Integrative Behavioral Couple Therapy for Relational Distress

Kyle StephensonClinical PsychologyCalifornia State University Monterey Bay

Overview• Definition of relational distress• Prevalence of distress and divorce

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of how couples become distressed▫ DEEP conceptualization▫ Factors that maintain relational distress

• Overview of IBCT▫ Format of IBCT assessment and therapy sessions▫ Acceptance and change-based interventions▫ Example

• Efficacy of IBCT▫ Efficacy▫ Treatment moderators▫ Treatment mediators

What is relational distress?•Subjective evaluation of the relationship

as a whole and subsequent affective response▫Different from quality, “adjustment,” and

stability▫Sample items from Couples Satisfaction

Index (Funk & Rogge, 2007): Please indicate the degree of happiness, all things

considered, of your relationship I have a warm and comfortable relationship with my

partner I really feel like part of a team with my partner

•Not included as a DSM diagnosis

Overview• Definition of relational distress• Prevalence of distress and divorce

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of how couples become distressed▫ DEEP conceptualization▫ Factors that maintain relational distress

• Overview of IBCT▫ Format of IBCT assessment and therapy sessions▫ Acceptance and change-based interventions▫ Example

• Efficacy of IBCT▫ Efficacy▫ Treatment moderators▫ Treatment mediators

How common are divorce and relational distress?•Divorce:

▫About 50% of first marriages (Bradbury et al., 2000)

•Distressed relationships:▫20% currently distressed (Lebow et al., 2012)

▫Satisfaction drops steeply over the first 10 years of marriage, then drops more gradually in the ensuing decades. (Bradbury et al., 2000)

Impact of relational distress•Poor relationships are related to

▫impaired work functioning (Lebow et al., 2012)

▫worse health (Robles et al., 2014)

▫difficulties in child adjustment (Fomby & Cherlin, 2007)

Risk factors for relational distress•Race and gender

▫E.g., being African American and female associated with lower marital quality and more IPV (Corra et al., 2009)

•Socio-economic status ▫Income correlates at .22▫Education correlates at .12

•Personality▫E.g., neuroticism correlates at .13 - .19

(Karney & Bradbury, 1995)

Comorbidity with relational distress •Physical health conditions

▫Correlations range from .15 to .17 (Robles et al., 2014)

•Mental health conditions▫Depression▫Anxiety ▫Substance abuse

Strong evidence for bi-directional relationships (Fals-Stewart et al., 2009; Whisman & Baucom, 2012)

Overview• Definition of relational distress• Prevalence of distress and divorce

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of how couples become distressed▫ DEEP conceptualization▫ Factors that maintain relational distress

• Overview of IBCT▫ Format of IBCT assessment and therapy sessions▫ Acceptance and change-based interventions▫ Example

• Efficacy of IBCT▫ Efficacy▫ Treatment moderators▫ Treatment mediators

IBCT theory of relational distress•Relational distress = differences +

sensitivities + problematic coping patterns

DEEP conceptualization•Differences

Closeness-Distance* Control and responsibility Expression of love & caring* Artist/Scientist

•Emotional sensitivities▫E.g., I am unlovable, I am incompetent

•External Stressors•Problematic Patterns of interaction

Sensitivities

Relational distress

Differences

Problematic Patterns → Polarization

Mutual Trap

External Stressors

Factors that maintain relational distress•Problematic Patterns of Interaction

▫Coercion One partner applies aversive stimulation until

the other responds▫Mutual avoidance

Both partners avoid talking about the difference▫Vilification

Differences become seen as deficiencies •Consequences: Polarization & Mutual

Trap▫Partners become even more different than

they were to begin with, and they feel hopeless

Overview• Definition of relational distress• Prevalence of distress and divorce

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of how couples become distressed▫ DEEP conceptualization▫ Factors that maintain relational distress

• Overview of IBCT▫ Format of IBCT assessment and therapy sessions▫ Acceptance and change-based interventions▫ Example

