Chapter 3 Integrative Behavioural Couple Therapy 1
Theory of therapeutic change 2
Structure of IBCT 3
Role of the therapist 3
Assessment and treatment planning 4
Functional analysis 4
Case Formulation 4
Theme 4
Polarization 4
Guiding questions 4
The first conjoint interview 4
Individual Interviews 5
Feedback Session 6
Goal setting 6
Processes, techniques and strategies of IBCT 7
Acceptance through empathic joining 7
Acceptance through unified detachment 7
Tolearance building 7
Faking negative behaviour at home between sessions 8
Chapter 3 Integrative Behavioural Couple Therapy
This grew out of Tradition BCT as it was found that TBCT
wasn’t working in many circumstances and what was missing was acceptance.
Acceptance isn’t resignation.
IPCT proposes that all couples will go through periods of
differences and disagreements. Distress is caused by the unhelpful way couples
respond to these disagreements.
Differences in the early day may have been seen as attractive. Differences cause problems when they spring
from vulnerabilities rather than preferences. These vulnerabilities may be
direct, or reminders of unpleasant things.
Three destructive patterns frequently characterise couples
conflict over differences
1.
Mutual coercion
2.
Vilification
3.
Polarisation
Couples deteriorate when they reduce their ability to
accept, compromise and tolerate their differences.
Differences that were once attractive are sought to be
changed.
Mutual coercion is where unhelpful behaviour, yelling,
withdrawal, criticising, is reinforced by the other and thus kept going, as
there could be intermittent reinforcing the behaviour can get more extreme.
Mutual coercion moves from a sense of my partner is
different to my partner is deficient and vilification happens.
So different that is valued, difference devalued, made worse
relationally then vilified and a desire is made to reform the other. Then you
get polarisation where the behaviour that the partner is already proficient in
becomes more accentuated and the deficiency of the other more noticed.
Happier couples confront difference with acceptance and
tolerance.
Acceptance is faced with an aversive stimulus to neither,
avoid escape or destroy. For a couple it
means being faced with difference and not going into a mutual coercion,
vilification and polarisation.
Theory of therapeutic change
IBCT is behavioural therapy. It integrates strategies for
change and strategies for acceptance. Views behaviours and change as a function
of the context in which that behaviour occurs. TBCT aims to change the context
through changing the agents. IBCT
focusses on the recipient of behaviour as on the agent.
So the context can change through changing the agent or the
recipient of behaviour for three reason. Firstly IBCT believes there are
unsolvable problems in a relationship A desires 1 from B but B won’t deliver.
In this area acceptance and tolerance are the way to improve things. Secondly pressure
to change may in these instance contribute to the maintenance of the problem.
When the difference is accepted then a partner may not be so assertive of it.
Third often the reaction to an offending behaviour is as problematic to the
relationship as the original behaviour
TBCT theory is rule governed behaviour: a rule is given and
then reinforced depending on the judgement of the alignment between rule and
behaviour. This is arbitrary reinforcement as the rule is abstract from its
environment.
IBCT theory is contingency shaped behaviour, i.e. the natural
consequences of behaviour are reinforcing, so I do a nice thing to my partner,
I feel good in the doing of it and they give me praise or are more intimate to
me.
Rule governed behaviour takes effort, contingency shaped
behaviour is natural and spontaneous.
TBCT uses rules governed behaviour, Behavioural exchange and
communication and problem solving techniques. BE couples decide on behaviours
that can improve their relationship in CPT learn good rules of communication, e.g.
use I rather than you, summarising and paraphrasing what the other says.
Rule governed behaviour feels very different, less natural
than natural contingencies. A kiss in the morning as an expression of feeling,
feels quite different to following a rule to express more intimacy. Contingency
shaped behaviour vs rule governed behaviour.
Functional areas are more amenable to RGB emotional goals, e.g.
be more interested in me, more sex, are amenable to CSB.
IBCT aims to make changes in the couple’s natural context.
So in session instead of teaching not to criticise, the therapist models validating
each partners perspective. Instead of teaching to be more open, the therapist.
The therapist may enquire about softer feelings, sad, hurt, lonely as opposed
to the harder feelings anger, hostile
Therapist continually tries to change context not give
rules.
Couple-therapist relationship essential to IBCT
Structure of IBCT
26 * 50 minute sessions
3 evaluation sessions
IBCT assumes that problems and differences are part of life,
we don’t wait to terminate until all problems are resolved.
Therapy success= patterns discussing more calmly,
understanding the others perspective and less distressed behaviour
Acceptance orientated sessions focus on 4 areas:
1.
