Integrative marital intensive therapy: a strategy for marriages in severe distress.
The National Institute of Marriage (NIM) has been serving married couples in distress through the use of an innovative format called Integrative Marital Intensive Therapy (IMIT). NIM is a nonprofit organization with an overt identification with mainstream evangelical theology, unaffiliated with a specific denomination. Integration of marital therapy traditions and evangelical theology is foundational to IMIT. The therapy draws on family, experiential, and cognitive therapy traditions in psychotherapy with groups, individuals, and families. The term "Intensive" refers to the use of a multi-hour format for therapy over consecutive days. It also implies a commitment to address deeply personal and often "intense" emotional processes impacting relationship dynamics. This approach allows therapeutic exploration and intervention without the constraints of conventional office marital therapy.The two primary programs at NIM where IMIT is used are the Couples Intensive program and the Marriage Intensive program. The Couples Intensive is a group experience with five couples working with two therapists over four days. the Marriage Intensive involves one couple with two therapists for two full days.
The purpose of this article is to document the theoretical and technical elements of IMIT as it is currently being practiced at NIM. It is our intention in this article to (a) place IMIT in a theoretical/historical context of family/marital counseling/psychotherapy; (b) outline the relative theoretical assumptions and model guiding IMIT; (c) describe some of the specific distinguishing interventions and techniques of IMIT; (d) present some of the current research data documenting IMIT effectiveness as measured in follow up surveys; and (e) discuss issues related to the future development of IMIT as a therapeutic approach including training, out of office use of IMIT, and further research.
Theoretical Context for Working With Couples in a Multi-hour Format
Before examining the theoretical and historical context of Integrative Marital Intensive Therapy (IMIT), it is important to note that the IMIT team of professionals have been primarily guided by pragmatic values in working with marriages in distress. These pragmatic and eclectic influences eventually resulted in a consistent yet flexible model of working with married couples that defined a process of relationship recovery and guided therapeutic intervention. The following sections highlight the theoretical influences shaping IMIT as it developed under the pragmatic objective of having as significant an impact on couples in distress as possible.
Family Therapy
The importance of attending to the marital dyad in family therapy is documented in the work of Satir (1967) and Minuchin (1974) and is the subject of focus for many other family therapy approaches as well. Without delineating all the various places where this perspective has been asserted, suffice it to say that the validity for treating relationships and relationship dynamics is considered standard practice today because of the family therapy movement.
In addition family therapy approaches are known for being especially pragmatic. This has presented some challenges over the years in that family therapy approaches have been historically long on techniques of intervention and short on cohesive theory and empirical research. But that status has changed over the years with increased theoretical articulation and the establishment of several journals devoted to encouraging rigorous research and critique of family therapy methods.
IMIT is deeply rooted in the tradition of family therapy and this is evidenced by the strict adherence to seeing couples versus seeing individuals. Additionally, several interventions in IMIT are aimed at altering relationship dynamics, challenging clients to examine their participation in the marital relationship and consider new ways of participating in the relationship. IMIT developed with a strong influence from family systems theory.
Experiential Couples Therapy and Emotion Focused Therapy
The experiential approaches to psychotherapy growing out of humanistic/existential psychology, such as Gestalt therapy, eventually made their way into the field of family therapy. Carl Whitaker and Virginia Satir certainly fostered the experiential element of family therapy early on. More recently Emotion Focused Couples Therapy (Greenberg & Johnson, 1988) and Internal Systems Therapy (Schwartz, 1995) have highlighted the experiential aspect of attending to affect and experience during couples therapy. Emotion Focused Couples Therapy (EFT) has been documented as being successful with helping couples achieve greater satisfaction and recovery from relationship dysfunction (Johnson & Whiffen, 1999). Briefly summarized, the approach facilitates spouses to becoming more aware and attentive to emotional states and dynamics in the relationship. As emotion is identified and attended to more secure attachment is facilitated between spouses. EFT recognizes a "reactive emotional cycle" operating in all relationships, where by the emotional threat and resulting reactive coping triggers emotional threat and resulting reactive coping in the other spouse. These emotional insecurities and coping reactions become a cycle in the couple relationship which is repetitive and habitual.
In recent years the EFT approach has drawn heavily on attachment theory and the work of John Bowlby (Johnson & Whiffen, 2003). The experience of clients in EFT typically results in softening to one's own emotions and the emotional experience of one's spouse. The spouses typically experience increased insight and compassion for themselves and their spouse. The overall result appears to be stronger attachment and bonding between spouses which results in greater resiliency as well as insight about maintaining the bond.
Integrative Marital Intensive Therapy (IMIT) likewise emphasizes emotional experience and examination of emotion in its approach to working with couples. Therapists using IMIT place a premium on client's emotional expressions and "in the moment" emotional experience. Clients are given conceptual constructs to understand the origin and function of these emotional states. Moreover, it is the capacity for spouses to connect at an emotional level that is held as critical to relationship recovery and satisfaction. Relationship safety is the confidence that one can be emotionally vulnerable and still find acceptance, understanding and support. This relationship safety is pursued through a variety of means so that emotional vulnerability is more likely to occur between spouses. Facilitating an experience during an Intensive in which clients experience, express and address intense emotional states is a higher priority than any conceptual insights or principles of relationship functioning. In IMIT the experience of deep emotional understanding and connection is seen as basic to meeting client goals for relationship renewal.
At present attachment theory is considered a primary theoretical foundation of EFT (Johnson & Whiffen, 2003). It may be that like EFT, IMIT may find useful theoretical insight for it's development in Bowlby's attachment theory.
