Integrative Behavioral Couple Therapy: Andrew Christensen and Shirley Glynn

Chapter 17
INTEGRATIVE BEHAVIORAL
COUPLE THERAPY
Andrew Christensen and Shirley Glynn
Copyright American Psychological Association. Not for further distribution.
Integrative behavioral couple therapy (IBCT) was IBCT has been adapted into a 6- to 8-hour online
developed in the 1990s by Andrew Christensen and program for couples at www.ourrelationship.com,
the late Neil S. Jacobson (Christensen, Jacobson, and tested via a nationwide clinical trial. In this
& Babcock, 1995; Jacobson & Christensen, 1998). chapter we examine the theoretical background
It grew out of their dissatisfaction with traditional for IBCT, contrasting it to traditional and cognitive
behavioral couple therapy (TBCT; Jacobson & behavioral approaches. We describe the assessment
Margolin, 1979), the most empirically validated and treatment strategies of IBCT and the efficacy
treatment at the time (Christensen & Heavey, 1999). studies that evaluated its success. Finally, we discuss
Although firmly situated within behavioral theory, the recent efforts at dissemination through VA and
IBCT, as compared with TBCT, broadened the through the online program for couples.
conceptualization of couple distress and thus the
assessment of that distress, pushing past the notion
CONCEPTUALIZATION OF COUPLE
that the ratio of positive to negative events was the
DISTRESS AND INTERVENTION
key to understanding couple distress. IBCT also
expanded the conceptualization of the goal of couple Every approach to couple therapy rests on a theory
intervention, moving beyond the idea that the key to or at least a conceptualization of couple distress and
successful therapy was promoting simple behavior a related theory or conceptualization of intervention
change (i.e., increasing positive behaviors and in that distress. In this section we describe how
decreasing negative behaviors) and incorporating IBCT views distress and intervention.
the therapeutic objective of emotional acceptance.
Because of this emphasis on emotional acceptance, Couple Distress
IBCT is more closely linked to third wave behavioral Scholars studying close relationships focus on
approaches than to either traditional behavioral or interpersonal interaction as the essence of relationships
cognitive behavioral approaches. (Kelley et al., 2002). The back and forth interactions
Since its development more than 25 years ago, the between partners is what constitutes their relationship.
efficacy of IBCT has been examined in comparison Barring extrasensory perception on the part of either
with TBCT as well as wait-list controls. The effective partner, partners can only experience what the other
ness of IBCT in the real world has been examined in person does or does not do. Certainly, each person
a system-wide dissemination effort through the U.S. has many cognitive, emotional, and physiological
Department of Veterans Affairs (VA). In addition, reactions to what his or her partner does or does not
http://dx.doi.org/10.1037/0000101-017
APA Handbook of Contemporary Family Psychology: Vol. 3. Family Therapy and Training, B. H. Fiese (Editor-in-Chief)
Copyright © 2019 by the American Psychological Association. All rights reserved.
275
APA Handbook of Contemporary Family Psychology: Family Therapy and Training,
edited by B. H. Fiese, M. Celano, K. Deater-Deckard, E. N. Jouriles, and M. A.
Whisman
Copyright © 2019 American Psychological Association. All rights reserved.
Christensen and Glynn
do, but each is privy to those reactions only through to focus primarily on differences since it is these
the observable interaction. Thus, this interpersonal disparities that are more likely to create problems for
interaction takes a central position in analyses of partners. However, similarities can occasionally lead to
close relationships and in IBCT. difficulties as well. For example, both partners may be
From an IBCT perspective, problems occur in very cautious about taking financial risks and hesitate
close relationships when one partner’s (P’s) actions or to buy a home until prices have escalated beyond their
inactions lead to negative responses such as anger and financial means. They may then criticize each other for
disappointment in the other (O), which in turn leads O not pushing more to take a risk on real estate.
to respond in ways (e.g., critical comment, withdrawal) The second part of the DEEP refers to emotional
that produce negative responses in P. Occasional sensitivities or vulnerabilities that partners bring to
occurrences of such negative reactions are typical the relationship. Common sensitivities that affect
in any relationship and do not become problems relationships are fears of abandonment by the other,
until they are repetitive and intense. When couples concern that the other may cheat, lack of confidence
experience these negative interactions repetitively and in one’s attractiveness to the other, a tendency
intensely—when they form a negative cycle or pattern to easily feel rejected by the other, being “thin-
of interaction—then the partners are likely to define skinned” and thus reactive to any kind of criticism or
their relationship as having problems and may seek disappointment from the other, and strong reactivity
intervention for those problems. to any kind of control or influence by the other. These
Interaction in romantic relationships, and indeed sensitivities can make differences between partners
interaction in any dyad, is influenced by three even harder to manage. For example, if one partner
broad, distinguishable factors: the characteristics is a saver and the other is a spender and they each
that P brings to the relationship, the characteristics have sensitivities associated with this difference, then
that O brings to the relationship, and the physical navigating the difference will be especially difficult.
and social context in which the relationship occurs. Imagine if the saver has a history of economic
IBCT conceptualizes these three factors as well as deprivation that makes him or her especially fearful
the interactions they influence through a conceptual of potential future financial difficulties; his or
framework called the DEEP understanding or her saving preferences would be driven by strong
DEEP analysis. DEEP is an acronym that refers to emotional concerns. If the partner of the saver—
Differences between partners; Emotional sensitivities the spender—has a history that renders him or her
in partners and the subsequent emotional reactions especially emotionally reactive to feeling controlled
that partners bring to the relationship; External by the other, then the spender may have difficulty
circumstances, particularly external stressors, that accommodating the saver’s concerns.
provide the context for the relationship; and the The third part of the DEEP, external circumstances,
Pattern of interaction that is influenced by the DEE refers to the context of the relationship. IBCT focuses
and which in turn influences the DEE. primarily on external stressors, since these are the
Differences between partners can refer to any kind circumstances that most often create difficulties for
of characteristic in which they vary and that influences couples. External stressors typically refer to concerns
their interactional behavior. For example, differences such as job pressures, challenges generated by
can refer to (a) personality differences such as P being family members or friends, economic conditions, or
more extraverted than O; (b) differences in preferences illness. If, for example, the spender and saver couple
such as P being more frugal than O; (c) differences experience some economic setback, such as loss of
in interests, such as P having greater enthusiasm for money in the stock market, unemployment, or a
outdoor activities than O; (d) differences in family reduction in work hours, the challenge the partners
connection, such as P having stronger connection to face in dealing with financial issues will even be
his or her family of origin than O; or (e) any other more daunting.
