From traditional behavioral couple therapy to integrative behavioral couple therapy: new research directions.Integrative behavioral couple therapy (IBCT IBCT Infantry Brigade Combat Team
IBCT Interim Brigade Combat Team (US Army)
IBCT Initial Brigade Combat Team
IBCT Institute for Business Continuity Training
IBCT Ingénierie et Biologie Cellulaire et Tisulaire ; Jacobson & Christensen, 1996) grew out of traditional behavioral couple therapy (TBCT TBCT Two B-Channel Transfer ; Jacobson & Margolin, 1979), but has expanded on this approach to emphasize the important role of acceptance in relationships. Addressing many of the limitations highlighted in research on TBCT, integrative behavioral couple therapy focuses on different controlling variables in the development of couple dysfunction and is part of an ongoing movement in behavior therapy behavior therapy or behavior modification, in psychology, treatment of human behavioral disorders through the reinforcement of acceptable behavior and suppression of undesirable behavior. toward the use of acceptance strategies. Early in its development, IBCT has not yet been researched thoroughly enough to be classified as efficacious ef·fi·ca·cious
Producing or capable of producing a desired effect. See Synonyms at effective.
[From Latin effic ; however, this approach has the potential to significantly enhance TBCT and is being evaluated in ongoing clinical trials. Future research should capitalize on Cap´i`tal`ize on`
v. t. 1. To turn (an opportunity) to one's advantage; to take advantage of (a situation); to profit from; as, to capitalize on an opponent's mistakes s>. the unique emphasis in IBCT on acceptance. Specific recommendations for future research include (a) establishing IBCT as an empirically supported treatment, (b) investigating the efficacy of IBCT to varied populations, (c) more closely defining and examining the mechanisms of action in IBCT.
Traditional behavioral couple therapy (TBCT; Jacobson & Margolin, 1979) has had the distinction of being the most widely studied and empirically supported intervention available for the treatment of relationship distress for more than two decades. TBCT was developed to target the dysfunctional patterns, communication difficulties, and poor problem-solving behaviors often associated with relationship discord Discord
See also Confusion.
demon of discord. [Occultism: Jobes, 93]
discord, apple of
caused conflict among goddesses; Trojan War ultimate result. [Gk. Myth. . Based on social learning theory and findings from research with distressed couples, TBCT consists largely of strategies to promote skill acquisition and behavioral change among partners. Empirical support for the efficacy of TBCT is considerable; however, several studies have highlighted key limitations of this approach. In an effort to address the shortcomings of TBCT, Jacobson and Christensen (1996) developed Integrative Behavioral Couple Therapy (IBCT). IBCT is grounded in contextually based behavioral theory and interweaves the well-established components of TBCT that promote accommodation and change between partners with newer acceptance-based strategies. Consequently, many of the treatment recommendations in IBCT share similarities with those proposed in several of the burgeoning treatment approaches based in contextual-behavioral theory that emphasize acceptance-based strategies, such as Acceptance and Commitment Therapy Acceptance and Commitment Therapy, ACT (pronounced "act" not "ay see tee"), is a branch of cognitive-behavioral therapy, an empirically based psychological intervention, that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to (ACT; Hayes, Strosahl, & Wilson, 2000), Functional Analytic Psychotherapy psychotherapy, treatment of mental and emotional disorders using psychological methods. Psychotherapy, thus, does not include physiological interventions, such as drug therapy or electroconvulsive therapy, although it may be used in combination with such methods. (FAP (language) FAP - The assembly language for Sperry-Rand 1103 and 1103A.
[Listed in CACM 2(5):16 (May 1959)]. ; Kohlenberg & Tsai, 1991), and Dialectical di·a·lec·tic
1. The art or practice of arriving at the truth by the exchange of logical arguments.
a. Behavior Therapy (DBT DBT Department of Biotechnology (India)
DBT Drive-By Truckers (band)
DBT Design Basis Threat
DBT Deutscher Bundestag (German Parliament) ; Linehan, 1993).
Traditional Behavioral Couple Therapy (TBCT)
Jacobson and Margolin (1979) developed TBCT (formerly known as behavioral marital therapy; BMT BMT bone marrow transplantation.
n.pr See bone marrow transplant.