There are important differences between EFT and IMIT. EFT is rarely applied in an intensive format as is IMIT. Further IMIT utilizes the use of communication skills and conflict resolution skills training, where EFT would not generally directly train and coach spouses in communication. EFT generally avoids interactions which might be considered "content focused" such as articulation of relationship principles and concepts. IMIT actively integrates cognitive restructuring during therapy. There are other important differences but these are the most significant between IMIT and EFT. Despite these differences the similarities between the two approaches remain significant and noteworthy.
Cognitive Therapy
There is a large body of literature researching cognitive and cognitive behavioral approaches to working with couples (Dattilio & Epstein, 2003). The team at NIM, like many marriage therapists, have been influenced by this research and the resulting approaches to marital/family therapy. In particular IMIT will identify and challenge client's beliefs, expectations, and perceptions about themselves, their spouse and how marriage relationships should function. These interventions are similar to interventions aimed at cognitive restructuring, assisting clients in examining and restructuring their systems of belief, thought, and expectation. Baucom and colleagues attempted to examine whether cognitive restructuring and emotional processing would enhance behavioral marital therapy (Baucom, Sayers, & Slier, 1990). While they did not find significant differences between their randomly assigned groups, they identified a number of reasons for this lack of effect and recommended combining cognitive restructuring with other relationship skill interventions.
Marathon Group Format
Because of Robert Paul's exposure to working with groups of individuals over several days at a time, and the influence of group marathons in experiential therapy, the group marathon format was a logical choice for developing IMIT. The therapeutic factors of group therapy identified by Yalom (1995) are certainly evident in Couples Intensives conducted at National Institute of Marriage (NIM). Marett (1988) examined published research regarding the use of group therapy in treating couples and found it as effective as individual and conjoint approaches to couples therapy. The group experience combined with the emotional intensity facilitated by meeting with groups for several days, several hours at a time make for a very productive environment for personal emotional reflection/exploration and relationship recovery.
The idea of working with individuals in a multi-hour or marathon format is well documented in the literature on various humanistic and existential approaches to psychotherapy. Weigel (2002) documents very well the enthusiasm surrounding marathon group therapy in the 1960's and 1970's. As noted by Weigel (2002) these approaches seemed to lose popularity during the 1980's and 1990's. Indeed some of these approaches because of their association with particular personalities and communities even became viewed as borderline cultic and therefore out of the mainstream of conventional psychotherapy. But for those willing to examine the experiences of those participating in group encounters, therapy marathons, guided retreats, etc., the results seem to have influenced the literature on group psychotherapy. Greendorfer (2004) reports using marathon groups in his work with couples with powerful and "surprisingly long-lasting results." Thus, working with couples in a multi-hour marathon type format is neither new nor unique to IMIT.
NIM has taken pains to correct some of the abuses to personal welfare and self-determination that are sometimes associated with group therapy marathon anecdotes. IMIT aggressively asserts the individual's control on their participation in all sessions and members are supported and affirmed for withdrawing when they feel uncomfortable or reluctant to participate in therapy. The client's place as authority over their own experience and emotions is affirmed as well. Great efforts are expended to contribute to each client's sense of personal safety, care and comfort during a Couples Intensive. From the selection of the location for a Couples Intensive to the training of the hospitality staff to the conduct of the therapists, each person's safety and comfort is paramount.
Integrative Couples Therapy
An essential theme within IMIT is that of integration. The approach draws on theory and technique from several sources. As can be seen from the above discussion IMIT draws upon the theory and applications of family, experiential, cognitive, group and insight oriented psychotherapies. In addition there are portions of every Intensive that have a didactic or psycho-educational element as well. When the opportunity for teaching presents itself and can be done in such a way as to foster the experience of relationship insight, IMIT therapists may use an easel with large adhesive pages to diagram or list relevant principles and insights on relationship functioning. This psycho-educational element runs the risk of defining the Intensive experience and therapists take steps to ensure they do not overwhelm clients with information. Teaching in IMIT is secondary to emotional expression, exploration and insight. The psycho-educational element is utilized to enhance and provoke further emotional processing.
Permeating through IMIT and a primary example of the integrative commitment is the influence of evangelical Protestant Christian theology. While intentional measures are taken to avoid indoctrination of clients, discussion and exploration of spiritual experience and understanding is given high priority. The Christian faith is positioned as a viable and worthwhile option for informing and inspiring the personal transformation necessary to realize a fully recovered and satisfying marital relationship. This has been one of the most highly regarded and appreciated elements of IMIT as reported by clients.
A Foundation of Integration
The role of integration is so central and foundational to IMIT that it bears dissecting further. The following section will attempt to elaborate some of the current thinking on the important concepts of self, individuality, and marriage.
Psychology and Theology of Self
Psychologists have studied and theorized for decades on the concept of self. For a large segment of the psychological community the notion of self and personality are assumed elements of how to conceptualize the individual. In its simplest form self is that internal awareness in an individual that they themselves are an objective being with cognition, emotion and behavior, similar yet unique to others around them. Millon (1996) described the importance of self definition in the following way:
... the diffuse swirl of events buffeting the young child gives way over time to an increasing sense of order and continuity. The most significant configuration that imposes a measure of sameness on a previously more fluid environment is self-as-object, a distinct, ever-present, and identifiable 'I' or 'me.' Self-identity, the image of who we are provides a stable anchor to serve as a guidepost that creates continuity in an ever changing world. (p. 202)
During development the individual gathers information about themselves, from internal and external sources. As development progresses a relationship emerges between the self and the imagined representation of self. This relationship is imperceptible in its earliest stages but by adulthood all humans seem to have some internally held judgments about their worth, capabilities, values, intentions and aspirations. It is this relationship with one's self that becomes the focus of so much psychotherapy.