kind of important differences such as those in libido, The final part of the DEEP, the pattern of
cultural identity, or emotional expression. IBCT tends communication, refers to the manner in which a
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Integrative Behavioral Couple Therapy
couple tries to solve the problems created by their what from their perspective should be helpful but
differences, emotional sensitivities, and external that in fact does not resolve the problem. In fact,
stressors. Optimally, the spender and saver couple the pattern of communication and the resulting
would deal with the challenges presented by their frustration often makes the problem worse in several
differences, emotional sensitivities, and external ways. First, the couple’s interactions may escalate
stressors around money by engaging in detailed in intensity so that their voices and their emotions
discussion and planning of how much each person both rise. Second, they may become more polarized
can spend individually as well as how much they on the issue as a result of their pattern of interaction.
will spend jointly, and then executing the agreed- For example, the saver may become more anxious
upon plan. Of special interest in IBCT are patterns about money and thus more focused on saving,
of communication that do not effectively deal with while the spender may feel threatened regarding
a couple’s challenges and that may even make them his or her autonomy and become more focused on
worse. For example, suppose the saver gets mad spending without influence from the other. Third, the
at the spender when he or she learns of certain partners may begin to vilify each other’s positions, so
purchases by the spender, and the spender reacts that they view the other in terms of deficiencies rather
by hiding his or her purchases or refusing to talk than differences. The saver may see the spender as
about them. This may lead to greater anxiety on immature and irresponsible, while the spender views
the part of the saver, who then tries to monitor the the saver as uptight and unable to enjoy life. Finally,
spender more closely and challenge him or her a central conflict can metastasize so that tension
more adamantly, which could in turn lead to even around one conflict begins to color other aspects of
less disclosure, more resentment, and perhaps even their lives that were formerly pleasurable or conflict-
more purchasing on the part of the spender. Such a free. The partners become alienated from the other.
pattern could then escalate further until spender and Feeling hopeless and helpless to solve the problem,
saver are stuck in a vicious cycle of interaction that they may seek therapy.
leads to alienation.
A key aspect of the pattern of interaction in Intervention in Integrative
distressed couples is what Rohrbaugh and Shoham Behavioral Couple Therapy
(2015) highlight as ironic processes. From their Because it is a behavioral approach to therapy for
standpoint, each partner behaves in ways that would couples, IBCT shares the broad theoretical foundation
seem to achieve his or her goals. The saver monitors of behaviorism (see Volume 1, Chapter 4, this
the spender and challenges him or her on purchases handbook) with TBCT (Jacobson & Margolin,
as a way of controlling expenditures. The spender 1979) and with traditional cognitive behavioral
hides his or her purchases as a way of having the couple therapy (CBCT; D. H. Baucom & Epstein,
freedom to spend without negative reaction from the 1990; see Chapter 16, this volume). However, IBCT
saver. However, these well-intentioned efforts often differs from these two behavioral approaches in its
backfire, resulting in the saver having less influence definition of problems, its targets of change, and its
over purchases and the spender facing increased strategies of change.
negative reaction from the saver. Rather than solving A hallmark of behaviorism was its focus on clearly
the problem created by their differences, emotional defining specific, observable, molecular behavioral
sensitivities, and external stressors around money, targets of change. Rather than considering therapy
their pattern of interaction has exacerbated that an effort to alter character traits or unconscious
problem. Their external stressors may even increase conflicts, therapy was viewed as an effort to change
if their financial resources are reduced due to their specific behavioral actions. As applied to couples,
lack of cooperation on a budget. this emphasis on behavioral targets meant that TBCT
Because of the factors conceptualized in the DEEP focused on changes such as reducing the frequency of
analysis, couples often feel “stuck” or “trapped” verbal criticism of appearance and dress, for example,
in their pattern of interaction, repeatedly doing or increasing the frequency of physical affection such
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as hugs and kisses. In CBCT, the focus on specific, egregious, but are rather garden-variety slights,
molecular targets was expanded to include thoughts, rejections, criticisms, and frustrations that may occur
such as negative attributions about the partner (“You in daily intimacy. Egregious acts that do sometimes
are only nice to me when you want something from happen in relationships are often the result of an
me”) or negative interpretations of the partner’s escalation that began with those more common
actions (“You didn’t listen to me so you must not care emotional injuries. In IBCT, it is further assumed
much about me”). In contrast, in IBCT, the focus is that the problems everyday negative behaviors
on broad molar patterns of behavior, such as those and thoughts create are a function not just of the
described in the DEEP analysis. For example, a noxiousness of the behaviors or thoughts, but also
couple might be described as being in a broad pattern of the partner’s sensitivity and reactivity to them. In
where P is in a demanding pursuit of O, while O other words, a sensitive person may get upset at a
is in a resentful retreat from P. IBCT would involve critical partner’s remarks not just because they are
describing behavioral exemplars of that pattern, but cutting, but also because he or she is reactive. Thus,
would not assume that the pattern was fully described a major goal in IBCT is emotional acceptance of the
by those particular exemplars. More importantly, in other and his or her behavior as well as change in
IBCT, it is assumed that behaviors within a broad that behavior. In addition, IBCT assumes there is an
pattern often have a similar functional value. For interplay between acceptance and change. Partners
example, the various critical and pursuing behaviors who push too hard for change may actually decrease
of P may be a way to seek engagement from O. If O the chances of change, whereas acceptance may
does engage with P in a meaningful way, perhaps foster change. And, if some change does take place,
some of the negative actions of P, such as P’s criticism, acceptance becomes easier.