BMT Bone marrow transplant, see there ) largely based on social learning and behavioral exchange theories of marital discord. Research from social learning theory suggested that couples who exchange negative or aversive aversive /aver·sive/ (ah-ver´siv) characterized by or giving rise to avoidance; noxious.
adj. behaviors with high frequency and who lack communication and problem resolution skills were likely to experience poor relationship adjustment (Gottman, 1980). These findings fit well within the context of social exchange theory, which posits that relationship satisfaction is associated with the ratio of costs and benefits received in the current relationship, relative to perceived alternatives to the current relationship. A higher ratio of positive to negative behavior denotes a higher frequency of reinforcing behaviors, fewer punishers, and more satisfaction. From this framework, TBCT treatment primarily involves: (a) behavioral exchange, strategies aimed at increasing the exchange of positive behaviors between partners, (b) communication training, to enhance skills in communicating desires, needs, feelings and thoughts, and (c) problem resolution training, to improve the couples' facility and efficiency in working together to resolve problems inside and outside of the marriage.
The Status of TBCT Research
The overall efficacy of TBCT and its components have been evaluated in numerous controlled treatment outcome studies over the years. Findings from these studies have been combined in several review articles (e.g., Alexander, Holtzworth-Monroe, & Jameson, 1994; Baucom & Epstien, 1990; Baucom & Hoffman; Bray & Jouriles, 1995) and meta-analytic studies (e.g., Dunn & Schwebel, 1995; Hahlweg & Markman, 1988). Generally, this literature supports the efficacy of TBCT for the treatment of couple distress and has not isolated any particular treatment component as the active ingredient An active ingredient, also active pharmaceutical ingredient (or API), is the substance in a drug that is pharmaceutically active. Some medications may contain more than one active ingredient. of the treatment package. Using current guidelines to define empirically supported treatment approaches outlined by Chambless and Hollon (1998), TBCT has been established as both an efficacious and specific treatment for marital distress (Baucom, Shoham, Mueser, Daiuto, & Stickle stick·le
intr.v. stick·led, stick·ling, stick·les
1. To argue or contend stubbornly, especially about trivial or petty points.
2. To have or raise objections; scruple. , 1998). Thus, TBCT has been demonstrated to produce greater treatment effects than non-treatment control conditions in at least two studies by independent research teams and to demonstrate greater efficacy than conditions that control for nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.
2. not directed against a particular agent, but rather having a general effect.
1. processes associated with treatment, such as attention or expectations of change. Generally, couples in TBCT have fared substantially better than couples assigned to control groups, with a mean effect size of 0.95 observed across studies (Hahlweg & Markman, 1988; Shadish, et al. 1993). Results are even more encouraging when cross- cultural findings are included. The positive effects of TBCT have been observed with couples in both Europe and the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , supporting the generalizability of this treatment approach (Hahlweg & Markman. 1988).
Despite considerable support for TBCT in the literature, researchers have begun to focus their attention on the substantial numbers of couples who do not experience clinically meaningful changes by the completion of therapy (Jacobson & Addis, 1993). Jacobson, Follette, and Ravensdorf (1984) define a clinically significant treatment as one in which (a) there is a statistically significant change from pre to post-treatment assessment, and (b) couples are no longer categorized as "distressed" by the end of treatment. Estimates indicate that although TBCT is efficacious, only about half of all couples who participate in therapy are successfully treated using these criteria, and nearly one third of these couples experience a pattern of relationship deterioration over time (Hahlweg, Revenstorf, & Schindler, 1982; Jacobson, Schmaling, & Holtzworth-Munroe, 1987; Snyder, Wills, & Grady-Fletcher, 1991).
Several explanations have been offered for the limited long-term efficacy and clinical significance of TBCT, including failure to modify treatment to meet the individual needs of each presenting couple, limiting the treatment focus to current relationship functioning without regard to the historical context in which problems have developed, and overemphasizing behavior change Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. strategies (Jacobson & Addis, 1993). Jacobson and Christensen (1996) have addressed these concerns in the development of IBCT. These authors suggest that, for some couples, focusing first on acceptance of one another is essential in facilitating needed behavioral change. Thus, partners who enter therapy less willing to compromise, accommodate to change, or collaborate are less likely to benefit from change-oriented TBCT strategies. In fact, it has been suggested that change-focused TBCT may reinforce the faulty notion that partners must make considerable behavioral changes before the relationship can become satisfactory (Jacobson & Christensen, 1996).