This relationship to self is a core ingredient in relationship dynamics. The relative health or dysfunction around self esteem, self worth and self objectivity permeates relationship events and processes. IMIT makes some assumptions about self that guide many of the interventions and cognitive restructuring that occurs in IMIT. These assumptions are informed by evangelical Protestant Christian theology as well as psychological research and theory.
Value of self. First of all, IMIT operates on the assumption that human beings were created with indescribable worth and value. This value is not so much inherent as it is God given. From a theological standpoint the self is at least in some part present in the soul and has an eternal existence. The self additionally was designed for relationship with God and other human beings. The self functions optimally when it is in right relationship with God and others. This then leads to the second assumption underlying IMIT.
Self integrity. Created with free will human beings are capable of making choices and leading lives that corrupt the self, dysfunction and suffering are the result. Not all suffering is assumed to originate from individual corruption of self but much of what an individual is confronting in relationship dysfunction is a consequence of corruption and neglect of self. Thus, the aim of IMIT is to stop the degradation of self through neglect and self abuse and begin processes of embracing the value and vulnerability of self. IMIT challenges clients to invest in personal integrity as their most powerful tool of personal and relationship change.
Other Important Theoretical Assumptions
Role of emotion. Another critical assumption in IMIT has to do with the role of emotional processes. Human emotions are seen as the window to the self. Emotional processes are the feedback system for the relative health or distress of the self. Emotional processes provide the self with ongoing information as to the relative safety of the self in both the internal and external environment. Emotional awareness equips the individual to recognize patterns of thought and belief which perpetuate neglect and internal injury to self. Likewise growing emotional awareness equips the individual to recognize indications in the environment of potential threat to self. Armed with a commitment to integrity individuals take responsibility to grow in this emotional awareness so that self is protected, nurtured and empowered to meet challenges and take advantage of opportunities to grow the capacity of self for greater actualization of God's purposes in one's life.
Emotional bonding. A fourth assumption guiding IMIT is that emotional bonding between spouses is the fabric binding individuals to each other in a vibrant fulfilling marriage. The best marriages are those in which spouses experience a deep sense of emotional connection informing and enhancing each spouse's emotional reality. Consequently, interventions aimed at facilitating and enhancing processes of emotional communication and connection are pursued in IMIT aggressively, utilizing the current research on facilitating emotional communication and attachment.
Fear cycles. Fifth in the list of assumptions operating in IMIT has to do with the dynamics of dysfunction in marriages. Based on psychological theory and observation of adaptive coping, human beings seem to be designed to react when self is threatened. In many cases this reactive coping appears unconscious or below awareness. Something occurs during the course of the relationship which triggers fear, anxiety, and threat. The individual reflexively reacts to this threat with coping strategies, many of which were formed early in development. These reflexive reactions in turn impact one's spouse's set of fears and insecurities. The spouse then also reflexively reacts with their set of coping strategies, which in turn inspire more threat in their spouse. Conflict and distress in relationship is understood to be driven by this submerged cycle of emotional reactivity.
The notion of reactive emotional cycles, or "Fear Cycle," is not unique to IMIT. This dynamic is referenced by EFT proponents as well as other family therapy approaches. Scheinkman (2008) provides a current detailed explanation of the concept of reactive cycles in marital relationships and how it can be utilized in a family therapy context. Scheinkman describes different levels of the cycle and how interventions with a couple can be guided by greater understanding of the cycle.
Definition of marital unity. The last assumption of IMIT to be outlined here concerns the concept of relationship unity. Unity in relationship is accomplished through embracing diversity versus trying to eliminate differences.
Relationship processes that provide each spouse room and opportunity to express and contribute their individual experience, hopes and ambitions are ultimately more fulfilling for both spouses. By pursuing this definition of unity couples find motivation to constantly pursue resolution to conflict. In this definition of relationship unity, outcomes that both spouses can embrace and support are to be prized above any other alternative.
This is also in sharp contrast to a compromise model of relationship functioning. Compromise may allow partners to hold a temporary truce but the conflict or issue remains unresolved. By defining unity as an expression of purpose, each spouse's contribution to the resolution of conflict is regarded as necessary for resolution to occur. In this approach spouses first determine what goals and purposes they share, then they can become creative team mates in finding strategies, and solutions to conflict.
An Integrative Model of Relationship Recovery
Armed with the above theoretical assumptions IMIT conceptualizes a model for recovery from relationship distress. This model informs the structure of IMIT and guides the placement of therapeutic intervention.
The Promise, Intimacy, and Fear Cycles
Somewhere during courtship, shortly before or during discussions regarding marriage, couples make a promise to each other, often it is an explicit promise but it can be implicit. This is a pledge of fidelity and commitment to pursue a relationship together that will be defined by fidelity and intimacy in its various forms. It is well established that some couples make this promise with little forethought or consideration. Many married individuals though report a definite internal reflection about the gravity of the commitment they were entering into with their spouse. This promise is ritualized in a wedding in which bride and groom exchange vows articulating the promise of fidelity and pursuit of intimacy.