may decrease on their own without ever being A final characteristic of IBCT that distinguishes
specifically targeted for change. it from TBCT and CBCT has to do with the strategy
A second hallmark of early behavioral approaches of change. TBCT and CBCT focus on deliberate or
to couples related to the focus on specific target rule-governed behavior, whereas IBCT focuses on
behaviors was that the goal of therapy was to spontaneous or contingency-shaped behavior
increase the frequency of positive behaviors that (Skinner, 1966). In the former, people engage
partners wanted from each other, and to decrease in behaviors because they have been taught that
the frequency of negative behaviors that they found they should, and they know their performance of
aversive. Increasing the ratio of positive to negative these behaviors will be reinforced. For example, a
behaviors was a clear goal of TBCT and was thought student may pay attention in class despite a lack of
to be a causal determinant of relationship satisfaction interest in the material because he or she knows the
(Jacobson & Margolin, 1979). As noted previously, material could be included on an exam. In contrast,
CBCT not only focused on positive and negative in contingency-shaped behavior, people engage in
behaviors, but also broadened the scope to include behavior as they are guided by the contingencies
positive and negative thoughts about the partner. occurring in the immediate situation. In this case,
Improvement in ratios of positive to negative for example, a student may pay attention in class
behaviors and thoughts is certainly valued in because he or she finds the material fascinating and
the practice of IBCT, and some behaviors such wants to discuss it with a partner.
as violence and cruelty must change. However, As a strategy of change, TBCT and CBCT employ
for most couples, each partner’s long-standing rule governed-behavior by identifying a behavioral
characteristics mitigate against the possibility of target, instructing partners to engage in that behavior
eliminating most negative behaviors and thoughts or training partners in the performance of that
or increasing most positive behaviors and thoughts behavior, and then shaping and reinforcing the
that partners might desire. Furthermore, in IBCT, it resultant behavior. Common strategies in TBCT and
is assumed that most of the negative acts or thoughts CBCT include communication training, in which
that partners wish to abolish in the other are not partners are taught effective ways to communicate
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about and solve problems, and cognitive restructuring but focuses on positive changes that have been
in CBCT, in which negative thoughts are identified made during therapy and the maintenance of those
and challenged. In contrast, IBCT attempts to create changes. We will now describe each of those phases.
both acceptance and change through contingency-
shaped behavior. IBCT guides couples through a Assessment Phase
discussion of emotionally salient material, such as a The initial session is always conducted jointly so the
recent conflict, and exposes or highlights previously therapist can learn about each partner’s perspectives
overlooked but important material that might change on the presenting complaints and make a connection
the nature of the interaction. For example, a wife may with each partner. After hearing about these
have felt rejected by her husband when they were presenting complaints, the IBCT therapist may
out with another couple who were very physically summarize his or her initial understanding of the
affectionate and her husband did not even hold her concerns before transitioning into the couple’s
hand. As the therapist helps the couple explore this relationship history. The IBCT therapist attempts
difficult scenario, particularly the emotions they to learn what attracted the partners to each other,
experienced during the event, perhaps the husband what holds them together despite their concerns,
reveals that he felt uncomfortable and awkward when those concerns developed, and what may
around this new couple, and his wife reveals that have triggered the concerns. At the end of the initial
seeing the other couple’s easy display of affection session, the IBCT therapist gives each partner a
made her feel bad about their own relationship. Such series of questionnaires to complete and bring back
a discussion may lead the wife to be more accepting to the individual session. These questionnaires
of her husband’s difficulty in displaying affection, or assess, at a minimum, (a) overall satisfaction in the
the husband to be more tender toward his wife. If any relationship, (b) intimate partner violence in the
positive change results from the discussion, it would relationship, (c) commitment to the relationship,
not be because it was deliberately targeted and trained and (d) problems in the relationship. Currently,
by the therapist, but because new, important material the authors use the Couples Satisfaction Inventory
was disclosed or discussed in a way that naturally led (CSI-16; Funk & Rogge, 2007) to assess satisfaction,
to the changes. the Couple Questionnaire (Christensen, 2009) to
assess violence and commitment, and the Problem
Areas Questionnaire (Heavey, Christensen, &
DESCRIPTION OF EVALUATION AND
Malamuth, 1995) to assess problems that may
INTERVENTION IN INTEGRATIVE
not have been mentioned in the interview (these
BEHAVIORAL COUPLE THERAPY
questionnaires may be freely obtained at http://
IBCT consists of four phases: assessment, feedback, ibct.psych.ucla.edu/questionnaires.html).
active treatment, and termination. During the During the individual session with each partner,
assessment phase, partners are seen together and the IBCT therapist collects the questionnaires listed
individually and complete various questionnaires above and follows up on the presenting complaints
to provide the therapist with information about to obtain more information about each partner’s
their concerns. Following this assessment, the perspectives. The IBCT therapist also explores
IBCT therapist provides the couple with feedback salient and relevant features of each partner’s
about their relationship and an overview of how history, such as previous psychological treatment,
IBCT would proceed. Assuming the couple makes psychiatric medication, and significant events
a decision to continue, then the active intervention that might be related to the current problems. For
phase of IBCT occurs, which almost always involves example, perhaps infidelity by a parent or infidelity in
multiple joint sessions with both partners. During a previous romantic relationship has made a partner
the termination phase, the couple may taper off their sensitive to issues around trust. During both the
contact with the therapist until the final termination initial joint session and the individual sessions, the
session, which is similar to the feedback session IBCT therapist identifies one or two core issues and
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tries to fill in the pieces of a DEEP analysis of these Feedback Phase

core issues. After the initial session and the individual sessions
Also during the individual sessions, the IBCT with each partner, the IBCT therapist consolidates
therapist explores possible intimate partner the information obtained from those interviews and
violence by examining questionnaire responses to from the questionnaires the partners completed, and
violence items and by asking partners about any constructs an outline of feedback for the couple.
incidents of such violence. With the occurrence This feedback, which takes place during the fourth
of intimate partner violence, which is common in session with both partners present, consists initially
distressed relationships, the therapist must evaluate of a clinical conceptualization of the problems. This
whether couple therapy can proceed safely and conceptualization includes the following:
effectively. The usual criteria for concluding that 1. Level of distress. The therapist discusses how
couples cannot engage in couple therapy safely and happy or unhappy each partner is and may
effectively is whether there has been injury and/or provide them with the scores on the CSI-16 along
intimidation previously. If either partner has been with appropriate norms (e.g., showing the couple
injured or is afraid to voice her or his feelings openly that their scores place them in the borderline
for fear of physical reprisal, then couple therapy range between satisfied and dissatisfied couples).
is usually contraindicated, particularly if injury or 2. Commitment. The therapist discusses the partners’
intimidation has occurred in the last year. level of interest in improving the relationship and
Another issue routinely assessed in the individual their willingness to work on the relationship.
