues, interactions, goals
From measures and first session
Violence, commitment, affairs
Personal history & current situation
Personal psychiatric history
Family of origin (parent’s marriage, relationship with each parent)
Relationship history (e.g., previous marriage)
Current situation

52. Feedback Session Problematic issues – theme
Level of distress and commitment
Case Formulation
Problematic issues – theme
Provide education about disorder as appropriate
Differences or incompatibilities
Emotional reactions/sensitivities/vulnerabilities
External circumstances/stressors
Patterns of communication/interaction
Impact – hopeless/helpless, adversaries/strangers
Strengths – individual and couple
Treatment – goals, incidents, issues
Go over Weekly Questionnaire as guide

53. Therapeutic Goals of IBCT: Acceptance and Change
Primarily Acceptance for
Differences
Emotional sensitivities
Acceptance and change for
External stressors
Primarily Change for
Patterns of problematic interaction

54. Therapeutic Methods in IBCT
Guiding Formulation – DEEP understanding
Focus on emotionally salient, in-vivo experience
Events in therapy that reflect formulation
Recent or upcoming incidents that reflect formulation
Issues of current concern that reflect formulation
Strategies:
Affective change – “Empathic Joining”: New emotional experience of problem
Cognitive change: “Unified Detachment”: New perspective on the problem
Behavioral change: New coping with problem

55. Three Typical Therapeutic Discussions in IBCT
Compassionate discussions - empathic joining
Analytical discussions – unified detachment
Practical discussions – making concrete changes

56. Format for Treatment Sessions
Weekly Questionnaire; check-in
Review violent/destructive event, major changes
Debrief positive events
Set agenda based on client reported incidents/issues
Use of Weekly Questionnaire
Use interventions for incidents/issues
Shift agenda as problem discussion leads to problem
Wind down and summary
Questionnaire, homework

57. Who Talks to Whom? Each partner talks to the therapist
Therapist has most control
Therapist insures hearing and validation for each
Therapist can reinforce each appropriately
Therapist can transition effectively
Less generalization
Couple talks to each other
Therapist directs the discussion - enactments
Therapist intervenes in the discussion
Therapist watches and applauds discussion

58. Empathic Joining - Purpose
Heart-to-heart discussion of a significant relationship experience
Both partners share feelings, some that they may not have shared before
Partners experience understanding and validation, from therapist & partner
Partners experience greater intimacy and emotional acceptance

59. Empathic Joining: Therapeutic Strategy
Be attentive to emotional reactions
Primary, initial, unrevealed, soft emotions
Versus secondary, reactive, hard emotions
Prompt personal disclosure
Probe, explore, elicit, suggest emotions
Highlight, validate and reflect emotions
Prompt disclosure to partner
Prompt partner response (e.g., summary, reaction)

60. Unified Detachment - Purpose
Intellectual discussion about a significant relationship experience
Partners reveal thoughts, views, perspectives, and observations
Discussion of relationship experience is
descriptive, nonjudgmental, dyadic, and mindful
versus evaluative, blaming, individually oriented and responsibility-seeking
Partners often feel a sense of common, unified perspective on a problem and greater acceptance of the problem

61. Unified Detachment: Therapeutic Strategies
Engage couple in a discussion that
Describes sequence and patterns
Identifies “triggers” and “buttons”
Makes comparisons/contrasts (e.g., ratings)
Distinguishes intentions from effects
Employs humor, metaphor, and images
Treats the problem as an “it” versus a “you”

62. Direct Change - Purpose
Communicate more effectively
Problem solve more effectively
Increase positive interactions
Increase tolerance of negative events
Partners often experience a greater sense of confidence and control

63. Direct Change - Strategies
Prompt existing behavioral repertoires first
Teach new communication/problem solving strategies or suggest new positive events secondarily
Interventions
Replay difficult interactions
Discuss vexing problems and possible solutions
Identify, prompt, & debrief positive actions
Teach traditional CT/PST (Communication Training/Problem Solving Training)
Conduct tolerance interventions

64. How to Intervene in Problematic Interactions
Interrupt the process early
Reframe, redirect, and referee interaction
Empathic joining:
Identify primary emotional responses
Reflect, elaborate, discuss
Discuss functional relationships
Enactment, replay

65. How to Intervene in Improved Interactions
Goal – ensure partners are reinforced
Leave it alone if partners reinforced
If not reinforced sufficiently
Highlight the reactions each had
Normalize awkwardness, embarrassment
Reinforce directly if partner won’t
Help partners understand why
Discuss functional relations