At some point individuals experience disillusionment in their relationship. It would appear that the vast majority of marriage relationships encounter difficulty in living up to their promise of fidelity and intimacy. As noted earlier this disillusionment is generally reflective of a reactive emotional cycle in the relationship, referred to in IMIT as the "Fear Cycle." Sadly, if couples do not find effective ways to manage the stress upon the relationship from this cycle they will find themselves experiencing greater and greater disappointment, disillusionment and emotional distance in the relationship. In the model of relationship recovery used by IMIT establishing and maintaining emotional safety in the relationship is paramount to recovering from the effects of a relationship fear cycle. This task of establishing and maintaining safety is the threshold for openness and intimacy. Without some degree of confidence of safety individuals will not take the necessary emotional risk needed to be vulnerable enough to experience intimacy.
Intimacy in this model of relationship recovery is a general term to refer to the complex mix of expectations and longings motivating individuals to seek a lifelong committed marital relationship. In order for intimacy to occur individuals must risk being vulnerable. When vulnerability is breached and met with acceptance, validation and affection, intimacy begins to flourish and the longings fulfilled. Without vulnerability however intimacy is never quite realized. Thus, to experience and maintain intimacy a relationship environment of perceived safety must be present. The perception of safety is then tested over time as partners risk and subsequently discover their hopes met by experiences of acceptance, validation and affection.
To accomplish this environment of relationship safety the IMIT model of relationship recovery asserts four critical elements. These elements theoretically demonstrate a logical hierarchy but are experienced interpersonally dynamically versus linearly. Each element moving in and out of the foreground of focus as the marriage relationship unfolds and develops.
Personal Foundations of Safety
The first two elements of establishing and maintaining relationship safety are processes of commitment which occur within the individual spouse. These elements are predicated on the acceptance of personal value and personal vulnerability.
Personal responsibility. Human beings are born to parents who are expected by society to be responsible for the protection and nurturing of the new born. In some societies and cultures this responsibility is not only taken on by the biological parents but by extended family and even the community at large. At some point during development the responsibility for this care and nurturing of the individual shifts. At some point societies expect individuals to manage and account for how they choose to live their lives.
In contemporary western culture it would appear that many individuals can become confused and uncertain about assuming personal responsibility for how they choose to live. Some abdicate personal responsibility and purpose to live according to the perceived expectations of others. Some abdicate personal responsibility by denying the impact of their actions upon their own well being or the well being of others. It would seem at least psychologically, many individuals are uncertain about their own sense of responsibility. "Am I the way I am because of someone or something controlling me? Or, do I have control over my thoughts, beliefs, emotions, and behavior?" In addition romantic ideals of western culture seem to foster the abdication of personal responsibility by defining the preferred relationship as one in which partners "take care of each other." Or, the notion that successful relationships are the result of partners fulfilling each other's "needs." These influences can foster an unhealthy form of emotional dependence between partners.
IMIT challenges individuals to embrace personal responsibility as a means of establishing emotional and psychological freedom and self-determination. This embrace of personal responsibility opens the door for the individual to act with independence and intention according to chosen values and aspirations. From a relationship standpoint it empowers an individual to begin participating in the relationship according to personally chosen values of integrity and well being. This empowers an individual to break free of the fear cycle controlling how they participate in the relationship. Without a strong sense of personal responsibility spouses are vulnerable to assume their spouse is controlling their thoughts, beliefs, feelings and behavior. In addition they may assume they are responsible not for themselves but for their spouse's thoughts, beliefs, feelings and behavior. This confusion about responsibility in the relationship adds fuel to the fear cycle. Assuming personal responsibility is critical to breaking the power of a relationship fear cycle.
Personal care. One of the primary ways personal responsibility is applied to propel relationship recovery and more importantly personal recovery, is by the individual becoming active in pursuing their own personal health and well being. The health and well being of the individual is set as a priority. The health of a relationship is predicated on the respective health of the individuals in it. Sadly, many married individuals do not see their own well being as relevant to their marriage relationship, either ignoring their well being or expecting their spouse to do the job of taking care of them. When individual spouses embrace the importance of their own health and well being they are able to accept caring from their spouse as a gift of support versus an obligation their spouse owes them. Likewise, the spouse who is committed to their own health and well being has more to give to their spouse in the way of caring. Caring is offered as an expression of love and commitment not simple duty and obligation.
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Relational Supports to Safety
While personal responsibility and personal care occur primarily within the individual spouse and at the individual spouse's discretion, two additional elements of relationship safety require the collaborative participation of spouses.
Caring for one's mate. During IMIT spouses are challenged to encourage, support and assist their mate's efforts to heal, recover and grow. One way IMIT instructs and facilitates spouses caring about one another is through effective emotional communication. Spouses are instructed, supported and coached in the skills of emotional empathic communication. These communication skills are explored and experienced under the close tutelage of the IMIT therapists. The experience of connecting emotionally with one's spouse during conversation powerfully demonstrates to couples what emotional connection can feel like and how to accomplish it as well.
Caring for the Relationship. The integrity of the marital relationship is experienced most fully when spouses operate with unity of purpose, as team mates or partners, journeying through life together fulfilling their pledge to one another. Spouses are challenged to invest in their marriage relationship by making it a priority. This relational unity will be stressed during conflict and can be fractured by the dynamics of the relationship fear cycle.
IMIT challenges spouses to invest in the integrity of their relationship by observing a principle of unity referred to as the No Loser's Policy. This relationship principle asserts a definition of conflict resolution as when both spouses embrace a selected decision, strategy or outcome. In essence neither spouse feels as though they are losing in the direction they pursue with an issue. This criteria of both spouses feeling good about the direction, places the relationship bond as a higher priority than some specific conflict, decision, or issue.
