integrative behavioral couple therapy (ibct) these ibct slides are based on a va training...

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)

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.

VA Training in Evidence-Based Psychotherapies

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

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

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

Anticipated EBP Trainings

Interpersonal Therapy (IPT) for Depression Pain Management Substance Use Disorders

Motivational Enhancement Contingency Management Cognitive Behavioral Therapy Behavioral Couples Therapy

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

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

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

INTEGRATIVE BEHAVIORAL COUPLE THERAPY

I

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)

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 110-387 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)

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

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.

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

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”

Similarities and Differences in EBTs Similarities are great

Dyadic conceptualization Alter destructive interactions Promote constructive communication Build on strengths

Substantial differences exist

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

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

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

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

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

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

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

Integrative BehavioralCouple 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

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)

IBCT Formulation ofRelationship Problems DEEP analysis of an issue (content area)

Differences or incompatibilities Emotional sensitivities External circumstances/stressors Patterns of problematic interaction

Patterns of problematic interaction Couple’s efforts to cope with DEE Interaction makes the problem worse

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

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

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

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

External Stressors Anything outside the couple relationship Common stressors

Children, family of origin Career, finances Illness Friends, neighbors

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

Purpose of Assessment Distress – interview and questionnaires

Couple Satisfaction Inventory (CSI-16) (Funk & Rogge, 2007) http://www.courses.rochester.edu/surveys/funk/

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

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

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

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

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

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

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

Three Typical Therapeutic Discussions in IBCT

Compassionate discussions - empathic joining Analytical discussions – unified detachment Practical discussions – making concrete changes

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

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

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

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)

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

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”

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

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

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

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

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

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

Problem Solving Training

Problem Definition Acknowledge positive Define problem (unilaterally or bilaterally) Acknowledge own role

Problem Solution Brainstorming Pros and Cons Negotiation; Agreement; Experimentation

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

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

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

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

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

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)

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

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%)

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

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.