These discouraging findings have formed the impetus for investigations of the factors associated with less favorable outcomes in TBCT. This treatment approach tends to be less effective with couples who are more severely distressed (Baucom & Hoffman, 1986), as well as when one partner is suffering from psychological difficulties such as depression (Jacobson, Fruzzetti, Dobson, Whisman, & Hops, 1993). There is also evidence that older age, emotional disengagement disengagement /dis·en·gage·ment/ (dis?en-gaj´ment) emergence of the fetus from the vaginal canal.
n. , non-egalitarian gender roles, and having divergent views about important aspects of marital relationships are poor prognostic prog·nos·tic
1. Of, relating to, or useful in prognosis.
2. Of or relating to prediction; predictive.
1. A sign or symptom indicating the future course of a disease.
2. signs for treatment (Baucom & Hoffman, 1986; Hahlweg, Schindler, Revenstorf, & Brengelmann, 1984; Jacobson, Follette, Pagel, 1986).
Integrative Behavorial Couple Therapy (IBCT)
TBCT was designed specifically to address the limited clinical significance and long-term efficacy of TBCT's largely change-oriented approach. The theory behind IBCT diverges from TBCT in that it represents a change in emphasis toward an increasingly radical behavioral or contextual perspective (Hayes, Hayes, & Reese, 1988; Jacobson, 1997). This change in theoretical perspective is associated with a stronger emphasis on understanding the phenomenon of private behavior in the context of couple therapy (e.g., thoughts, feelings, and desires). However, these behaviors are not granted causal status as they are in traditional cognitive treatment approaches. Instead, feelings and thoughts are viewed merely as another form of behavior that is under the same environmental influences as any publicly observable behavior.
Contextual behaviorism behaviorism, school of psychology which seeks to explain animal and human behavior entirely in terms of observable and measurable responses to environmental stimuli. Behaviorism was introduced (1913) by the American psychologist John B. has an operant operant /op·er·ant/ (op´er-ant) in psychology, any response that is not elicited by specific external stimuli but that recurs at a given rate in a particular set of circumstances.
adj. focus that classifies behavior according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. its purpose or function, rather than emphasizing the topographical features of the behavior. For example, consider a couple with an angry wife who reports that her partner routinely jokes when she brings up the idea of starting a family, stays out until midnight with the guys every chance he gets, and regularly fails to remember dates that are important to her (e.g., anniversary, birthday, Valentine's Day). A topographical approach to treatment might target each of these behaviors as discrete relationship problems. Treatment strategies might include helping partners to clarify and communicate their needs, to identify ways of solving each problem through compromise, and to practice behavioral changes in each area. While these strategies may also be useful in IBCT, a contextual conceptualization con·cep·tu·al·ize
v. con·cep·tu·al·ized, con·cep·tu·al·iz·ing, con·cep·tu·al·iz·es
To form a concept or concepts of, and especially to interpret in a conceptual way: would place more importance on understanding the common functions that these problem behaviors serve in order to identify the controlling variables in the relationship. For instance, this set of behaviors might function to limit emotional closeness and commitment in the marriage and to set up conditions where the wife feels unloved and undervalued Undervalued
A stock or other security that is trading below its true value.
The difficulty is knowing what the "true" value actually is. Analysts will usually recommend an undervalued stock with a strong buy rating. . In turn, this may lead to sadness, anger, and coercive attempts to force her husband to change his behavior, thus increasing the likelihood that her husband's attempts to withdraw and avoid will escalate. The strategy in IBCT is to target the controlling variables in the relationship rather than to focus on solving the derivative problems that often bring couples into treatment. In contrast, TBCT would focus on the derivative problems through teaching a general set of communication and problemsolving skills that are expected to enhance functioning across couples. By emphasizing controlling variables unique to each couple, the IBCT approach de-emphasizes universally problematic patterns of reciprocity reciprocity
In international trade, the granting of mutual concessions on tariffs, quotas, or other commercial restrictions. Reciprocity implies that these concessions are neither intended nor expected to be generalized to other countries with which the contracting parties (i.e., the exchange of negative behaviors). Correspondingly, interventions in IBCT are guided by an idiographic id·i·o·graph·ic
Relating to or concerned with discrete or unique facts or events: History is an idiographic discipline, studying events that cannot be repeated.