The relationship recovery model just described is expressed in Figure 1.
The Process of Integrative Marital Intensive Therapy (IMIT)
As important as the theoretical/historical context and theoretical assumptions and model of relationship recovery are to understanding IMIT, appreciating how IMIT actually unfolds during a Marriage Intensive (one couple, two days, two therapists) or Couples Intensive (five couples, four days, two therapists) is perhaps where the real distinguishing features of IMIT stand out.
Creating a Safe Therapeutic Environment
Considerable planning and adjustment has been made at National Institute of Marriage (NIM) over these initial years of using IMIT to assist couples in recovery from relationship distress. Because of the understood importance of safety in the recovery model, attention to the safety and comfort of individual clients has been given explicit attention. The priority of hospitality, comfort and respect of the individual client has guided NIM to specific facilities, partnerships, and staff selection.
The respect given to each individual to manage their own participation in therapy according to their own sense of readiness and safety is expressed during a client couple's registration, as well as during the actual therapy. Clients are carefully and sensitively educated about what they can realistically expect from the experience and encouraged to pass on participation if they are not comfortable.
While the attention to hospitality as an expression of organizational caring of the individual client is tangible to most clients, the personality and presence of the therapists is perhaps the most intense expression of caring couples experience. IMIT sees the personhood of the therapist as part of the therapeutic intervention. Like other approaches to psychotherapy that emphasize the therapeutic impact of the individual therapist personality, IMIT is best when practiced by therapists who are themselves examples and models of IMIT principles in their own personal lives and relationships. Therapist self disclosure is highly regarded as a therapeutic intervention. The presence of a co-therapist or "second chair" therapist helps ensure that therapist self-disclosure is firmly guided by client welfare and therapeutic rationale. IMIT allows for wide variation in therapist personal style and demeanor. This emphasis on personal presence facilitates the client's experience of a very personalized form of therapeutic care. The therapist is more likely to be seen by clients as a genuine individual applying their training and experience for the benefit of the client and their relationship not simply a professional doing their "job."
Experiential Priority
There are a number of therapeutic interventions at the disposal of IMIT. The therapy is less defined by a circumscribed set of interventions than it is by a therapeutic rationale. IMIT places the emphasis on a client's experience during an Intensive. Any intervention that enhances the therapeutic experience of the client is valued providing it supports and expresses vs. contradict other theoretical assumptions and the relationship recovery model. It is this commitment to what Yalom (1995) called a "corrective emotional experience" that guides therapists in the application of IMIT. What is "therapeutic" is defined by the theoretical assumptions reviewed earlier in this article. It essentially involves therapeutic experiences in which the client is a primary initiator/respondent and results in greater felt responsibility, emotional awareness and empathic bonding with the client's spouse.
Given this rationale interventions are only limited by the imagination and conscience of the therapist. Many interventions in IMIT begin as "in the moment" enactments in which a client or client couple is invited to try new relationship behaviors. The client or couple will then be guided by the therapist through the experience and the present emotional response is reviewed and explored. In each case the therapist looks for opportunities to explore with clients how their present therapeutic experience positions them for change outside of therapy. Clients are consistently affirmed for their courage in facing long held fears and behavior patterns, as well as affirmed for showing facility with new relationship skills. These affirmations are intended to build confidence and new self/relationship definition in clients. It is these therapeutic experiences that are seen as the most critical element of IMIT. Information and articulation of relationship principles is secondary to facilitating therapeutic experiences. These experiences because of the emotional intensity attached to them will be more memorable for clients and represent emotional reference points for recall and review in the future when adaptive coping and emotional upheaval challenges a client's resolve for change.
Cognitive Restructuring
While therapeutic experience is held as primary, IMIT will utilize psycho-educational instruction to stimulate cognitive restructuring often needed for clients to maintain gains in therapy. Care must be taken to not allow "intellectualizing" and thus loss of more emotional processing during therapy, but providing clients with new definitions and perspectives on their emotional and relationship experience can enhance, even motivate the emotional processing needed for therapeutic experience. It would appear most people do not sharply disengage their emotional processing from their cognitive processing. IMIT borrows the dictum from cognitive therapies, that identifying dysfunctional beliefs and maladaptive cognitive processes can then alter emotional processing.
Therapist's self-disclosure may be used to illustrate insights as well as the use of analogy and metaphor. The integrative aspect of IMIT is almost imperceptible to clients in that therapists may appear to move seamlessly between cognitive restructuring and emotional processing. This fluid therapeutic movement between cognitive restructuring and emotional processing can be very stimulating for clients because they are utilizing a broader range of sensory and cognitive modalities for learning and experiencing.
In addition the cognitive restructuring interventions afford opportunities to invite clients to test the insights and principles presented. Again being careful to not let the process deteriorate into intellectual debate exclusively, therapists are free to engage in some "intellectual wrestling" with clients. As insights and principles are presented clients may experience significant cognitive dissonance because the new perspective being suggested to them contradicts some long held belief. IMIT seeks to create a safe environment to press such dilemmas and provide clients with rationale to resolve the cognitive dissonance. The resulting insight and emotional relief can be dramatic and provide again an opportunity to return to emotional processing.
