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Integrative Behavioral Couple Therapy (IBCT) These IBCT slides are based on a VA training presentation by Andrew Christensen, Ph.D., Professor of Psychology.

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Presentation on theme: "Integrative Behavioral Couple Therapy (IBCT) These IBCT slides are based on a VA training presentation by Andrew Christensen, Ph.D., Professor of Psychology."— Presentation transcript:

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 Psychotherapies

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 I

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 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

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 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 Presenting problems and context 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 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 From measures and first session 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 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 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  EverydaySmallInterpersonal  PositiveLow costAction 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, couples (8 IBCT vs. 9 wait list control) IBCT (group Rx) > wait list control Jacobson et al., 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 Couples showing clinically significant improvement: 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: 0.92 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 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.


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