Adj. 1. conceptualization that emphasizes the particular needs of each couple rather than global skill deficits presumed to exist across distressed couples.
> From a contextual perspective, an effective intervention is one that produces behavior change that generalizes to the couple's natural setting. The TBCT approach attempts to produce generalization by teaching specific skills, encouraging homework practice, and fading therapist prompts and reinforcement over time. Jacobson (1997) noted that these skill-based strategies may fail to produce generalization because they promote rule-governed rather than the more flexible, natural contingency-shaped behavior. Contingency-shaped behavior is defined as that which is under the direct control of reinforcement contingencies in the couple's relationship. For example, a man who avoids making requests of his wife in front of others after experiencing repeated punishment (e.g., being ridiculed, scolded, or ignored) is displaying contingency-shaped behavior. In contrast, rule-governed behavior is that which occurs in response to verbal rules that specify relations between behavior and environment (Hayes, 1986; Skinner, 1969; Zettle & Hayes, 1982). For example, this same husband may eventually avoid going to social gatherings with his wife in response to the rule "If I socialize so·cial·ize
v. so·cial·ized, so·cial·iz·ing, so·cial·iz·es
1. To place under government or group ownership or control.
2. To make fit for companionship with others; make sociable. with my wife, she will humiliate me". Jacobson has suggested that, since the therapist is the primary reinforcing agent for new behavioral rules, skill-based interventions may not generalize generalize /gen·er·al·ize/ (-iz)
1. to spread throughout the body, as when local disease becomes systemic.
2. to form a general principle; to reason inductively. to daily interactions that occur in the absence of the therapist. Furthermore, strategies to help couples generalize rule-based skills have met with somewhat limited success (Jacobson, Schmaling, & Holtzworth-Monroe, 1987), and it has been noted that rule-following may decrease individuals' sensitivity to direct contingencies (Hayes, Brownstein, Zettle, Rosenfarb, & Korn, 1982). In sum, the IBCT approach shares contextual roots with TBCT but represents a more idiographic approach emphasizing functional rather than topographical features of couple interactions.
The Practice of IBCT
Within an IBCT perspective, the focus on changing partner behavior is a central controlling variable that leads to many of the problems associated with couple discord, such as coercion and negative behavioral reciprocity (Jacobson & Christensen, 1996). The struggle around behavior change is identified as the key problem, and it is proposed that behavior change techniques may be insufficient and ineffective without a corresponding foundation of mutual acceptance. In this way, IBCT is part of a broader movement in behavior therapy to integrate acceptance and mindfulness-based strategies into existing change orienting approaches to enhance treatment outcomes and prevent relapse (e.g., Hayes et al., 1999; Linehan, 1993; Segal, Williams, & Teasdale, 2002).
While the empirically supported change strategies of TBCT continue to be used in IBCT (i.e., behavior exchange, communication/problem-solving training), the primary emphasis of this approach is to help partners to accept (and even embrace) aspects of each other and their relationships that have come to be defined as intolerable. Acceptance in this context includes letting go of the struggle to change each other, but it is not resignation or learning to live with clearly unacceptable behavior (e.g., abuse). Jacobson and Christensen (1996) define acceptance as the act of relinquishing the struggle to change partner behavior and using differences as opportunities to create enhanced intimacy. Thus, for partners in relationships with seemingly intractable problems, IBCT facilitates progress by providing alternative ways of establishing closeness. Enhanced acceptance is expected to facilitate contact with a larger variety of the stimulus functions of a partner's behavior, thereby changing responses to such behavior from extremely negative (e.g., disgust, contempt) to neutral or even positive (e.g., tolerance, appreciation) in valence Valence, city, France
Valence (väläNs`), city (1990 pop. 65,026), capital of Drôme dept., SE France, in Dauphiné, on the Rhône River. .
