SYSTEMS BRIEF STRATEGIC FAMILY THERAPY INTERGENERATIONAL/TRANSGENERATIONAL FAMILY THERAPY BOWEN FAMILY SY ntegrative Behavioral Couple Therapy (IBCT) is a relatively new approach to couple therapy that has garnered promising empirical support and is current- ly the focus of a major clinical trial on the outcome of couple therapy being conducted at UCLA and the University of Washington. IBCT was developed by Andrew Christensen of UCLA and the late Neil S. Jacobson of the University of Washington. Sometimes referred to as Integrative Couple Therapy, this approach is integrative in two senses. First, it inte- grates the twin goals of acceptance and change as pos- itive outcomes for couple therapy. Also, it integrates a variety of treatment strategies under a consistent behavioral theoretical framework. 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 emo- tional acceptance as a basis for concrete change. Third, it emphasizes evocative rather than prescriptive inter- ventions. These features will be discussed throughout the treatment descriptions. 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 their presenting problems and relationship history, emphasizing the attractions that brought them together. The second and third sessions are individ- ual sessions with each partner. In these sessions, more information on the presenting complaints and an indi- vidual history of each spouse is obtained. In these sessions, IBCT therapists try to specify the most impor- tant problems the couple is facing, to examine the theme or themes that underlie these problems, and to identify the context that makes these problems under- standable. All of this information leads to a case for- mulation of the couples problems. In the fourth session, IBCT therapists share with the couple a formulation of their problems. One can think of this formulation as a new story about the problem. Typically, a couple comes to therapy with two stories about the problemone 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. First, there is a difference or seeming incompatibility between partners. As an example, let us consider a common difference between partnerscloseness. Joan wants more contact, connection, and communi- cation with her husband John, who prefers a connec- tion that involves less contact and leaves more room for independence. Second, there are vulnerabilities in one or both partners that provide emotional fuel for this difference. If Joan is sensitive about abandon- september october 2005 31 A N D R E W C H R I S T E N S E N , P H D Couple Therapy IBCT therapists may teach the couple communication training or PROBLEM SOLVINGto help them handle their problems more effectively and directly. INTEGRATIVE BEHAVIORAL I YSTEMS PSYCHODYNAMIC OBJECT RELATIONS INSIGHT-ORIENTED COUPLE THERAPY RELATIONAL THERAPIES TODAY GESTA ment, or if John is vulnerable to being restricted or constrained in any way, then this common difference on close- ness 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, each partner tries to cope with these differences in ways that seem rea- sonable, but often unintentionally exac- erbate the stress and polarize their dif- ferences. For example, John may withdraw from Joan in order to achieve the level of independence with which he is comfortable. However, this with- drawal increases Joans anxiety so that she pursues, criticizes, and makes demands on John, who, out of anxiety, withdraws further from Joan. A vicious cycle of withdrawing and demanding then develops between the two of them. Finally, the two may experience a vari- ety 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 dur- ing 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. It is beyond the scope of this short descrip- tion to discuss these special issues, but the more detailed references cited below can provide further information about these problems. After the feedback session, the treat- ment formally begins, guided by the for- mulation. The content of the treatment usually concerns recent, emotionally salient incidents, both positive and neg- ative. However, upcoming events that are of concern, or broader issues of cur- rent concern, are also common topics. These incidents and issues that are the focus of therapy are usually directly or indirectly related to the formulation. For example, an incident around Johns leav- ing for a short business trip would cer- tainly be a focus for therapy, while an argument over Joan being late for a lunch meeting would not be a focus for therapy, unless it were indirectly relat- ed to their formulation. However, the formulation is not a static, conceptual framework for viewing the couple. As the therapist and the couple work together to reach increasingly greater understanding of their issues, they may alter and enrich their formulationor storyof their concerns. There are three primary treatment strategies in IBCT that are meant to pro- mote emotional acceptance: empathic joining, unified detachment, and toler- ance building. In the first intervention, IBCT therapists try to create an empath- ic connection between the partners around the very issues that drive them apart. Partners are liable to first discuss their problems by expressing