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ntegrative Behavioral Couple Therapy (IBCT)is a relatively new approach to couple therapy that hasgarnered promising empirical support and is current-ly the focus of a major clinical trial on the outcomeof couple therapy being conducted at UCLA and theUniversity of Washington. IBCT was developed byAndrew Christensen of UCLA and the late Neil S.Jacobson of the University of Washington. Sometimesreferred to as Integrative Couple Therapy, thisapproach is integrative in two senses. First, it inte-grates the twin goals of acceptance and change as pos-itive outcomes for couple therapy. Also, it integratesa variety of treatment strategies under a consistentbehavioral theoretical framework.

There are three important clinical features of IBCT.First, it is driven by a case formulation, which is basedon a thematic analysis. Second, it focuses on emo-tional acceptance as a basis for concrete change. Third,it emphasizes evocative rather than prescriptive inter-ventions. These features will be discussed throughoutthe treatment descriptions.

The first three sessions in IBCT are devoted to aclinical assessment of the couple, which leads to a caseformulation of the couple. An initial conjoint sessionfocuses on their presenting problems and relationshiphistory, emphasizing the attractions that brought themtogether. The second and third sessions are individ-ual sessions with each partner. In these sessions, moreinformation on the presenting complaints and an indi-vidual history of each spouse is obtained. In these sessions, IBCT therapists try to specify the most impor-tant problems the couple is facing, to examine thetheme or themes that underlie these problems, and toidentify the context that makes these problems under-

standable. All of this information leads to a case for-mulation of the couple’s problems.

In the fourth session, IBCT therapists share withthe couple a formulation of their problems. One canthink of this formulation as a new story about theproblem. Typically, a couple comes to therapy withtwo stories about the problem—one generated by eachpartner who emphasizes the faults in the other. Theformulation provides a single unified story that takesinto account both partners’ experiences and puts themtogether in a non-blaming framework.

A formulation consists of several components.First, there is a difference or seeming incompatibilitybetween partners. As an example, let us consider acommon difference between partners—closeness.

Joan wants more contact, connection, and communi-cation with her husband John, who prefers a connec-tion that involves less contact and leaves more roomfor independence. Second, there are vulnerabilities inone or both partners that provide emotional fuel forthis difference. If Joan is sensitive about abandon-

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A N D R E W C H R I S T E N S E N , P H D

Couple Therapy

IBCT therapists may teach the

couple communication training

or PROBLEM SOLVING to

help them handle their problems

more effectively and directly.

INTEGRATIVEBEHAVIORAL

I

YSTEMS • PSYCHODYNAMIC • OBJECT RELATIONS • INSIGHT-ORIENTED COUPLE THERAPY • RELATIONAL THERAPIES TODAY • GESTA

ment, or if John is vulnerable to beingrestricted or constrained in any way,then this common difference on close-ness may be uncommonly emotional forthem. These vulnerabilities typicallycome from each partners’ experiences intheir family of origin, but may also comefrom more recent experiences, such asexperiences in a previous marriage.Third, each partner tries to cope withthese differences in ways that seem rea-sonable, but often unintentionally exac-erbate the stress and polarize their dif-ferences. For example, John maywithdraw from Joan in order to achievethe level of independence with which heis comfortable. However, this with-drawal increases Joan’s anxiety so thatshe pursues, criticizes, and makesdemands on John, who, out of anxiety,withdraws further from Joan. A viciouscycle of withdrawing and demandingthen develops between the two of them.Finally, the two may experience a vari-ety of negative emotions that lead themto feeling “stuck” and “trapped.” Theharder they try, the worse the problemgets. They feel desperate, but hopelessto change the situation.

There are other issues assessed dur-ing the evaluation period and discussedin the feedback session. For example,individual diagnoses such as substanceabuse or dependence and depression areassessed. Relationship problems such asaffairs or violence are assessed. It isbeyond the scope of this short descrip-tion to discuss these special issues, butthe more detailed references cited belowcan provide further information aboutthese problems.