Several key acceptance strategies are described in the IBCT treatment manual (Jacobson & Christensen, 1996) and are distinct from interventions used in TBCT. These strategies include empathetic em·pa·thet·ic
empa·theti·cal·ly adv. joining, unified detachment, and tolerance building. Empathetic joining involves magnifying the expression of feelings and thoughts that are likely to elicit empathy, as opposed to those that may elicit defensiveness, non-acceptance, or invalidating responses. For instance, the couple might be encouraged to express the "softer" side of their emotional experience, such as sadness instead of anger or frustration. Unified detachment involves strategies to create a context in which couples are able to communicate about their problems in a detached, intellectual, and nonaccusatory manner. One intervention within the framework of unified detachment involves describing relationship problems in a clear, nonaccusatory manner that frames the problem as an "it" that both partners are working to resolve. Tolerance building involves changing the function of negative partner behavior by allowing partners to experience such behavior with less distress and conflict. For example, a partner may be urged to intentionally engage in an undesirable behavior in order to observe the impact that this behavior has on their partner (in a context that is not emotionally intense) and as a means of changing the stimulus properties of the behavior for the partner. Finally, an additional tolerance building exercise involves self-care strategies, designed to encourage partners to avoid seeking fulfillment of all of their emotional needs from the relationship.
Important Directions for Future Research on IBCT Establishing Efficacy. Although it is a relatively new intervention, IBCT builds on the vast empirical base of TBCT and has promising data to support its efficacy for couple distress. The first published data on the efficacy of IBCT (Jacobson, Christensen, Prince, Cordova Cordova, Spain: see Córdoba. , & Eldridge, 2000) suggest that the addition of acceptance strategies may enhance the efficacy of traditional behavior change interventions. Jacobson et al. (2000) randomly assigned 21 couples between the ages of 21 and 60 to receive TBCT or IBCT for a maximum of 26 sessions. TBCT was conducted as outlined in Jacobson and Margolin (1979), and IBCT was conducted using both acceptance and change strategies. Therapist compliance to the treatment protocols was found to be strong, and acceptance interventions were significantly more common in IBCT than in TBCT sessions. Results show that couples receiving IBCT experienced greater increases in marital satisfaction than couples in the TBCT condition, and effect sizes were moderate to large (.62 for husbands and .78 for wives). These results are especially promising considering that two active treatments were compared, and that the sample size was small. Based on the standards outlined by Jacobson & Truax (1991), 80% of IBCT couples experienced clinically significant improvements compared to 64% of the TBCT couples. Moreover, the gains in the IBCT condition were maintained at both 6-month and 1-year follow-up, whereas couples in the TBCT condition showed some relapse between post-test and 1-year follow-up.
Since completion of this pilot research, Christensen and colleagues obtained NIMH funding to conduct a large-scale clinical trial to further investigate the efficacy of IBCT (Christensen, personal communication). In this study, 134 couples with stable and serious marital distress were randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. to either IBCT or TBCT conditions. These investigators used stringent criteria to assess for consistent marital discord at three time intervals prior to treatment. Couples were stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers.
Arranged in the form of layers or strata. into moderately distressed and severely distressed groups based on marital satisfaction scores. Couples met with experienced therapists from the community who were trained in both approaches and administered both treatments, minimizing potential allegiance effects. Adherence data showed that the therapists administered the two different treatments according to protocol. These researchers examined the trajectory of marital satisfaction over four time points during therapy (pre, 13 weeks, 26 weeks, final session) and have examined marital satisfaction over 4 follow-up time points (6, 12, 18, and 24 months). Results indicated that the process of change differed during treatment between groups. The trajectory of change in marital satisfaction scores in the TBCT condition showed an initial improvement greater than IBCT, but then slowed and eventually began a downward trend. In contrast, couples in IBCT showed a gradual but steady increase throughout treatment. Overall, IBCT couples were more likely than TBCT couples to experience clinically significant improvements during treatment and to maintain treatment gains at two-year follow-up (Christensen, personal communication).