session is commitment to the relationship. IBCT 3. One or two core problems and the corresponding
therapists need to know if partners want the relation DEEP analysis. This is the key part of the clinical
ship to succeed and are willing to put in effort to conceptualization. The IBCT therapist shares his
make it succeed. Partners often are ambivalent, or her initial views of the DEEP analysis of the
but if either partner has “checked out” of the couple’s core problems, presenting the analysis
relationship or is unwilling to make any efforts to tentatively and encouraging partners to elaborate
improve the relationship, IBCT cannot proceed or alter the analysis as they see fit. The therapist
since it is a treatment for relationship improvement may also elaborate on how the pattern of inter
and not relationship dissolution. In the context action has impacted the partners, polarizing
of commitment, therapists often inquire about them in their positions, leading them to view
affairs. IBCT focuses not just on sexual affairs each other negatively, alienating them from each
but on any significant relationship that is hidden other, and making them feel trapped or stuck and
from a partner. If there were past affairs but there thus hopeless or helpless.
are no current affairs and the commitment to the 4. Strengths. The IBCT therapist discusses key
marriage is strong, the therapist can discuss with individual and relationship strengths that the
the partner the pros and cons of revealing the past couple maintains that will help them deal with
affair, but revelation is not mandatory for the IBCT their difficulties.
to proceed. However, if there is a current affair, After the clinical conceptualization has been
the IBCT therapist insists that the partner end the thoroughly discussed with the couple, the therapist
affair or reveal it to the other person, or both. describes the active intervention phase of IBCT.
IBCT cannot be conducted effectively if there is a The content of this phase of therapy is driven by
significant, secret relationship in competition with the couple, and namely those incidents and issues
the relationship for which therapy is sought. If of emotional salience to the partners. The therapist
the partner agrees to end the affair but not reveal helps partners discuss these emotionally salient
it to the other partner, the therapist arranges for incidents and issues in a constructive way. As part
periodic individual meetings with each partner of this discussion, the therapist introduces the
during treatment so that therapist can be sure that Weekly Questionnaire (Christensen, 2010; available
the affair was indeed discontinued. at http://ibct.psych.ucla.edu/questionnaires.html),
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a one-page survey that partners will be asked to Weekly Questionnaire and examines the items to
complete independently right before the session see how their week has gone. If there were incidents
each week and that will guide the therapy. The of violence or destruction, problems with drugs or
questionnaire consists of four CSI items that allow alcohol, or major changes, these events will be the
the therapist to monitor the satisfaction of the focus of the session at the beginning and, depending
couple with their relationship since the last session; on their importance, may occupy the entire session.
questions about whether there have been any If none of these events occurred, then typically the
incidents of violence or destruction, any problematic IBCT therapist would begin by discussing the most
incidents around drug or alcohol use, and any major important significant positive events that occurred.
events or changes (to allow the therapist to routinely If a positive event was significant for the couple
monitor these events if they occur); and questions (e.g., they handled their core issue in a better way,
about interactions with their partner, including had sex for the first time in a long time), then the
the most significant positive event experienced therapist will give it significant attention, trying to
with the partner, the most significant negative ensure that the couple receives sufficient reinforcement
event experienced with the partner, any upcoming and understands how they were able to bring about
challenging event with the partner, and any other such a positive event on their own. If the positive
issue of concern even though there may not have event was not significant (e.g., the couple went to
been an incident about it since the last session. The a fun movie together), the therapist will not spend
active phase of therapy will involve discussion of much time on it, but will note how the couple is still
these salient incidents and issues, with the therapist able to enjoy time together despite their difficulties.
playing an active role in the discussion. The IBCT therapist then sets an agenda with
After the therapist has discussed the clinical the couple based on the incidents and issues they
conceptualization and the process of IBCT with the listed. Partners sometimes both list the same recent
couple, the partners are asked to go home and discuss
negative or upcoming incident as a focus for their
the therapy with each other. If they feel comfortable
discussion. If they have an urgent need to discuss
with the approach and with the therapist, then they are
separate incidents or issues, the therapist ensures
asked to confirm this with the therapist and the first
that time is given to both. During the discussion of a
session of the active intervention phase is scheduled.
difficult incident or issue, couples often will fall into
Active Intervention Phase their usual pattern of problematic interaction. The
The goals of IBCT are both acceptance and change, therapist then shifts attention away from the incident
but the emphasis is on one or the other depending on or issue to what is happening during the session—
the aspect of the DEEP analysis under consideration. namely, their problematic pattern of interaction.
Because differences and emotional sensitivities Now, a central focus of therapy is happening in real
are often related to personality characteristics that time and provides both a good opportunity and a
are unlikely to change quickly if at all, emotional challenge for the therapist. Toward the end of the
acceptance is the IBCT goal for these. Sometimes session, the therapist summarizes the major points
external circumstances and stressors can be changed, that were discussed and what might be taken away
but often they cannot be changed without creating from the session. If the session was heated, the
even greater distress. Therefore, acceptance or change therapist starts the process of ending it early enough
is targeted for these external factors, depending on so that partners don’t feel cut off, and can discuss
their role in the couple’s life. However, change is whether they can leave the topic in the therapy session
the goal for the couple’s pattern of interaction. IBCT or want to continue discussing it after they depart.
helps couples interact about their difficulties so they The therapist works to actively engage the
do not get stuck in their usual pattern of interaction. couple in constructive discussions of their difficult
As noted previously, the typical content of an incidents and issues, but their typical pattern of
IBCT therapy session focuses on salient events and problematic interaction is the default setting for
issues in the couple’s life. The therapist collects the these discussions. In place of this default pattern of
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problematic interaction, the IBCT therapist tries argument ensued. The therapist would acknowledge
to substitute compassionate discussions, analytic the anger that Bill felt about what he perceived as
discussions, and practical discussions. These are a violation of their relationship, and would also
conceptually separate discussions and will be acknowledge the reciprocal anger that Sue felt about
discussed as such in this section of the chapter. being, from her point of view, unjustifiably attacked.