hard feel- ings and thoughts that present the self as strong, and shower accusations on the partner (I am tired of being con- trolled by you, I am resentful of how you have taken advantage of me). These accusations usually create sepa- ration and defensiveness. IBCT thera- pists look for the softer, more vulnera- ble 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 accusa- tory wayYou always hurt me. So, it is a challenge for the therapist to cre- ate 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 envi- ronment where Joan could openly dis- cuss 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, aimed at increasing acceptance, is unified detachment. Whereas empathic join- ing focuses on a close, emotional look at the problems and each partner, uni- fied 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 trig- ger escalation, and the efforts at recov- ery 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), 32 Fami ly Therapy magazi ne 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 HURTthat may lie behind the anger and resentment. AL VIEW RELATIONAL THERAPIES TODAY PROBLEM-CENTERED SYSTEMS BRIEF STRATEGIC FAMILY THERAPY SOCIAL CONSTRU 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 tol- erance building, but one of importance is to enact negative behavior in the ses- sion. 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 defen- sive at Joans reenactment of a blow up) or are occasions for unified detach- ment if the enactments lead to a more detached look at the problem (e.g., Joan and John both laugh at Johns 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 toler- ance 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 Joans 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 Johns difficulties with control, she may alter her behavior in ways that do not arouse his fears so intensely. Thus, impor- tant 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 differ- ent experience of the problem rather than to prescribe different actions that the partners should take. The IBCT therapist does not tell each partner what he or she 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 part- ner what should be accepted. The ther- apist is trying to create conditions that will lead to greater acceptance. If these evocative strategies that focus on greater acceptance are not suf- ficient to bring about the desired increase in relationship satisfaction, the IBCT therapist may also use some of the well-know, change-oriented, pre- scriptive strategies of traditional behav- ior 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 satisfac- tion of the other and may encourage them to engage in these positive actionsthese are familiar strategies of behavioral approaches of which you are probably already aware. Two empirical studies have been completed on IBCT and a major clini- cal trial is now in its follow-up stages. A dissertation by Wimberly in 1997 showed that IBCT administered in groups was more effective than a wait list control group. A small study by Jacobson and colleagues in 2000 showed that IBCT was at least as effec- tive as traditional behavioral couple therapy for distressed couples. In the current, randomized clinical trial, 134 chronically and seriously distressed couples were treated with either IBCT or TBCT in Los Angeles or Seattle. Almost 100 couples wanting treatment were excluded because they did not meet the criteria of chronic and serious distress (they were too happy for the study). Of this difficult group of 134 couples, 71% of IBCT couples showed clinically significant improvement or recovery at the end of treatment com- pared to 59% for TBCT couples. During a two-year follow-up period, most cou- ples in IBCT continued to show greater improvement than couples in traditional behavioral couple therapy. This follow- up data is based on a majority of the cou- ples, but not all of them, as some have not reached the 2-year follow-up point. For more information on IBCT, consult Jacobson and Christensens Acceptance and Change in Couple Therapy (1998), which is the therapists manual for conducting IBCT, and also Reconcilable Differences (2000), which is a book for couples to read as they go through the treatment. ANDREW CHRISTENSEN, PHD, is with the department of psychology at the University of California, Los Angeles. He is the co-developer of Integrative Behavioral Couple Therapy. RE F E RE NCE S CHRISTENSEN, A., & Jacobson, N. S. (2000). Reconcilable differences. New York: Guildford. JACOBSON, N. S. & Christensen, A. (1998). Acceptance and change in couple therapy: A therapists guide to transforming relationships. New York: Norton. 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. WIMBERLY, J. D. (1998). An outcome study of integrative couples therapy delivered in a group format (Doctoral dissertation, University of Montana, 1997). Dissertation Abstracts International: Section B: The Sciences & Engineering, 58(12-B), 6832. An earlier version of this article appeared in Briefings, a news magazine of the California Psychological Association, Number 160, April 2003. september october 2005 33 CTIONIST CONSTRUCTIVIST COLLABORATIVE LANGUAGE-BASED MODELS SYMBOLIC EXPERIENTIAL INTERNAL FAMILY SYSTE