• Efficacy of IBCT▫ Efficacy▫ Treatment moderators▫ Treatment mediators

What is IBCT?•Grew from TBCT

▫Primary focus on behavior and skills training

▫Goal is to change behavior, communication, and cognitions of partners

▫Based on basic behavior therapy principles Reinforcement, punishment, extinction

▫Interventions often rule-governed

Why Expand TBCT?• TBCT interventions work

▫designated “efficacious and specific” treatment▫Has never failed to outperform a control group

• But▫only about a 50% rate of improvement (Lebow et al., 2012)

▫Poor maintenance of treatment gains • Particularly difficult on partner who is more

satisfied with status-quo▫Underlying assumption that change is necessary

can invalidate more satisfied partner and increase attempts of other partner to force change

IBCT vs. TBCT•Emphasis on molar targets (themes and

patterns) versus molecular targets (specific behaviors)

•Inclusion of distal and historical as well as proximal variables in case formulation

•Emphasis on emotional acceptance as well as active behavior change

•Use of evocative versus deliberate change strategies

Goals of IBCT•Have couple adopt conceptualization•Increase acceptance of differences and

sensitivities•Change interactions by decreasing

counterproductive attempts to force change in behavior, and by fostering engagement and understanding

•(changes in behavior should naturally follow changes in understanding)

IBCT assessment• 4 sessions

▫ Joint initial session Overview of presenting problem(s) Assess each partner’s goals Relational history

▫ 2x individual assessment sessions Understanding each partner’s point of view and

needs/desires Gather information regarding personal background

(emotional sensitivities*) Assess for IPV, affairs, etc. Assess satisfaction & commitment

▫ Feedback session Review presenting problems, satisfaction, and commitment Present DEEP conceptualization Introduce basic concepts of IBCT

Format of weekly IBCT therapy sessions•Review weekly questionnaires•Jointly decide on topic

▫Positive incident, negative incident, or upcoming event

•Identify how topic is related to one or more themes

•Allow discussion of problem to become problem

•Implement interventions ▫ideally focusing on here and now

Acceptance-based interventions•Empathic joining around the problem

▫Compassionate / empathic•Unified detachment

▫Analytical•Building tolerance

▫Practical

Change-based interventions•Behavior exchange•Communication training•Problem solving training

Importance of acceptance•Coercion

▫Acceptance – decrease attempts to forcefully change partner and his/her behaviors

•Mutual avoidance▫Acceptance – Increase engagement and joint

understanding of problems

•Vilification▫Acceptance – brings understanding of, and

empathy for, sifter emotions. Makes vilification much more difficult

IBCT theory of relational distress

•Relational distress = differences + sensitivities + problematic coping patterns

Reduce frequency & power

Increase understanding

Reduce counterproductive

attempts to change

Overview• Definition of relational distress• Prevalence of distress and divorce

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of how couples become distressed▫ DEEP conceptualization▫ Factors that maintain relational distress

• Overview of IBCT▫ Format of IBCT assessment and therapy sessions▫ Acceptance and change-based interventions▫ Example

• Efficacy of IBCT▫ Efficacy▫ Treatment moderators▫ Treatment mediators

Pilot Study•21 couples randomly assigned to IBCT or

TBCT (Jacobson et al., 2000)

•Findings:▫Treatments were distinct▫Percentage of couples no longer distressed

following treatment IBCT: 70% TBCT: 55%

THE clinical trial of couple therapy• Christensen et al., 2004; 2006• Sample

▫134 highly distressed couples▫78% Caucasian, Mean age = 42, 17 years of

education on average, married 10 years on average

• Methods▫Multi-site trial ▫Highly trained and closely supervised

therapists▫Ongoing assessment of treatment adherence

• Treatment▫ 4 assessment sessions▫ Max of 26 weekly therapy sessions (mean = 23;

94% attended 10+)