However, in practice, the discussions are blended. However, the therapist would try to uncover and
To facilitate these three types of discussions, develop other, hidden emotions that the partners
the therapist often begins by having all interaction might also have been experiencing. Bill may have
directed at him or her. If partners talk to the felt like he was snubbed by Sue, or that she was
therapist rather than to each other, the therapist more interested in another man than in him. He may
has the greatest control and can ensure each have felt competitive with the other man. When
partner’s perspective is heard and acknowledged, revealed through careful probing by the therapist,
can shift partners’ often blaming statements to the Bill’s emotions might lead to a different reaction in
understandable emotions behind those statements, Sue than anger. Similarly, Sue may have had some
can validate those emotions, and can transition mixed feelings about the man she talked to or her
between partners to minimize defensiveness and own behavior. Maybe she also felt that she had
counterattacks. At certain points, the therapist moved into a “gray zone,” and felt a little guilty or
can switch the direction of the conversation so bad that it bothered Bill. Maybe she had been feeling
that partners talk directly to each other. If an IBCT unappreciated or undesired by Bill and enjoyed the
therapist discovers an important but overlooked attention of another man. This hidden material has
emotion or perspective in one partner that might the potential to change the nature of the discussion
change the dynamics of their interaction, the from argument (attack, defense, and counterattack)
therapist may encourage the partner to express that to something more meaningful, during which
emotion or voice that perspective directly to the Bill and Sue can come to a greater understanding
other partner, since direct contact may heighten and appreciation of each other that leads to some
the power of the revelation. As partners get better emotional acceptance and possible change. Even if
at discussing their concerns without reverting to the partners are unable in the moment to be more
their usual pattern of interaction, the therapist may open and vulnerable with each other or move to
encourage direct conversation between them, but a kinder and more understanding place with the
intervene when it goes off track. other, each partner gets understanding and validation
A major intervention in IBCT is empathic joining, from the therapist, who may suggest possible hidden
which is designed to promote compassionate emotions that could be going on in the other partner.
discussions around emotional wounds that the Each partner hears what the therapist says to the
relationship has created. In empathic joining, IBCT other partner, and those therapist comments can
therapists help the couple engage in a heart-to-heart soften the interaction later, even if partners haven’t
discussion about a significant relationship event or been able to let down their guard with each other or
issue in which partners share feelings, some of which show empathy for each other in the session.
they may not have shared previously or shared so A second major intervention in IBCT is unified
fully. To promote this compassionate discussion, detachment, which is meant to promote analytic
IBCT therapists are attuned to emotional reactions, discussions. In contrast to empathic joining, in
both surface reactions that are easily displayed as which the emphasis in the discussion is on mutual
well as the hidden reactions that are not so easily emotional disclosure, in unified detachment the
revealed. For example, Bill may have shown the emphasis is on sharing observations, perspectives,
surface reaction of anger and irritation on the way thoughts, and analyses. As in empathic joining,
home from a party where he thought his partner Sue in unified detachment a significant relationship
was flirting with another man. Sue did not think experience (e.g., an incident or issue) is discussed,
she was behaving inappropriately, and a heated but in a descriptive, nonjudgmental, dyadic, and
282
mindful way. IBCT therapists shift partners away involves accessing the couple’s existing behavioral
from discussions that are evaluative, blaming, repertoire. Because of data indicating that couples
individually oriented, and responsibility-seeking. often do not retain the communication skills
How do IBCT therapists promote these kinds of taught to them (Hawkins et al., 2008), and because
analytic discussions and keep partners from placing couples sometimes find the communication skills
blame and making judgments about their partner or uncomfortable or alien compared with their normal
themselves? The therapist guides partners through a way of talking, IBCT therapists prefer to focus on
discussion of the sequence of their behavior during positive communication abilities in each partner’s
an incident or issue, taking care to have them current repertoire of behavior. In IBCT it is assumed
identify the “triggers” or “buttons” that escalated the that behavior will be more durable if it is already
discussion or were turning points in the interaction in the person’s repertoire and just needs to be used
and finding out how the interaction ended and if appropriately. Therefore, IBCT teaches traditional
and how they were able to come together again. communication and problem-solving skills only
During these discussions, the IBCT therapist might secondarily.

distinguish intentions from effects (“You were One common direct change strategy is to replay
genuinely trying to help her, but it sounds like what difficult interactions that occurred during the week
you did, out of the best of intentions, made her feel or that happen in therapy. In the replay of these
incompetent and put down”); make comparisons interactions, IBCT therapists promote both unified
and contrasts (“The incident yesterday was very detachment and empathic joining strategies. For
similar to the one we discussed last week, but you example, the therapist may remind partners of
got over it much more quickly; do you have any the usual pattern of interaction in which they get
idea why you were able to recover so quickly?”); or stuck (unified detachment) and give them a general
employ irony (“Isn’t it ironic that you hurt her the prompt, such as, “Have the same general discussion
most when you are trying to be the most helpful?”), but try to do it better so you do not get stuck in your
metaphor (“It seems like your pattern is kind of usual bind.” To encourage empathic joining, the
like a game of cat and mouse”), or humor (“Could therapist may give specific prompts such as, “Talk
you two come up with a name for this pattern that more about yourselves and your own feelings,” and,
captures some of its craziness and irony?”). In its “Try to stay away from focusing on your partner and
ideal form, unified detachment enables partners to what he or she did wrong or what he or she may
step back and examine a relationship incident or issue be feeling.” If the interaction starts going better but
using a kind of joint mindfulness. When partners are gets off track, the therapist will intervene to help
able to do this, they can view the problem as an “it” partners understand what led them off track (e.g.,
rather than a “you,” they may feel a common unified what one partner said or did that triggered the other
perspective on the problem, and they may experience partner and his or her emotional reaction). The IBCT
greater acceptance of the problem, which may soften therapist may help each partner clarify the message
their interactions about it. he or she wishes to give to the other partner and to
A third major intervention in IBCT focuses on articulate that message in a way that the other person
practical discussions that create direct change. can hear it. If the discussion involves problem-
A variety of interventions are included in this solving and concrete changes might be beneficial, the
category; they attempt to improve communication therapist encourages partners to suggest actions that
and problem-solving, encourage positive behavior, they could each take that might resolve the problem.
increase tolerance for inevitable negative events, Again, in IBCT it is assumed that solutions that
and foster self-reliance. In contrast to TBCT, which come from the partners themselves and refer to their
promotes direct change by teaching communication own behavior are more likely to be maintained than
and problem-solving skills, having couples specify solutions suggested by the therapist. IBCT therapists
pleasing events for each other, and agreeing to may also intervene to reinforce and complement
engage in those events more frequently, IBCT what the partners are doing, or to normalize the
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difficulty that they are having in trying to engage something that they often do so easily. This humor
in a more constructive conversation. In these ways, can lead to greater unified detachment from the
IBCT therapists guide couples through better, pattern. If they are able to truly engage in the pattern
more meaningful communication than they had and they begin to get emotional, the therapist can
experienced previously. interrupt their enactment and debrief their emotional
To promote positive interactions between partners, reactions, perhaps achieving some empathic joining
IBCT therapists routinely attend to the partners’ most between them. The couple might also discuss how
important positive interaction during the week. By they can maneuver out of the pattern, and may
discussing these naturally occurring positive events, make some direct change based on the experience.