Common Factor Theory and IMIT
Davis and Piercy (2007a, 2007b) have examined common factors in three different approaches to couples therapy that share similarities with IMIT. It is not surprising that their research on "model dependent" and "model independent" factors in couples therapy confirms many of the theoretical conceptualizations and interventions used in IMIT. Common factor theory suggests that effective therapeutic approaches share certain "common factors" which account for their effectiveness. These common factors may not be ascertained unless the approaches and their theoretical models are somehow examined side by side for similarities and differences.
Davis and Piercy examined Emotion Focused Couples Therapy (EFT) (Johnson, 2004), Cognitive Behavioral Marital Therapy (CBMT) (Dattilio & Epstein, 2003), and Internal Family Systems Therapy (IFS) (Schwartz, 1995). Their examination of these three approaches through interviews with the major proponents of each approach, their students, and their clients produced an impressive array of factors which all three approaches share. A thorough review of how IMIT includes and addresses the common factors identified by Davis and Piercy (2007a, 2007b) is beyond the scope of this present article. Suffice to state at this time that a careful review of IMIT in the frame of common factors theory would confirm IMIT as an approach utilizing the same theoretical and therapeutic components identified in the Davis and Piercy (2007a, 2007b) research.
Outcome Research Summary
The National Institute of Marriage (NIM) has been collecting data for several years on participants who have completed their intensive marital therapy programs. Follow-up data recently was summarized on a group of couples who responded to email follow up surveys, and had been in either a Marriage Intensive or Couples Intensive between September 2004 and July 2007. Plans are currently being pursued to present these results in a formal research article for scholarly review and possible replication. The results are summarized here to demonstrate some of the data supporting IMIT as a viable approach alternative to working with marriages in distress.
Subjects
The study included 426 individuals representing 359 couples. Overall, 1043 couples attended the Intensive program during the study period. The survey respondents accounted for 34.4% of the population of couples who completed intensive programs at NIM during the three year time period. This response rate is within one standard deviation of the average response rate for e-mail surveys used in organizational research as reported by Baruch and Holtom (2008). This group likely contains more motivated former clients of NIM however as a group they are assumed to be representative of the population on many relevant parameters. To summarize some of the demographics of the participants in this follow up study; they were generally in their 30's and 40's age wise, overwhelmingly Caucasian, in their first marriage, married more than 12 years with 2 or more children and profess a strong Protestant Christian faith.
Results
Several questionnaires and surveys are used with intensive participants pre-treatment to screen for severe mental disorder and distress. Among these measures is the Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996). The mean BDI score for the follow-up sample was 16.13 (SD = 10.32) and a range from 0 to 43. This suggests as a group the follow up sample prior to their experience with IMIT were moderately depressed. BDI results were not collected post-treatment. The Index of Marital Satisfaction (IMS; Hudson, 1997) is also used to assess how satisfied spouses feel about their marriage. On the IMS the mean score was 56.32, (SD = 18.46 with a range from 5 to 93). According to Hudson, an IMS score of more than 30 indicates a spouse who feels levels of relationship distress of "clinical" proportions. Scores above 70 are considered the most severely distressed marriages. Thus, the survey group is made up of individuals who prior to IMIT, saw their marriage similar to other spouses who believed their marriages were in severe enough distress to warrant professional attention (see Table 1).
Data was gathered from subjects at four intervals following their intensive, 3 months, 6 months, 12 months, and 24 months. At 3 months, there were no divorces. At 6 months, 97.9% of 141 couples were still married, at 12 months 94.6% of 129 couples were still married, and 24 months 84.5% of 71 couples were still married (see Table 2).
Does marital satisfaction increase?
Two measures of marriage satisfaction were examined pre- and post-intensive marital therapy utilizing IMIT: The Kansas Marital Satisfaction Scale (KMSS; Schumm, et al., 1986); and The Quality of Marriage Index (QMI; Norton, 1983). Statistically significant increases in marriage satisfaction occurred at all four intervals (3, 6, 12 and 24 months) as measured by the KMSS. With the QMI significant increase in marriage satisfaction was found at the 3 and 6 month follow-ups. Unfortunately, not enough data was available to run a pre-post comparison at 12 months and 24 months with the QMI. The two measures confirm significant positive changes in marriage satisfaction following a couples experience with IMIT in intensive marital therapy at NIM (see Table 3).
In addition 94% of Couples Intensive participants in 2007 report being "very satisfied" with their experience in an Intensive at NIM in a satisfaction survey they complete at the conclusion of the experience. In addition when asked in a survey at the conclusion of the Couples Intensive, 100% report they would recommend the experience to a friend.
The results of this initial outcome study are encouraging. Between 40-50% of those marrying for the first time today will separate or divorce in their lifetime (Popenoe, 2007). When this prevalence of divorce is considered along with the relative degree of crisis and distress most couples are in when they come to NIM, plus the fact that most of the spouses individually are moderately depressed, the results are indeed encouraging. More work is needed for IMIT to fully establish itself as an empirically validated approach to marital therapy.
Applications of the Recovery Model and Integrative Marital Intensive Therapy Process
Integrative Marital Intensive Therapy (IMIT) likely has application beyond the format used by National Institute of Marriage (NIM) where IMIT has developed and is currently being used. The manner in which IMIT is used at NIM represents the present standard for practicing IMIT. In both the Marriage Intensive format and the Couples Intensive format there is a registration process that involves obtaining appropriate consent for treatment and pre-intensive data collection. The pre-Intensive data assist therapists in preparing to work with each couple.
