Integrative Behavioral Couple Therapy
Integrative behavioral couple therapy (IBCT) is an empirically validated approach that integrates the twin goals of acceptance and change as positive outcomes for couples in therapy. Using a variety of treatment strategies in a consistent behavioral theoretical framework, IBCT's key features include emphases on case formulation, emotional acceptance as a basis for concrete change, and evocative rather than prescriptive interventions.
IBCT is keenly focused on the emotional underpinnings of a couple's problems as the therapist offers a conceptualization of the problem from an IBCT perspective and engages in a variety of strategies to promote greater emotional acceptance as well as concrete change.
In this demonstration, Andrew Christensen works to give the couple a dyadic perspective on their problems and uses the IBCT interventions of empathic joining and unified detachment to evoke compassionate and caring responses from the couple.
Integrative behavioral couple therapy (IBCT) is a relatively new approach to couple therapy that has garnered promising empirical support. Developed by Andrew Christensen of the University of California, Los Angeles, and the late Neil S. Jacobson of the University of Washington, IBCT is integrative in two senses. First, it integrates the twin goals of acceptance and change as positive outcomes for couple therapy. Also, it integrates a variety of treatment strategies under a consistent behavioral theoretical framework. Because of its emphasis on acceptance, it is somewhat similar to other "third wave" behavioral approaches such as ACT and DBT.
There are three important clinical features of IBCT.
- First, it is driven by a case formulation, which is based on a thematic analysis.
- Second, it focuses on emotional acceptance as a basis for concrete change.
- Third, it emphasizes evocative rather than prescriptive interventions.
The first three sessions in IBCT are devoted to a clinical assessment of the couple, which leads to a case formulation of the couple. An initial conjoint session focuses on the presenting problems of the couple and their relationship history. The second and third sessions are individual sessions with each partner in which information on the presenting complaints and an individual history of each spouse is obtained. In the fourth session, IBCT therapists share with the couple a formulation of their problems based on information obtained in the previous three sessions from the interviews and related questionnaires.
One can think of this formulation as a new story about the problem. Typically, a couple comes to therapy with two stories about the problem — one generated by each partner who emphasizes the faults in the other. The formulation provides a single unified story that takes into account both partners' experiences and puts them together in a non-blaming framework.
A formulation consists of several components which make up what is called a DEEP analysis.
First, there are the Differences or seeming incompatibilities between partners. As an example, consider a common difference between partners — closeness. Joan wants more contact, connection, and communication with her husband John, who prefers a connection that involves less contact and leaves more room for independence.
Second, there are Emotional sensitivities or vulnerabilities in one or both partners than provide emotional fuel for this difference. If Joan is sensitive about abandonment or if John is vulnerable to being restricted or constrained in any way, then this common difference on closeness may be uncommonly emotional for them. These vulnerabilities typically come from each partners' experiences in their family of origin but may also come from more recent experiences, such as experiences in a previous marriage.
Third, there are External stressors which may exacerbate the differences and sensitivities. For example, if John's work requires him to travel extensively, that may accentuate the problems between them.
Finally, there is the Pattern of communication or interaction that partners use to cope with the problems created by their differences, emotional sensitivities, and external stressors. Each partner may interact in ways that seem reasonable to them but often unintentionally exacerbate the stress and polarize their differences. For example, John may withdraw from Joan in order to achieve the level of independence with which he is comfortable. However, this withdrawal increases Joan's anxiety so that she pursues, criticizes, and makes demands on John, who out of his anxiety and frustration, withdraws further from Joan. A vicious cycle of withdrawing and demanding then develops between the two of them, a pattern of interaction that makes their problems worse rather than better.
As a result of these four factors in the DEEP analysis (differences, emotional sensitivities, external stressors, and the pattern of interaction), the two may experience a variety of negative emotions that lead them to feeling "stuck" and "trapped." The harder they try, the worse the problem gets. They feel desperate but hopeless to change the situation.