IBCT therapists help partners understand what they Thus, the tolerance intervention exercise leads to
enjoy about each other and what gives the other possibilities to engage in the other three basic IBCT
pleasure. Only secondarily would IBCT therapists intervention strategies.
invoke the TBCT rule-governed strategy of formal Another version of a tolerance intervention is for
behavioral exchange, in which partners specify the therapist to encourage only one partner to engage
behaviors that they think the other would like, in the provocative behavior. For example, one partner
review whether those behaviors are truly pleasing might be encouraged to criticize the other while
to the other, are encouraged to engage in more of the therapist focuses on the reactions of the partner
those pleasing behaviors, and are debriefed about the being criticized. If the criticizer has trouble being
impact of those behaviors. authentic, it may result in lightness and laughter
Tolerance interventions are another key IBCT that promotes unified detachment. If the criticizer is
strategy, though these are typically only used authentic enough to trigger an emotional reaction in
later in therapy as they are grounded in the prior the partner, this provides an opportunity for empathic
acquisition of other skills. When partners have joining. In either case, the therapist might engage the
achieved a level of unified detachment so that they couple in a discussion about how the partner could
can describe—without judgment or blame—the react to the criticism in ways that do not lead to the
pattern of interaction in which they get stuck typical escalating criticism–defensiveness pattern,
and recognize this pattern when it occurs or soon thus allowing some direct change.
after it has occurred, the couple may be suited for A final version of a tolerance intervention,
tolerance interventions. These interventions reflect usually presented after one of the previously
the reality that most couples are not going to avoid described in-session interventions, is to ask one or
their troubling patterns of interaction completely, both partners to “fake” the provocative behavior
but can experience them less intensely and recover at home when they are not feeling it. The criticizer
from them more quickly. To do so, partners need might be asked to be critical sometime during the
to develop some tolerance for some of the other’s week when he or she does not feel critical, or the
triggering behaviors. defender asked to be defensive sometime during the
In a common version of a tolerance intervention, week when he or she does not feel defensive. After
an IBCT therapist asks partners to enact their taking the provocative actions, the partners are to
problematic pattern of interaction during the session. observe the other person’s reactions to understand
For example, a couple that gets stuck frequently in the impact of their behavior when they themselves
an accuse–defend pattern might be asked to engage are not emotional. As a result of these tolerance
in that pattern during the session. Because the interventions, partners often feel greater control
catalyst for this pattern is the therapist’s instruction over their problematic patterns of interaction, so
rather than the usual triggering events, the couple that these patterns are not so disruptive.
is unlikely to engage in the pattern with the usual
level of intensity that occurs during a conflict. The Termination Phase
partners may find it difficult to totally engage in The last phase of IBCT is the termination phase,
the pattern, and laugh at their difficulty in enacting which consists of several sessions spaced at lengthier
284
intervals followed by a final termination session. 100 couples who wanted treatment were excluded
In the clinical trial discussed in the next section, because they were not distressed enough or distressed
for example, couples were allowed a maximum of consistently; a follow-up showed that almost half of
26 sessions that had to take place over the course of those excluded couples later sought couple therapy
no more than a year. However, there is no minimum in the community. Also, approximately 100 couples
number of sessions that couples are required to in which the male partner had engaged in moderate
attend in IBCT. When significant progress has been to severe violence were excluded because they were
made such that the couple can manage issues so deemed unsafe for couple therapy. All partners
well that that there is little of emotional significance were given diagnostic interviews, but were excluded
to discuss during the sessions, and/or when the only for a very few Axis I or Axis II disorders in the
couple wishes to terminate, the termination process Diagnostic and Statistical Manual of Mental Disorders,
should begin. Ideally, the IBCT therapist begins 4th Edition (American Psychiatric Association, 1994),
seeing the couple at lengthier intervals for a few such as psychotic disorders and antisocial personality
sessions as part of this process—every two weeks or disorder. To ensure that couples were given the
monthly, for example—to ensure that the couple can best possible treatment, only licensed, experienced
maintain their progress. Then a termination session therapists were used; all were given extensive training
is held during which the therapist reviews the DEEP before and during the treatment program. Adherence
formulation of the couple’s core concerns again and and competence procedures, as well as ratings of
emphasizes the changes that have been made. The adherence and competence, insured that IBCT and
termination session also involves discussion about TBCT were demonstrably different and competently
how to maintain the changes and how to handles delivered. To assess the long-term and short-term
setbacks. At the end of the session the therapist effects of treatment, multiple measures were taken
assures the couple that they can now manage on during treatment and every 6 months for 5 years
their own, but lets them know that the door is after treatment ended. No additional couple therapy
always open for booster sessions if needed. was offered during the follow-up period.
Measures of relationship satisfaction taken
during treatment indicated a significantly different
RESEARCH ON THE EFFICACY
trajectory of change in TBCT and IBCT. Couples
OF INTEGRATIVE BEHAVIORAL
in TBCT showed immediate positive effects of
COUPLE THERAPY
treatment that than leveled off, whereas couples in
Two small clinical trials and one large two-site IBCT showed consistent improvement throughout
clinical trial have provided data on the efficacy treatment. However, there were no significant
of IBCT. Wimberly (1998) randomly assigned differences between the two conditions at the
17 heterosexual couples to either IBCT delivered in end of treatment: Pretreatment to posttreatment
a group format or a wait-list control group, and the effect sizes on marital satisfaction were d = 0.90
results showed the superiority of IBCT. Jacobson, for IBCT and d = 0.71 for TBCT (Christensen,
Christensen, Prince, Cordova, and Eldridge (2000) Atkins, Baucom, & Yi, 2010). For the first 2 years
randomly assigned 21 heterosexual couples to either after treatment termination, couples generally
IBCT or TBCT, and found that IBCT performed as maintained their treatment gains, but couples in
well as or superior to TBCT. Based in part on these IBCT fared better than couples in TBCT, showing
latter findings, Christensen et al. (2004) randomly significantly greater relationship satisfaction at each
assigned 134 heterosexual couples to IBCT or TBCT; 6-month measurement period. However, during
approximately half the couples were treated in the remaining 3 years of follow-up, couples in both
Seattle, WA, and the other half in Los Angeles, CA. conditions lost some of their treatment gains, and
In order to provide a challenging test for these relationship satisfaction in the two groups merged so
couple therapies, only seriously and chronically that there were no significant treatment differences.