66. Behavior Exchange: Increasing Positive Behavior
Specification of changes
Everyday Small Interpersonal
Positive Low cost Action not inaction
What do instead of ….
Instigation of positive changes
Debriefing of positive changes

67. Communication Training
Expresser skills - no fault communication
Non-blaming “I” statements of feeling
Partner’s specific behavior in situation
“When you do X in Y situation, I feel Z”
Listener Skills
Active listening: paraphrase, reflection
Check out, summary before change roles

68. Problem Solving Training
Problem Definition
Acknowledge positive
Define problem (unilaterally or bilaterally)
Acknowledge own role
Problem Solution
Brainstorming
Pros and Cons
Negotiation; Agreement; Experimentation

69. Tolerance Building Tolerance is on continuum of acceptance:
grudging tolerance   embracing differences
Goals of tolerance interventions
Make partner’s behavior less painful
Enhance ability to cope
Decrease intensity of conflict
Shorten duration of recovery
Types of tolerance interventions:
Highlight positive features of negative behavior
Rehearsal of negative behavior (desensitization)
Faking of negative behavior (relapse prevention)
Self-care: Promotion of independence, self-reliance

70. Ordering of Interventions
Start with Empathic Joining & Unified Detachment, not Direct Change Interventions
Partners get heard, understood, and true issues and feelings exposed
May on its own trigger improved functioning
Integrate Empathic Joining and Unified Detachment
Debriefing incident in or out of therapy
When doing Direct Change Interventions
Prompt existing behaviors before teaching new behaviors

71. Ordering of Interventions - Continued
Tolerance interventions are:
Done later rather than earlier
Are used when couples have some distance
Adapt interventions to the couple
Capitalize on their strengths (e.g., humor)
Address needed deficits (e.g., difficulty in expressing emotion, shutting down during difficult communication)
Repeat what works

72. Termination Phase When should you begin termination?
Significant progress made
Couple desires termination
Little of emotional significance to discuss
Note – 26 sessions maximum in clinical trial
Process of termination
Space sessions at longer intervals
Allow booster sessions as needed
Post measures – feedback to couple

73. Desired Outcomes
Couples who can not learn from the past are condemned to repeat it (Santayana)
The unexamined relationship is not worth living (Socrates)
Goal: A more accepting and adaptive relationship based on the psychological reality of each partner

74. Empirical Evidence for IBCT
John Wimberly Dissertation, 1997
17 couples (8 IBCT vs. 9 wait list control)
IBCT (group Rx) > wait list control
Jacobson et al., 2000
21 married couples (10 IBCT; 11 TBCT)
Clinically significant change by termination
TBCT – 64%; IBCT - 80% reliable improvement or recovery
Christensen et al. (2004; 2006, 2010)

75. Current On-going Study
NIMH Multi-Site Study of Marital Therapy
Los Angeles & Seattle: 134 married couples
Comparing Traditional Behavioral Couple Therapy (TBCT) (68) vs. IBCT (66)
26 sessions of treatment plus 2 year follow-ups
Special Features
Seriously and stably distressed couples
High quality therapy

76. Data on Current Study
Termination Data
Couples in TBCT improve quickly but plateau; couples in IBCT improve steadily throughout treatment
Couples showing clinically significant improvement:
60.6% TBCT; 70.3% IBCT
Two year follow-up data
Significantly greater maintenance of changes in relationship satisfaction in IBCT than TBCT through 2 years of follow-up assessments
IBCT showed significantly greater maintenance of gains in observed communication at 2 year follow-up
60% TBCT; 69% IBCT
Separations/divorces (15-20%)

77. Data on Current Study 5 year follow-up data
Separation/divorce: 28% TBCT; 26% IBCT
Effect size: TBCT; 1.03 IBCT
Cl. Sig. Improvement: TBCT – 46%; IBCT – 50%
Conclusions about TBCT and IBCT
Similar, substantial improvement during Rx
Substantial maintenance for 2 years post treatment
Greater maintenance of gains in IBCT for 2 yrs
Without booster sessions, some loss of gains from 3-5 years and convergence of treatment effects
Seriously distressed couples may need additional booster sessions post treatment

78. Treatment manuals For Therapists For Couples and Therapists
Jacobson, N.S., & Christensen, A. (1996). Acceptance and Change in Couple Therapy: A Therapist’s Guide to Transforming Relationships. New York: Norton.
For Couples and Therapists
Christensen, A., & Jacobson, N.S. (2000). Reconcilable Differences. New York: Guilford.