There are other issues assessed during the evaluation period and discussed in the feedback session. For example, individual diagnoses such as substance abuse or dependence and depression are assessed. Relationship problems such as affairs or violence are assessed. Depending on their severity, substance problems and violence can be exclusionary factors for couple therapy.
After the feedback session, the treatment formally begins, guided by the DEEP formulation. The content of the treatment usually concerns recent, emotionally salient, incidents, both positive and negative. However, upcoming events that are of concern or broader issue of current concern are also common topics. However, these incidents and issues that are the focus of therapy are usually directly or indirectly related to the formulation.
For example, an incident around John's leaving for a short business trip would certainly be a focus for therapy. However, the formulation is not a static conceptual framework for viewing the couple. As the therapist and the couple work together and get increasingly greater understanding of their issues, they may alter and enrich their formulation or "story" of their concerns.
Three are three primary treatment strategies in IBCT that are meant to promote emotional acceptance:
- empathic joining
- unified detachment
- tolerance building
In the first intervention, IBCT therapists try to create an empathic connection between the partners around the very issues that drive them apart. Partners are liable to first discuss their problems by expressing "hard" feelings and thoughts that present the self as strong and shower accusations on the partner ("I am tired of being controlled by you," "I am resentful of how you have taken advantage of me"). These accusations usually create separation and defensiveness.
IBCT therapists look for the "softer" more vulnerable feelings and thoughts that may also exist alongside the harder feelings and thoughts. IBCT therapists may probe for feelings of disappointment, neglect, and hurt that may lie behind the anger and resentment. However, even these softer feelings may be presented in an accusatory way ("You always hurt me").
So it is a challenge for the therapist to create a safe environment where partners can voice their deepest hurts and fears without fear of attack. For example, the therapist would want to create an environment where Joan could openly discuss her fears of abandonment and John could openly discuss his fears of being controlled. By the therapist modeling an empathic approach to each partner, they may begin to take a similar approach to each other.
The second treatment strategy which is aimed at increasing acceptance is "unified detachment." Whereas "empathic joining" focuses on a close, emotional look at the problems and each partner, "unified detachment" takes a more distant, intellectual, and objective look. IBCT therapists engage the couple in a descriptive analyses of their problem that may emphasize the context in which the problem develops, the sequence of actions each partners goes through, the primary events that trigger escalation, and the efforts at recovery and reconnection that each makes.
For example, the therapist might work with John and Joan to describe the context in which a particular problem arose (an incident of parting, when John was to leave on a business trip), the triggering events (John failed to tell Joan of the trip until right before it happened; Joan "blew up" at John about the trip), the sequence of events that made up the incident (they argued until John left in a huff), and their efforts at recovery and reconnection (e.g., John called later that day and tried to "make nice.").
A third strategy for promoting acceptance is tolerance building. There are a number of different aspects of tolerance building, but one important one is to enact negative behavior in the session. Since it is impossible for partners to completely remove negative behavior that triggers emotional reactions in the other, it is sometimes helpful to have partners enact these negative behaviors in session. For example, Joan may enact a "blow up" at John or John might enact a "late notification of an upcoming trip" to Joan.
These enactments are often occasions for empathic joining if the enactments arouse similar emotions to the real events (e.g., John gets defensive at Joan's reenactment of a "blow up.") or are occasions for unified detachment if the enactments lead to a more detached look at the problem (e.g., Joan and Joan both laugh at John's effort to stage a "late notice"). However, the enactments serve as a reminder for the couple that these negative actions will likely occur and give them some opportunity to experiment with how they handle them.
These three strategies of empathic joining, unified detachment, and tolerance building are designed to increase partners' emotional understanding and acceptance of each other. They are not designed to directly change any of the offending behaviors that partners may have listed at the beginning of treatment.
However, emotional understanding and acceptance often lead to "spontaneous changes" in problematic behavior. As John comes to understand and accept Joan's difficulties with abandonment, he may alter his behavior in ways that do not arouse her fears so intensely. Similarly, as Joan comes to understand and accept John's difficulties with control, she may alter her behavior in ways that do not arouse his fears so intensely. Thus, important changes may follow from the focus on acceptance.