distressed couples were included. Approximately At treatment termination, 70.4% of IBCT couples
285
and 60.6% of TBCT couples showed clinically Eldridge, Baucom, & Christensen, 2005; Marín,
significant improvement (reliable improvement or Christensen, & Atkins, 2014). Finally, couples with
recovery). However, at 5-year follow-up, only 50% children showed less conflict over child-rearing and
of IBCT couples and 45.9% of TBCT couples showed some improvement in child adjustment, although
clinically significant improvement, with 25.7% of the latter was not maintained over follow-up (Gattis,
IBCT couples and 27.9% of TBCT couples divorcing. Simpson, & Christensen, 2008).
None of these differences between conditions in Several demographic, intrapersonal, and inter
percent of clinically significant improvement were personal variables were examined as possible
statistically significant. Pretreatment to 5-year predictors of both pretreatment satisfaction and
follow-up effect sizes on relationship satisfaction for change in satisfaction. Although several variables,
those couples who remained together were strong: particularly interpersonal variables, were associated
d = 1.03 for IBCT and d = 0.92 for TBCT. The with initial satisfaction, very few consistently
authors concluded that for many of these seriously predicted change in satisfaction, particularly at long-
and chronically distressed couples, some booster term follow-up. Higher relationship commitment
sessions might be needed to maintain treatment and longer length of marriage were the only variables
gains, including the differences between conditions predictive of long-term positive outcome across
that existed during the first 2 years of follow-up treatment conditions (Atkins, Berns, et al., 2005; B. R.
(Christensen et al., 2010). Baucom, Atkins, Rowe, Doss, & Christensen, 2015).
Although relationship satisfaction and stability Two potential mechanisms of change were
are considered the crucial outcomes for couple examined: change in the frequency of behavior that
therapy, the Christensen et al. (2004) clinical couples targeted as important, and change in the
trial also assessed other important variables. Self- acceptance of that behavior. Targeted behaviors could
reported communication showed improvement be either positive behaviors that a partner wanted
during treatment and maintenance for 2 years of increased or negative behaviors that a partner wanted
follow-up. Observational measures of communication decreased. Change would therefore mean that the
also showed improvement during treatment, with targeted behavior actually increased or decreased
TBCT couples showing greater improvement appropriately, and acceptance would mean that
in communication by the end of treatment and partners were more comfortable with the occurrence
IBCT couples showing better maintenance of of the behavior. Both change and acceptance were
communication gains by the 2-year follow-up linked with positive outcome in both treatments,
(K. J. W. Baucom et al., 2011; Sevier et al., 2008). with change more strongly linked with outcome
Observational measures of communication were early in therapy and acceptance more strongly linked
not included at the 5-year follow-up. Self-reported with outcome later in therapy. As predicted, TBCT
measures of individual functioning, specifically a generated greater changes in frequency of targeted
mental health index and a measure of psychological behavior, whereas IBCT generated greater changes in
symptoms, varied in expected ways over time with acceptance of targeted behavior (Doss, Thum, Sevier,
marital satisfaction. Atkins, & Christensen, 2005).
Particular subsets of couples in the clinical trial Trained observer ratings of video-recorded
were also examined across treatment conditions therapy sessions throughout both IBCT and TBCT
to evaluate whether the treatment was effective for were collapsed into two broad categories: positive
different types of couples. Couples experiencing behaviors, such as collaboration and positive effect,
low-level violence benefited from treatment without and negative behaviors, such as blame and negative
any escalation of violence (Simpson, Atkins, Gattis, pressure to change. Analyses of these data revealed
& Christensen, 2008); couples experiencing infidelity a boost–drop pattern for couples in TBCT, in which
were at greater risk of separation than couples without increases in constructive behavior (more positive
infidelity, but those who stayed together showed as behavior and less negative behavior) early in therapy
much benefit as those without infidelity (Atkins, were followed by decreases in these behaviors later,
286
but a drop–boost pattern for couples in IBCT, in which seen to be an additional benefit of the IBCT model.
decreases in constructive behavior early in therapy VA serves a broad population of veterans, but most
were followed by increases in these behaviors later in are middle age or older, and many have longstanding
therapy (Sevier, Atkins, Doss, & Christensen, 2015). relationship and mental health challenges. A model
This pattern probably reflects the different sequence that could foster acceptance as one strategy to reduce
of intervention in the two treatments. TBCT starts relationship discord was seen as consistent with the
out with a focus on improving positive behavior needs of this population.
and delays discussing difficult issues until later in A formal training program in IBCT for licensed
therapy, while IBCT begins with whatever concerns VA mental health clinicians was initiated in 2010.
the partners wish to focus on, which is often their Licensed mental health clinicians from throughout
difficult issues. the VA system were invited to apply for the program,
consisting of 3 to 4 days of intensive face-to-face
IBCT training, which emphasizes both didactic
IMPLEMENTATION OF INTEGRATIVE
and experiential learning. The intensive training
BEHAVIORAL COUPLE THERAPY
is followed by a 6- to 8-month formal consultation
There have been two major efforts to move beyond period, in which trainees see a minimum of two
efficacy studies and examine the effectiveness of couples for IBCT and attend weekly small group calls
IBCT in the community. during which they are provided feedback on their
work by expert IBCT consultants who have listened
Integrative Behavioral Couple Therapy to audiotapes of their therapy sessions and rated
Rollout in the U.S. Department them using a standardized fidelity and competence
of Veterans Affairs rating scale. Program evaluation data on veteran and
Family problems and couple distress are among partner couple satisfaction are routinely collected
the most common precipitants of veterans seeking throughout the treatment, and application to the
mental health treatment (Batten et al., 2009; Khaylis, program is competitive.