The promising findings from these early studies support the potential efficacy of IBCT and encourage evaluation of this approach. However, there are still too few studies available to classify IBCT as an efficacious and specific treatment for couple discord. To establish IBCT as an efficacious treatment, guidelines suggest that at least two independent groups of researchers must demonstrate that treatment effects are superior to a no treatment condition. IBCT research to date has been conducted exclusively by the group of researchers who developed the treatment. To move the research on IBCT forward, future studies will need to focus on the replication of existing findings in independent laboratories. To further establish IBCT as a specific treatment, it must also outperform alternative treatment approaches or conditions that control for non-specific features of therapy, such as attention and the expectation of change (Chambless & Hollon, 1998). Although IBCT has outperformed TBCT in one published study showing better treatment effects and clinically significant outcomes, these results were based on a fairly small sample size and did not include a control group condition. It would be helpful to compare IBCT to a no treatment control condition (i.e., waitlist wait·list
A waiting list.
tr.v. also wait-list wait·list·ed, wait·list·ing, wait·lists
To put on a waiting list. control), as this is one criterion for treatment efficacy. However, it should be noted that IBCT has compared favorably to an established treatment (TBCT) that has outperformed no treatment conditions in numerous studies. In sum, IBCT is perhaps best classified as a possibly efficacious treatment at this time (Chambless & Hollon, 1998).
IBCT for difficult to treat couples.
One important issue in efficacy research on IBCT is whether or not this treatment is efficacious for those couples for whom it was originally designed, couples for whom TBCT did not produce significant or lasting improvements. These couples include severely distressed, older, emotionally disengaged dis·en·gage
v. dis·en·gaged, dis·en·gag·ing, dis·en·gag·es
1. To release from something that holds fast, connects, or entangles. See Synonyms at extricate.
2. , and non-egalitarian couples, as well as couples in which one or both partners are depressed or have alternative mental health problems. Research is needed to examine whether the addition of acceptance strategies enhances outcomes for couples who do not typically benefit from TBCT or who have traditionally been excluded in treatment outcome studies (i.e., older couples, and couples presenting with domestic violence). Although preliminary studies do appear to support the notion that IBCT may help a larger number of couples than TBCT, it is still unclear whether IBCT is efficacious for those specific types of couples who have not benefited from TBCT. As a first step in addressing this issue, there is a pilot study underway in our laboratory to investigate the feasibility, acceptability, and efficacy of treating depressed older adults and their spouses with IBCT. It is hoped that this study will pave the way for future studies that focus on couples that are traditionally very difficult to treat.
Understanding mechanisms of change.
In contrast to treatment outcome studies that examine whether treatments are efficacious, research on mechanisms of change aims to evaluate whether the process of change is consistent with the theory that underlies the treatment (Jacobson & Addis, 1993). A central premise of IBCT is that acceptance-oriented strategies produce therapeutic change above and beyond the change-based interventions that characterize TBCT. Thus, it is critical to measure the construct of acceptance and to examine whether changes in acceptance occur and are associated with treatment outcome. Findings from comparative studies of IBCT and TBCT provide initial support for this premise. For instance, couples in IBCT conditions received a higher frequency of acceptance-based strategies and, in turn, showed more favorable and longer-lasting treatment responses than couples in TBCT (Christensen, personal communication; Jacobson, et. al, 2000).
Future studies should carefully operationalize the construct of acceptance and elucidate those behavioral indicators that most clearly capture this construct. This will allow researchers to study whether IBCT's interventions are specifically associated with improvements in acceptance, whether these improvements produce meaningful therapeutic changes, and whether the process of therapeutic change in IBCT is distinguishable from that of alternative approaches. As an example of this type of research, Baucom and Epstein (1990) developed cognitive behavioral couple therapy (CBCT CBCT Cone Beam Computed Tomography
CBCT Catholic Bishops' Conference of Thailand ) to enhance TBCT by including cognitive strategies to specifically target dysfunctional thought patterns associated with couple discord. It was hypothesized that CBCT would produce a more notable change in attributions and perceptions of partner behavior than TBCT. A meta-analytic study of treatment outcome research indicated that only CBMT CBMT Certification Board for Music Therapists, Inc
CBMT Clinical Bulletin of Myofascial Therapy (not TBCT) produced significant changes in spouses' post-therapy relationship related cognitions (Dunn & Schwebel, 1995). Similarly, a treatment outcome study found some associations between the type of treatment intervention and the domain of change (Baucom, Sayers, & Sher, 1990). IBCT's acceptance-based interventions are based on a radical behavioral, rather than a cognitive conceptualization of couple discord. Accordingly, IBCT targets broader contextual controlling variables in contrast to CBCT's approach of modifying cognitive factors that give rise to derivative problems (i.e., coercion; Chapman & Dehle, 2002). Although these approaches are clearly distinguishable at the level of theory and practice, research is needed to determine whether they actively target and modify different relationship processes. Such research may involve comparisons of the types of therapeutic changes found with IBCT, CBCT, and TBCT. Whereas TBCT might be expected to result primarily in more skillful skill·ful