After the feedback session, the treat-ment formally begins, guided by the for-mulation. The content of the treatmentusually concerns recent, emotionallysalient incidents, both positive and neg-ative. However, upcoming events thatare of concern, or broader issues of cur-rent concern, are also common topics.These incidents and issues that are thefocus of therapy are usually directly orindirectly related to the formulation. Forexample, an incident around John’s leav-ing for a short business trip would cer-tainly be a focus for therapy, while an

argument over Joan being late for alunch meeting would not be a focus fortherapy, unless it were indirectly relat-ed to their formulation. However, theformulation is not a static, conceptualframework for viewing the couple. Asthe therapist and the couple worktogether to reach increasingly greaterunderstanding of their issues, they may

alter and enrich their formulation—or“story”—of their concerns.

There are three primary treatmentstrategies in IBCT that are meant to pro-mote emotional acceptance: empathicjoining, unified detachment, and toler-ance building. In the first intervention,IBCT therapists try to create an empath-ic connection between the partnersaround the very issues that drive themapart. Partners are liable to first discusstheir problems by expressing hard feel-ings and thoughts that present the selfas strong, and shower accusations onthe partner (“I am tired of being con-trolled by you,” “I am resentful of howyou have taken advantage of me”).These accusations usually create sepa-ration and defensiveness. IBCT thera-pists look for the softer, more vulnera-

ble feelings and thoughts that may alsoexist alongside the harder feelings andthoughts. IBCT therapists may probe forfeelings of disappointment, neglect, andhurt that may lie behind the anger andresentment. However, even these softerfeelings may be presented in an accusa-tory way—“You always hurt me.” So,it is a challenge for the therapist to cre-ate a safe environment where partnerscan voice their deepest hurts and fearswithout fear of attack. For example, thetherapist would want to create an envi-ronment where Joan could openly dis-cuss her fears of abandonment and Johncould openly discuss his fears of beingcontrolled. By the therapist modeling anempathic approach to each partner, theymay begin to take a similar approach toeach other.

The second treatment strategy, aimedat increasing acceptance, is “unifieddetachment.” Whereas “empathic join-ing” focuses on a close, emotional lookat the problems and each partner, uni-fied detachment takes a more distant,intellectual, and objective look. IBCTtherapists engage the couple in adescriptive analyses of their problemthat may emphasize the context inwhich the problem develops, thesequence of actions each partners goesthrough, the primary events that trig-ger escalation, and the efforts at recov-ery and reconnection that each makes.For example, the therapist might workwith John and Joan to describe the context in which a particular problemarose (an incident of parting, whenJohn was to leave on a business trip),

32 Family Therapy magazine

IBCT therapists look for

the softer, more vulnerable feelings and thoughts

that may also exist alongside the harder feelings and

thoughts. IBCT therapists may probe for feelings of

DISAPPOINTMENT, NEGLECT, ANDHURT that may lie behind the anger and resentment.

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the triggering events (John failed to tellJoan of the trip until right before it happened; Joan “blew up” at Johnabout the trip), the sequence of eventsthat made up the incident (they argueduntil John left in a huff), and theirefforts at recovery and reconnection(e.g., John called later that day and triedto “make nice”).

A third strategy for promotingacceptance is tolerance building. Thereare a number of different aspects of tol-erance building, but one of importanceis to enact negative behavior in the ses-sion. Since it is impossible for partnersto completely remove negative behaviorthat triggers emotional reactions in theother, it is sometimes helpful to havepartners enact these negative behaviorsin session. For example, Joan may enacta “blow up” at John or John might enacta “late notification of an upcomingtrip” to Joan. These enactments areoften occasions for empathic joining ifthe enactments arouse similar emotionsto the real events (e.g., John gets defen-sive at Joan’s reenactment of a “blowup”) or are occasions for unified detach-ment if the enactments lead to a moredetached look at the problem (e.g., Joanand John both laugh at John’s effort tostage a “late notice”). However, theenactments serve as a reminder for thecouple that these negative actions will likely occur and give them someopportunity to experiment with howthey handle them.