There are four conditions upon which couples would be denied services and referred to other forms of therapy and counseling. These conditions are generally identified during the registration process but occasionally may not be determined until the pre-Intensive assessment materials are all completed. Spouses who report that they are actively engaged in an extra-marital relationship are encouraged to resolve this circumstance before coming to an Intensive. Experience has demonstrated that a spouse who is currently engaged in an extra-marital affair, emotional or sexual, lack the necessary sufficient focus to benefit from IMIT. Generally the condition placed here is no current contact being maintained with the other relationship and it is not being actively pursued by the spouse considering an Intensive. To be sure some individuals are not entirely truthful about their extra-marital relationships but this criteria appears to provide an acceptable degree of screening individuals who are trying to maintain a relationship competing with their marriage.
Recent reports of domestic violence that appear to be part of a pattern of domestic violence suggest couples who need more specialized assistance in their relationship specific to stopping the pattern of violence before they participate in an Intensive. These couples are encouraged to seek services from local mental health professionals for this kind of therapy/counseling. In some cases a recommendation or consultation from a professional may be required to ensure that patterns of domestic violence have subsided before a couple is approved for an Intensive.
Likewise couples that report active untreated chemical dependency are encouraged to begin and progress through chemical dependency treatment before participating in an Intensive. Again, consultation with a professional to ensure active chemical abuse has ceased and treatment is progressing may be required before approving couples for an Intensive.
The fourth criteria may appear unusual but has proved to be very important in screening couples who are probably not appropriate for IMIT. Spouses are asked during the registration process, "If God were to perform a miracle in your marriage would you be willing to accept it?" This question certainly expresses the integration of faith and IMIT. It also serves to inform clients of the faith element present in IMIT. Most importantly it serves to identify individuals who really are not open to relationship recovery, at least a recovery process that might entail a spiritual element.
Individuals who are being treated for severe psychological disorders such as schizophrenia, bi-polar conditions, severe anxiety disorders, or personality disorders are considered for Marriage Intensives but generally discouraged from the group therapy format of a Couples Intensive. Such individuals are considered on a case by case basis as to the appropriateness of IMIT for these couples.
Traditional Office Couples Therapy and Integrative Marital Intensive Therapy
An obvious question regarding IMIT is whether or not it could be effective in an out of office setting. Many couples select Intensives at NIM precisely because they want an alternative to out of office therapy. The simple answer is that we do not have any current data to document IMIT effectiveness in the office setting but reports from NIM therapeutic staff who use IMIT in their private practices are encouraging. In depth emotional processing can occur in a conventional 45-50 minute therapy hour but the full benefit of IMIT will likely be experienced in sessions that run at least 90-120 minutes. Half day sessions and single day sessions with appropriate breaks are conceivable and worth exploring. The following recommendations may provide some guidance for out of office couples therapy using the IMIT approach:
1. Nothing about the use of IMIT should limit or interfere with any of the expected, required or advisable practices professionals use to inform clients of their privacy and obtain consent for treatment;
2. Provide the most comfortable, hospitable, and private atmosphere for therapy possible. Consider soft, overstuffed furniture with plenty of living room like appointments and accessories as possible. Snacks and drinks will result in eventual spills and stains but the resulting communication of caring is probably worth it;
3. Provide thorough explanation of what to expect of couples therapy using IMIT, including the potential for experiencing intense emotions. Assure clients that they will remain in control of their participation and encourage them to pass whenever uncomfortable with the process;
4. Give intentional consideration of how therapy interventions and processes are "framed" and structured for clients. Be sure there is ample time to pursue interventions before facilitating exploration of emotional processes. This is perhaps the most challenging aspect of conducting IMIT in an office setting. Use of 90 or 120 minute sessions is advisable to be sure there is adequate processing time. Half day or full day appointments are even better;
5. Consistent with the previous suggestion pay special attention to the beginning and ending of sessions. The close of a period of processing is especially important. Give clients an idea of when and how issues can be addressed if time runs out and processing has to be interrupted;
6. Make the initial priority to join and connect with each spouse's story of their emotional reality, both in the relationship and through their development. Affirmation, validation and support are critical interventions in the beginning of therapy;
7. Provide couples with the conceptual elements of the recovery model but do so in a manner that supports their insight as opposed to trying to impress them with information;
8. Incorporate homework assignments judiciously. Some couples will work best if they can see the time in between therapy as a "break." For others it will be important for them to engage in specific "practice" of some important principle or relationship skill. Let the couple's experience of felt movement and progress be a guide;
9. As spouses encounter inevitable obstacles and conflict with their own change process, use these experiences to explore the emotional conflict change is bringing to the surface. In particular explore reports of, "I know what I am supposed to do, I just don't do it." This often discloses the presence of deeper emotional barriers to change and relationship that need to be attended to;
10. The principle of therapeutic mutuality and neutrality is compatible with IMIT and it is valuable to inquire with couples about feelings of blame from therapy interventions. Differentiate healthy acceptance of responsibility from feelings of shame and blame.
There are a myriad of unique challenges that can occur in the context of marital therapy. The above 10 suggestions are aimed at some of the challenges which may occur in the application of IMIT in an office context.