Polusny, Erbes, Gewirtz, & Rath, 2011; Meis et al., To date, 12 VA IBCT trainings have been held,
2013). To meet the increasing need for couple including 412 trainees; each training typically
and family counseling within VA, a large national included approximately 30 licensed mental health
clinician training initiative was launched in 2006. clinicians. These trainees have engaged and collected
The goal of the training program was to provide VA at least baseline data on 692 veteran couples. Thus
mental health line staff with expertise in evidence- far, 82% of the eligible trainees (n = 288) have success
based couple and family interventions nationally fully completed the consultation and achieved a
throughout the VA system. good level of proficiency in IBCT, as reflected by the
Several criteria were used to select the couple fidelity score ratings of their sessions. Couples who
therapy intervention to be disseminated in VA clinics. attended more than just the initial IBCT session
The intervention needed to have a robust evidence attended an average of nine sessions, including the
base, an accessible manual, and be consistent with four assessment sessions.
the foundational training of most VA mental health Veteran couples achieve benefits from attending
clinicians, which was primarily cognitive behavioral. IBCT. For example, data from the couples seen by
Further, the developer of the intervention had to be the last two cohorts of trainees (n = 60) indicate
willing to collaborate closely with VA on the project significant improvements in couple satisfaction
to assure that the treatment met the unique needs for each partner, as measured on the CSI-16 from
of veterans. A review of the scientific literature on baseline to Week 4 and to Week 8, with within-
couple therapy for relationship distress suggested treatment effect sizes ranging from .31 to .48,
that IBCT might most closely meet the suitability and longer courses of treatment being associated
criteria for dissemination in VA. The integration of with greater improvements in martial satisfaction.
acceptance and behavioral change strategies was These data are particularly impressive in that one
287
or both partners in almost all of those couples has one or two core problems on which they wish to
one or more diagnosed mental disorder. These data focus throughout the remaining program. During
suggest IBCT can achieve benefits even in real-world the understand phase, partners develop a DEEP
settings with relatively less experienced therapists. analysis of their core issue or issues and then share
this understanding with each other in a conversation
Online Version of Integrative at the end of the phase. Finally, in the respond
Behavioral Couple Therapy phase, partners receive guidance on acceptance
Relationship distress is widespread: About one third and change, on communication strategies, and on
of married partners are distressed at any given time problem-solving strategies specific to their particular
(Whisman, Beach, & Snyder, 2008), and about half of issue. Partners separately develop a plan for altering
first marriages end in divorce (Copen, Daniels, Vespa, their usual pattern of communication, problem solve
& Mosher, 2012). Although evidence-based couple their specific issues, and then come together and
therapies have shown that they can reliably improve share their ideas with each other with the goal of
relationship satisfaction, only a small portion of creating a joint plan. At four points in the program,
distressed couples seek out therapy. A recent survey partners talk by phone or videoconference for about
indicated that only 19% of couples have sought 15 minutes with a staff coach who answers questions
couple therapy to improve their current relationship about the program, encourages partners in their
and only 37% of divorced couples reported seeking progress through the program, and helps them with
couple therapy prior to ending their marriage any difficulties. These “coach calls” are carefully
(Johnson et al., 2002). Presumably because of scripted, are done by nonprofessionals, and are
convenience and cost, people are more interested in designed to avert the conversation from becoming
seeking relationship help from relationship-oriented couple therapy.
websites than from couple therapy (Georgia & Doss, A nationwide clinical trial was conducted on this
2013). If an online program could reliably improve program (Doss et al., 2016), in which 300 distressed,
relationship satisfaction, it may dramatically increase heterosexual couples were randomly assigned to
the reach of couple intervention. either the OurRelationship program or to a 2-month
With this notion of expanded reach in mind, wait-list control group. These couples were roughly
Brian Doss, Andrew Christensen, and their representative of the U.S. population in terms of
graduate students developed an online version race, ethnicity, and education. Eighty-six percent of
of IBCT (Doss, Benson, Georgia, & Christensen, the couples completed the program and rated their
2013), www.ourrelationship.com, supported by satisfaction with the program high. Comparisons
a grant to Brian Doss from the National Institute between treatment and control groups indicated
of Child Health and Human Development. The that the OurRelationship program led to significant
program requires approximately 6 to 8 hours of increases in relationship satisfaction (d = 0.69) as
each partner’s time and consists of questionnaires, well as improvements in individual functioning,
exercises, animation, video examples, audio, such as reduced depressive symptoms (d = 0.50) and
text, and graphics tailored to partners’ responses anxiety symptoms (d = 0.21) and increased perceived
and designed to engage partners and maintain health (d = 0.51), work functioning (d = 0.57), and
their interest. The program consists of three quality of life (d = 0.44). The program is being
phases described by the acronym OUR: Observe, adapted for low-income families and a clinical trial
Understand, and Respond. In each phase, partners with those families is underway.
work individually through most of the phase and
then come together toward the end of the phase for
CONCLUSION
a conversation directed by the program. During the
observe phase, partners complete questionnaires Although it emerged from traditional and cognitive
about their relationship, get feedback about their behavioral couple therapies, IBCT is different from
responses, and then come together to decide on those therapies in its theoretical emphasis, its
288
assessment and evaluation protocol, and its interven Christensen, A., Atkins, D. C., Baucom, B., & Yi, J.
tion strategies. This chapter has documented these (2010). Marital status and satisfaction five years
following a randomized clinical trial comparing
differences and in so doing has described IBCT. traditional versus integrative behavioral couple
The chapter also discussed the body of efficacy and therapy. Journal of Consulting and Clinical Psychology,
effectiveness research that validates the positive 78, 225–235. http://dx.doi.org/10.1037/a0018132
impact of IBCT. IBCT has taken exciting new Christensen, A., Atkins, D. C., Berns, S., Wheeler, J.,
directions, extending its reach through dissemination Baucom, D. H., & Simpson, L. E. (2004). Traditional
versus integrative behavioral couple therapy for
in the U.S. Department of Veterans Affairs and significantly and chronically distressed married
through an online program. Further, as noted, this couples. Journal of Consulting and Clinical
online program is being adapted for low-income Psychology, 72, 176–191. http://dx.doi.org/
couples and a major clinical trial with these couples 10.1037/0022-006X.72.2.176
is being conducted. Christensen, A., & Heavey, C. L. (1999). Interventions for
couples. Annual Review of Psychology. Palo Alto, CA:
Annual Reviews.
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Chapter 17

tries to fill in the pieces of a DEEP analysis of these Feedback Phase

During these discussions, the IBCT therapist might secondarily.

of change in constructive couple behavior during

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