These three strategies of empathicjoining, unified detachment, and toler-ance building are designed to increasepartners’ emotional understanding andacceptance of each other. They are notdesigned to directly change any of theoffending behaviors that partners mayhave listed at the beginning of treatment.However, emotional understanding andacceptance often lead to spontaneouschanges in problematic behavior. As Johncomes to understand and accept Joan’sdifficulties with abandonment, he mayalter his behavior in ways that do notarouse her fears so intensely. Similarly, asJoan comes to understand and acceptJohn’s difficulties with control, she mayalter her behavior in ways that do not

arouse his fears so intensely. Thus, impor-tant changes may follow from the focuson acceptance.

These three strategies are primarilyevocative rather than prescriptive. Thatis, they are designed to evoke a differ-ent experience of the problem ratherthan to prescribe different actions thatthe partners should take. The IBCTtherapist does not tell each partner whathe or she should do differently. In fact,in tolerance building, the therapist maytry to get the partner to enact the verybehavior that is problematic. Eventhough the focus is on acceptance, theIBCT therapist does not tell each part-ner what should be accepted. The ther-apist is trying to create conditions thatwill lead to greater acceptance.

If these evocative strategies thatfocus on greater acceptance are not suf-ficient to bring about the desiredincrease in relationship satisfaction, theIBCT therapist may also use some ofthe well-know, change-oriented, pre-scriptive strategies of traditional behav-ior therapy. IBCT therapists may teachthe couple communication training orproblem solving to help them handletheir problems more effectively anddirectly. Also, the therapist may havethe partners specify positive events thateach could do to increase the satisfac-tion of the other and may encouragethem to engage in these positiveactions—these are familiar strategies ofbehavioral approaches of which you areprobably already aware.

Two empirical studies have beencompleted on IBCT and a major clini-cal trial is now in its follow-up stages.A dissertation by Wimberly in 1997showed that IBCT administered ingroups was more effective than a waitlist control group. A small study byJacobson and colleagues in 2000showed that IBCT was at least as effec-tive as traditional behavioral coupletherapy for distressed couples. In thecurrent, randomized clinical trial, 134chronically and seriously distressedcouples were treated with either IBCTor TBCT in Los Angeles or Seattle.Almost 100 couples wanting treatmentwere excluded because they did not

meet the criteria of chronic and seriousdistress (they were too happy for thestudy). Of this difficult group of 134couples, 71% of IBCT couples showedclinically significant improvement orrecovery at the end of treatment com-pared to 59% for TBCT couples. Duringa two-year follow-up period, most cou-ples in IBCT continued to show greaterimprovement than couples in traditionalbehavioral couple therapy. This follow-up data is based on a majority of the cou-ples, but not all of them, as some havenot reached the 2-year follow-up point.

For more information on IBCT, consult Jacobson and Christensen’sAcceptance and Change in CoupleTherapy (1998), which is the therapist’smanual for conducting IBCT, and alsoReconcilable Differences (2000), whichis a book for couples to read as they gothrough the treatment. ❍

ANDREW CHRISTENSEN, PHD,

is with the department of

psychology at the University

of California, Los Angeles.

He is the co-developer of

Integrative Behavioral Couple Therapy.

R E F E R E N C E S

CHRISTENSEN, A., & Jacobson, N. S. (2000).

Reconcilable differences. New York:

Guildford.

JACOBSON, N. S. & Christensen, A. (1998).

Acceptance and change in couple therapy: A

therapist’s guide to transforming relationships.

New York: Norton.

JACOBSON, N. S., Christensen, A., Prince, S. E.,

Cordova, J., & Eldridge, K. (2000). Integrative

behavioral couple therapy: An acceptance-

based, promising new treatment for couple

discord. Journal of Consulting and Clinical

Psychology, 68(2), 351-355.

WIMBERLY, J. D. (1998). An outcome study of

integrative couples therapy delivered in a group

format (Doctoral dissertation, University of

Montana, 1997). Dissertation Abstracts

International: Section B: The Sciences &

Engineering, 58(12-B), 6832.

An earlier version of this article appeared in

Briefings, a news magazine of the California

Psychological Association, Number 160,

April 2003.

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