Appropriate Preparation and Training in Integrative Marital Intensive Therapy
IMIT is an approach to working with married individuals who are in significant relationship distress and crisis. Due to the depth of emotional exploration and processing involved in using IMIT, only individuals with the requisite training and professional experience should attempt using IMIT. Exploration of intensely held emotional conflict without appropriate professional training is psychologically dangerous and should not be attempted. Graduate training in psychotherapy and/or counseling and appropriate licensure and/or certification would be essential to practicing IMIT. Ideally, professionals using IMIT will have had some continuing education and supervision in the use of IMIT. NIM is currently exploring how such continuing education and supervision can be provided. Currently there are several publications that provide an excellent introduction to IMIT and how it is practiced at NIM (e.g., Paul, 2007; Paul & Smalley, 2004: Smalley, Smalley, Smalley, & Paul, 2003).
New Directions in Integrative Marital Intensive Therapy
The present state of affairs from a societal/cultural standpoint suggests that marriage as an institution continues to struggle. Literally millions of individuals find themselves in deeply painful relationship circumstances with no idea of how to cope. It is both encouraging and distressing to be involved in the discipline of marriage and family therapy at this time. It is encouraging in that couples really can recover from marital distress if appropriately supported and guided. Not only is IMIT reporting evidence of successful treatment of distressed couples, but other approaches as noted earlier in this article are documenting success as well. At the same time it is distressing to note while there appears to be growing skill at helping couples the societal marital crisis remains.
Objectives for Further Research
A data pool of over 2000 couples now exists at NIM. This is a rich source of data on marital distress and the application of IMIT in assisting couples. Currently the staff at NIM has only scratched the surface of what this growing data pool can tell us about marital dysfunction and relationship recovery. The data has already been used in one master's thesis and one doctoral dissertation, as well as NIM's efforts at studying outcome described earlier in this article. The most glaring needs for study with IMIT is how it compares to conventional out-of-office couples therapy, and how it compares to other approaches to couples therapy. Few studies have placed different couples therapy approaches side by side with sufficient sample sizes to allow comparison. It is likely IMIT and other approaches are effective with certain types of couples and certain types of dysfunction. Differing approaches likely appeal to different couples based on any number of variables, i.e. availability, perceived effectiveness, immediacy of intervention, etc. These comparisons would be very helpful in starting to map which approach to couples therapy is effective with what type of couple dysfunction and presentation.
More work is needed in documenting the place IMIT fills in the broader context of couple's therapies. While present NIM outcome research serves as a type of within subjects research design. Other more experimental research application is needed. It is hoped with growing interest in IMIT and training of professionals in the approach many of these research questions will begin to be addressed.
Improving Follow Up Resources and Services
A significant challenge facing the staff at NIM in the use of IMIT and a challenge that needs to be understood further in the application of IMIT is post therapy support and intervention. While it certainly appears that IMIT is effective in the immediate and near term as well as at the one year and two year follow up points. It is likely that gains made during IMIT could be strengthened and further developed if appropriate follow up services and resources are applied. What the best strategies for follow up are has not been tested at this point. NIM currently offers resources and services to couples who have participated in a Couples Intensive or Marriage Intensive and new resources and services are being developed.
Whether or not Integrative Marital Intensive Therapy (IMIT) becomes established as a preferred method of treatment of relationship distress and crisis remains to be seen. The current analysis of available information certainly seems to validate IMIT as a viable treatment approach and alternative. Much work is needed before the full import of IMIT as an approach is understood. Determining which approach for which clients with what type of challenges has long been the goal of therapists and counselors. Hopefully the insight and confidence being generated around IMIT will aid that goal.
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Robert K. Burbee
Brett K. Sparks
Robert S. Paul
Christine Arnzen
National Institue of Marriage
Correspondence regarding this article should be addressed to Robert K. Burbee, Ph.D., 231 N. Hemlock, Springfield, MO 65802; drburbee@nationalmarriage.com.
Authors
Robert K. Burbee (Ph.D. California School of Professional Psychology) is a Psychologist with National Institute of Marriage and an adjunct professor at Evangel University. Dr. Burbee's interests include marital therapy, marital enrichment, integration of faith and psychology, psychopathology, and creativity.
Brett K. Sparks (Psy.D. Fuller Theological Seminary) is a Psychologist and Research Coordinator with National Institute of Marriage. Dr. Spark s interests include marital therapy and integration of faith and psychology.
Robert S. Paul (M.S. Georgia State University) is Co-President of National Institute of Marriage. His interests include marital therapy, marital enrichment, integration of faith into all areas of life, and leadership development.
Christine Arnzen (M.A. Forest Institute of Professional Psychology) is Clinical Director at National Institute of Marriage. Her professional interests include developing a training program for intensive marital therapy. In addition to her role at NIM, Christine Arnzen serves as an adjunct professor at Evangel University.
Table 1
Pre-Intensive Measures
Mean score at Standard
Instrument beginning of Intensive Deviation Range
Beck Depression 16.13 10.32 0-43
Inventory (BDI)
Index of Marital 56.32 18.46 5-93
Satisfaction (IMS)
Table 2
Percentage Couples Still Married From Sample Following
IMIT Experience
Months 6 months 12 months 24 months
No divorces 97.9% 94.6% 84.5%
Table 3
Significant Positive Change in Marital Satisfaction
Pre- and Post-IMIT
Measure 3 months 6 months
KMSS * Significant * Significant
positive change positive change
QMI * Significant * Significant
positive change positive change
Measure 12 months 24 months
KMSS * Significant * Significantt
positive change positive change
QMI Insufficient data Insufficient data
* (p < .05)
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| Author: | Burbee, Robert K.; Sparks, Brett K.; Arnzen, Robert S. Paul. Christine |
|---|---|
| Publication: | Journal of Psychology and Christianity |
| Date: | Mar 22, 2011 |
| Words: | 9228 |
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