1. Possessing or exercising skill; expert. See Synonyms at proficient.
2. Characterized by, exhibiting, or requiring skill. communication and problem resolution, IBCT may produce changes primarily in how partners emotionally respond to each other during interactions. For example, if the mechanism of action in IBCT is enhanced acceptance, emotional responses to previously undesirable behavior should be attenuated Attenuated
Alive but weakened; an attenuated microorganism can no longer produce disease.
Mentioned in: Tuberculin Skin Test
having undergone a process of attenuation. and behavioral interventions should reflect greater understanding and empathy.
Additional studies are needed to examine whether any specific acceptance intervention (i.e, empathetic joining, unified detachment, and tolerance building) stands out as being necessary or particularly efficacious. There may be certain types of acceptance interventions that are more globally useful across couples. It is possible that certain strategies are particularly well suited for couples with specific problems or characteristics. As this research progresses, it is likely that the core acceptance strategies currently proposed will be augmented with additional approaches to enhancing acceptance. Furthermore, it is necessary to clarify whether acceptance interventions alone constitute the active ingredient for therapeutic success in IBCT. Alternatively, it may be the unique combination, interaction, or order of acceptance and change strategies that constitute the driving force behind the beneficial effects of IBCT. Thus, investigations that explore the efficacy of each treatment component and the order of interventions would be a helpful addition to the literature.
The theoretical and pragmatic issues associated with understanding the mechanisms of change in IBCT are challenging. As part of a broader movement toward incorporating the construct of acceptance into treatment, IBCT researchers would benefit considerably from the work that has been done by other researchers in this area. For example, acceptance is a central feature of Acceptance and Commitment Therapy, a radical behaviorally oriented approach designed by Hayes and colleagues (Hayes et al., 1999). Within ACT, it is asserted that experiential avoidance is a key controlling variable in the development of psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je)
1. the branch of medicine dealing with the causes and processes of mental disorders.
2. abnormal, maladaptive behavior or mental activity. . Experiential avoidance is defined as behavior that has as its function the avoidance or escape from internal experiences (such as thoughts or emotional responses) or from those situations that elicit them (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). From an ACT framework, society reinforces the notion that distress is abnormal and should be eliminated, thus encouraging people to engage in a variety of behaviors (e.g., substance abuse, agoraphobic ag·o·ra·pho·bi·a
An abnormal fear of open or public places.
[Greek agor avoidance, and suicide) that function to terminate or avoid distress. The bi-directional nature of language, whereby an individual can experience distressing events simply by hearing or thinking words associated with such events, makes it very difficult to successfully avoid internal experiences. For example, an agoraphobic individual does not need to be in the mall to feel anxious; he or she can simply think, "mall, large crowds of people" and feel anxious. Further, the verbal rule, "If I stay away from the mall, I will not feel anxious", contains the very stimuli ("mall") that are anxiety provoking and to be avoided. ACT interventions are designed specifically to encourage individuals to expand their behavioral repertoires by changing the function of their behavior from experiential avoidance to meaningful, valued action.
The overall goal in IBCT is very similar to that of ACT: to increase valued behavior (i.e., intimacy enhancing and collaborative behavior) and to reduce maladaptive Maladaptive
Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.