These three strategies are primarily evocative rather than prescriptive. That is, they are designed to evoke a different experience of the problem rather than to prescribe different actions that the partners should take. The IBCT therapist does not tell each partner what they should do differently. In fact, in tolerance building, the therapist may try to get the partner to enact the very behavior that is problematic. Even though the focus is on acceptance, the IBCT therapist does not tell each partner what they should accept. The therapist is trying to create conditions that will lead to greater acceptance.
If these evocative strategies that focus on greater acceptance are not sufficient to bring about the desired increase in relationship satisfaction, the IBCT therapist may also use some of the well-known, change-oriented, prescriptive strategies of traditional behavior therapy. IBCT therapists may teach the couple communication training or problem solving to help them handle their problems more effectively and directly. Also, the therapist may have the partners specify positive events that each could do to increase the satisfaction of the other and may encourage them to engage in these positive actions.
As couples improve, the IBCT therapist may space out sessions for longer periods of time until a termination session. This termination session often includes a repeat of the DEEP formulation, but enhanced with additional information gleaned over the course of therapy and emphasizing the positive changes that have occurred in the relationship.
Andrew Christensen, PhD, is professor of psychology in the Department of Psychology at the University of California, Los Angeles. He studies couple conflict and couple therapy and has published over 150 professional articles, primarily on these topics.
He is coauthor of the influential scholarly book, Close Relationships (1983, reprinted in 2002). For therapists, he authored Acceptance and Change in Couple Therapy: A Therapist's Guide for Transforming Relationships (1998) with Neil S. Jacobson. He also completed a trade book for couples, Reconcilable Differences (2000) with Jacobson. Both describe Christensen and Jacobson's approach to couple therapy, integrative behavioral couple therapy (IBCT).
With support from the National Institute of Mental Health, he and Jacobson conducted the largest clinical trial to date of the impact of couple therapy, focusing on the impact of their form of couple therapy in particular, including a 5-year follow-up of these couples. IBCT has recently been adopted by the U.S. Veteran's Administration as one of their empirically supported treatments that they are "rolling out" throughout the VA system.
Christensen's therapy approach and research have been cited in the Washington Post, New York Times, Newsweek, Time Magazine, U.S. News and World Report, USA Today, and other magazines and newspapers.
Research on IBCT
- Atkins, D. C., Dimidjian, S., Bedics, J. D., & Christensen, A. (2009). Couple discord and depression in couples during couple therapy and in depressed individuals during depression treatment. Journal of Consulting and Clinical Psychology, 77, 1089–1099.
- Atkins, D. C., Eldridge, K., Baucom, D. H., & Christensen, A. (2005). Infidelity and behavioral couple therapy: Optimism in the face of betrayal. Journal of Consulting and Clinical Psychology, 73, 144–150.
- Baucom, B. R., Atkins, D. C., Simpson, L. E., & Christensen, A. (2009). Prediction of response to treatment in a randomized clinical trial of couple therapy: A 2-year follow-up. Journal of Consulting and Clinical Psychology, 77, 160–173.
- Baucom, K. J. W., Sevier, M., Eldridge, K. A., Doss, B. D., & Christensen, A. (2011). Observed communication in couples 2 years after integrative and traditional behavioral couple therapy: Outcome and link with 5-year follow-up. Journal of Consulting and Clinical Psychology, 79, 565–576.
- Christensen, A. (2010). A unified protocol for couple therapy. In K. Hahlweg, M. Grawe-Gerber, & D. H. Baucom (Eds.), Enhancing couples: The shape of couple therapy to come (pp 33–46). Göttingen, Germany: Hogrefe.
- Christensen, A., Atkins, D. C., Baucom, B., & Yi, J. (2010). Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 78, 225–235.
- Christensen, A., Atkins, D. S., Berns, S., Wheeler, J., Baucom, D. H. & Simpson, L. E. (2004). Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. Journal of Consulting and Clinical Psychology, 72, 176–191.
- Christensen, A., Atkins, D. C., Yi, J., Baucom, D. H., & George, W. H. (2006). Couple and individual adjustment for two years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 74, 1180–1191.