Change over the course of treatment

Initial and 2-year follow-up results

Initial and 2-year follow-up results

TBCT Post-treatment IBCT Post-treatment TBCT 2-year follow-up IBCT 2-year follow-up

18.2

7.8

2521.921.2 21.9

159.4

16.7 18.823.3 21.9

43.9

51.6

36.7

46.9

Treatment Outcome

Deteriorated Unchanged Improved Recovered

Changes after treatment

5-year follow-up results

Christensen et al., 2010

Treatment moderators•Little good evidence available to predict

who will benefit most from IBCT (Atkins et al., 2005)

•Initial satisfaction▫Slightly distressed couples benefit more

than severely distressed couples•Length of marriage

▫Couples married longer showed stronger treatment response

•Sexual satisfaction▫Sexually dissatisfied couples showed slower

gains initially, but more consistent gains (less flattening) later in treatment.

Treatment mediators• Change in behavior

Change in behavioral frequency was strongly related to improvements in satisfaction early in therapy

TBCT led to greater changes in behavior early in therapy (but not later)

• Acceptance of behavior Change in acceptance

more strongly related to satisfaction later in therapy

IBCT led to greater changes in acceptance of targeted behavior both early and late in therapy

Doss et al., 2005

Take-Home• IBCT is an efficacious treatment for relational

distress• It is at least as helpful as TBCT, a well-

established efficacious intervention• Booster sessions would likely be helpful

following therapy termination to maintain improvements

• Some initial evidence for treatment moderators and mediators, but more research is needed

• Effectiveness research is also needed

References1.Atkins, D. C., Berns, S. B., George, W. H., Doss, B. D., Gattis, K., & Christensen, A. (2005). Prediction of response to treatment in a randomized clinical trial of marital therapy. Journal Of Consulting And Clinical Psychology, 73, 893-903. 2.Bradbury, T. N., Fincham, F. D., & Beach, S. H. (2000). Research on the nature and determinants of marital satisfaction: A decade in review. Journal Of Marriage And The Family, 62, 964-980. 3.Corra, M., Carter, S. K., Carter, J., & Knox, D. (2009). Trends in marital happiness by gender and race, 1973 to 2006. Journal Of Family Issues, 30, 1379-1404. 4.Christensen, A., Atkins, D. C., 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. 5.Christensen, A., Atkins, D. C., Yi, J., Baucom, D. H., & George, W. H. (2006). Couple and individual adjustment for 2 years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal Of Consulting And Clinical Psychology, 74, 1180-1191. 6.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. 7.Doss, B. D., Thum, Y., 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. 8.Fals-Stewart, W., O’Farrell, T.J., Birchler, G.R., & Lam, W. (2009). Behavioral couples therapy for alcoholism and drug abuse. In J.H. Bray & M. Stanton (Eds.) The Wiley-Blackwell handbook of family psychology (pp. 388-401). Boston: Wiley-Blackwell.9.Fomby, P., & Cherlin, A. J. (2007). Family instability and child well-being. American Sociological Review, 72, 181-204. 10.Funk, J. L., & Rogge, R. D. (2007). Testing the ruler with item response theory: Increasing precision of measurement for relationship satisfaction with the Couples Satisfaction Index. Journal Of Family Psychology, 21, 572-583. 11.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, 351-355. 12.Karney, B. R., & Bradbury, T. N. (1995). The longitudinal course of marital quality and stability: A review of theory, methods, and research. Psychological Bulletin, 118, 3-34. 13.Lebow, J. L., Chambers, A. L., Christensen, A., & Johnson, S. M. (2012). Research on the treatment of couple distress. Journal Of Marital And Family Therapy, 38, 145-168. 14.Robles, T. F., Slatcher, R. B., Trombello, J. M., & McGinn, M. M. (2014). Marital quality and health: A meta-analytic review. Psychological Bulletin, 140, 140-187. 15.Whisman, M. A., & Baucom, D. H. (2012). Intimate relationships and psychopathology. Clinical Child And Family Psychology Review, 15, 4-13.