Mentioned in: Cognitive-Behavioral Therapy struggles to change partner behavior. Within an ACT framework, it is possible that attempts to change the behavior of a partner may function to avoid uncomfortable emotional reactions to such behavior. If IBCT acceptance strategies facilitate acceptance of such undesired reactions, coercive attempts to produce change would likely be reduced. That is to say, when partners accept their own experience (thoughts, feelings), they are more likely to be able to engage in behaviors that are consistent with their desire to improve their relationships. Therefore, a fundamental mechanism of change in IBCT may involve increasing partners' acceptance of their own internal or "private" behavior as experienced in the context of the relationship.
In other work on acceptance, Linehan (1993) has developed an approach to therapy, Dialectical Behavior Therapy (DBT), which includes several interventions to enhance acceptance of emotional discomfort. These interventions include mindfulness and distress tolerance skills that emphasize acceptance of the present moment, rather than focusing on past or future events. From a DBT framework, acceptance provides the opportunity to experience non-reinforced exposure to distressing events. Exposure is hypothesized to facilitate the habituation habituation
Reduction of an animal's behavioral response to a stimulus, as a result of a lack of reinforcement during continual exposure to the stimulus. Habituation is usually considered a form of learning in which behaviours not needed are eliminated. of aversive emotional responses to these events over time. IBCT tolerance building strategies similarly encourage non-reinforced exposure. For instance, the strategy of "faking bad behavior" provides partners with an opportunity to experience undesired behavior without the intense conflict that may typically follow such behavior. When the behavior occurs without ensuing conflict, the recipient essentially experiences a trial of nonreinforced exposure, which may lead to habituation of his or her emotional responses to the behavior (Christensen & Jacobson, 1995; Koerner et. al., 1994).
The notion of non-reinforced exposure suggests several important future directions for research on the mechanisms of change in IBCT. One way of investigating this potential mechanism of change is to use psychophysiological measurement to determine whether or not partners actually experience decreasing or habituation of emotional responses in response to previously undesired or unaccepted partner behavior. Research in this domain may also examine changes in facial expressions of emotion or changes in self-reported non-acceptance. To support the theoretical underpinnings of IBCT, it must be demonstrated that these changes (a) occur in response to acceptance interventions, and (b) are associated with improved relationship functioning.
Acceptance building through mindfulness training has received increasing attention in behaviorally and cognitive behaviorally oriented interventions, such as DBT and Mindfulness-Based Cognitive Therapy Mindfulness-Based Cognitive Therapy (MBCT) is a method of therapy which blends features of two disciplines:
MBCT Medium Brigade Combat Team (formerly Interim Brigade Combat Team; US Army) ; Segal et al., 2002). Essentially, mindfulness involves non judgmental judg·men·tal
1. Of, relating to, or dependent on judgment: a judgmental error.
2. Inclined to make judgments, especially moral or personal ones: awareness of the present moment. The IBCT intervention that perhaps most closely approximates a mindfulness intervention is the acceptance strategy of unified detachment (i.e., treating the problem as an "it"). This intervention involves encouraging partners to discuss the problem as it is, without judgment, thereby reducing their emotional reactions to the problem and facilitating effective problem resolution. Although this is the most obvious place for mindfulness in IBCT, we would argue that interventions such as empathetic joining also encourage non judgmental awareness of the present. Specifically, when one partner expresses "softer" emotions, the other partner is better able to attend to their emotional expression in an open, non judgmental fashion. If partners are able to attend mindfully to their interactions, including observing internal reactions and judgments, they may be better able to respond objectively to the interactional process.
In summary, IBCT is a promising new treatment designed to address many of the shortcomings of traditional behavioral couple therapy (TBCT). IBCT's focus on acceptance interventions opens the door for several interesting lines of research and theory that would not otherwise have been considered within the framework of TBCT. As the research and theory on IBCT becomes increasingly sophisticated, refinement of the measurement of acceptance and use of sophisticated methodologies (i.e., physiological measurements of emotion, direct observation of couple processes, "on-line" recording of the experience of acceptance during interactions) to assess the impact of acceptance on therapeutic change will become necessary. In order to further this process, behaviorally oriented couples researchers from diverse labs must utilize their strengths in theory and design to evaluate and expand this unique approach to ameliorating relationship discord.
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Alexander L. Chapman and Jill S. Compton
Duke University Medical Center
Author Note: Correspondence concerning this article should be addressed to Alex Chapman, Department of Psychiatry and Behavioral Sciences behavioral sciences,
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