- Cordova, J. V., Jacobson, N. S., & Christensen, A. (1998). Acceptance versus change interventions in behavioral couple therapy: Impact on couples' in-session communication. Journal of Marriage & Family Counseling, 24, 437–455.
- Doss, B. D., Thum, Y. M., Sevier, M., Atkins, D. C., & Christensen, A. (2005). Improving relationships: Mechanisms of change in couple therapy. Journal of Consulting and Clinical Psychology, 73, 624–633.
- Gattis, K. S., Simpson, L. E., & Christensen, A. (2008). What about the kids? Parenting and child adjustment in the context of couple therapy. Journal of Family Psychology, 22, 833–842.
- Jacobson, N. S., Christensen, A., Prince, S. E., Cordova, J., & Eldridge, K. (2000). Integrative behavioral couple therapy: An acceptance-based, promising new treatment for couple discord. Journal of Consulting and Clinical Psychology, 68(2), 351–355.
- Sevier, M., Eldridge, K., Jones, J., Doss, B., & Christensen, A. (2008). Observed communication and associations with satisfaction during traditional and integrative behavioral couple therapy. Behavior Therapy, 39, 137–150.
- Simpson, L. E., Atkins, D. C., Gattis, K. S., & Christensen, A. (2008). Low-level relationship aggression and couple therapy outcomes. Journal of Family Psychology, 22, 102–111.
- Simpson, L.E., Doss, B.D., Wheeler, J., & Christensen, A. (2007). Relationship violence among couples seeking therapy: Common couple violence or battering? Journal of Marital and Family Therapy, 33, 270–283.
Website on IBCT
- Integrative Behavioral Couple Therapy (IBCT) website
This website contains information on IBCT (description of the approach, books and articles on it, therapists trained in it, etc.). Many of the articles above are available for download at this website.
Readings for Therapists
- Christensen, A., Wheeler, J. G., & Jacobson, N. S. (2008). Couple distress. In D. H. Barlow (Ed.), Clinical Handbook of Psychological Disorders, 4th edition (pp.662–689). New York, NY: Guilford.
- Jacobson, N. S., & Christensen, A. (1998). Acceptance and change in couple therapy: A therapist's guide to transforming relationships. New York, NY: Norton.
Note: Hardback title was Integrative couple therapy: Promoting acceptance and change.
Readings for Couples
- Christensen, A., & Jacobson, N. S. (2000). Reconcilable differences. New York, NY: Guilford.
Note: This is a self-help book for couples to read during therapy.
- Cognitive–Behavioral Couples Therapy
- Couple Power Therapy
Peter L. Sheras and Phyllis R. Koch-Sheras
- Couples at an Impasse
- Emotionally Focused Therapy With Couples
Leslie S. Greenberg
- Enhanced Cognitive–Behavioral Couple Therapy
Donald H. Baucom
- Schema Therapy With Couples
Jeffrey E. Young
- Behavioral Interventions in Cognitive Behavior Therapy: Practical Guidance for Putting Theory Into Action
Richard F. Farmer and Alexander L. Chapman
- Couple Power Therapy: Building Commitment, Cooperation, Communication, and Community in Relationships
Peter L. Sheras and Phyllis R. Koch-Sheras
- Couples Coping With Stress: Emerging Perspectives on Dyadic Coping
Edited by Tracey A. Revenson, Karen Kayser, and Guy Bodenmann
- Couples Therapy for Domestic Violence: Finding Safe Solutions
Sandra M. Stith, Eric McCollum, and Karen H. Rosen
- Emotion-Focused Couples Therapy: The Dynamics of Emotion, Love, and Power
Leslie S. Greenberg and Rhonda N. Goldman
- Emotion Regulation in Couples and Families: Pathways to Dysfunction and Health
Edited by Douglas K. Snyder, Jeffry A. Simpson, and Jan N. Hughes
- Enhanced Cognitive–Behavioral Therapy for Couples: A Contextual Approach
Norman B. Epstein and Donald H. Baucom