Discussion of the basic differences between
partners and their patterns of interaction
2.
Discussion of upcoming events that could provoke
conflict
3.
Discussion of recent negative events
4.
Discussion of recent positive event
The important things to look at are relational themes.
Role of the therapist
IBCT therapists have a plan but nothing is more important
than the couple’s most recent statement
Therapist as teacher, skills of communication, paraphrasing,
summarising, using I
Therapist maintains the case formulation via good and
compassionate listening
Therapist offering genuine empathy and understanding to each
partner
Therapist as mediator
Therapist models taking a compassionate, non-confrontational
validating response to each partner
Therapist highlights the function of behaviours
Therapist as historian, relating early life experiences,
early couple experiences to current behaviour
Therapist uses language that hits home.
Assessment and treatment planning
4 sessions. One with each partner, one with the couple and
feedback with the couple.
Functional analysis
What is the stimuli that gives rise to behaviour? What is
the effect of the behaviour? The functional analysis can deal with abstracted
types of behaviour so that it can apply to other situations.
Case Formulation
This comes out of the functional analysis and has three
parts
1.
Theme
a.
Class of
behaviours with the same function
2.
Polarisation process
a.
3.
Mutual trap
Theme
Standard themes:
1.
Closeness and distance, one partner seeks
greater closeness the other greater distance.
2.
Control and responsibility
3.
Artist vs scientist, spontaneity vs logic and
planning
When you evaluate a theme, it’s also useful to find out what
in their early experience makes this theme so powerful
Polarization
When arguments come up around a theme, and the attempt is to
reduce the difference. In this process of trying to reduce the difference it
exaggerates this and you get polarisation. As differences are tried to be
changed they become more entrenched, and seen to be intractable and as the
other tries to change you and you don’t like it you dig your heels in. One partner can’t change the other, the other
partner resists change. Both partners feel trapped and hopeless.
Guiding questions
1.
How distress is this couple
2.
How committed are they to the relationship
3.
What issues divide the couple
4.
Why are these issues such a problem for them
5.
What are the strengths holding them together
6.
What can treatment do to help?
The first conjoint interview
What are the problems?
What is the process that happens when a problem arises?
Couples history=what was it like to start off with, what
were the enjoyments\pleasures. How did you act if you had problems? How is it different to now?
Early part of the relationship
Where did you meet?
What was your courtship like?
What was your relationship like before problems began
What initially attracted you to one another?
Often initial things that attracted the partner is now
something that causes distress. Partners can often be attracted to opposites,
things they lack, which at time can be complimentary to how they are, and at
other times these opposites may clash and grate. So a relationship may benefit
from the colour of emotional reactivity and the stability of being stoic, but
then the stoic may grate on the emotionally reactive.
What parts of your relationship worked well when you were first together
What parts of your relationship worked well when you were first together
What aspects of your relationship were you most proud of?
How would your relationship be different if the current
problem no longer existed?
What’s your relationship like now when you are getting on?
Session 1 assignment
Reconcilable differences from Jacobsen and Christensen
Individual Interviews
Confidentiality: unless you tell me otherwise I may share
information in this session in the conjoint session. If one partner tells the
therapist something in confidence, e.g. having an affair, then the therapists
asks the partner to resolve or disclose this to the other partner otherwise
therapy can’t continue. I have responsibility to be honest to each partner.
Four areas for assessment
1.
Relationship history
2.
Commitment to relationship
3.
History of family or origin
4.
Relationship history
5.
Current relationship
a.
How do you contribute to the current problem
b.
What changes do you need to make to improve the
relationship
6.
Extra marital relationships
a.
Emotionally significant
b.
Sexual
7.
Mental health history
8.
Substance abuse history
Keep eye out for interaction patterns, conflictual themes. Assess
relational style, parents’ marriage, relationship with mum and dad.
Feedback Session
This follows directly from the original one to one 6
questions. So the therapist combines the two individual sessions and feeds back
for the relationship.
So feedback
1.
Levels of distress
2.
Levels of commitment
3.
Themes that divide the couple
4.
Why these theme provide such a problem:
including mutual coercion, vilification and polarization
5.
Couples strengths
6.
What treatment can do
Contra indicators
1.
Domestic abuse
a.
Battering: use of violence to subjugate or
intimidate
b.
Couple therapy can be inflammatory so if low
level aggression without injury use a no violence clause
2.
Extra marital affair
3.
Individual psychopathology
Assessing domestic abuse
1.
Can you describe an recent argument
2.
How do you express anger
3.
Do arguments ever get out of control
4.
Do arguments ever become physical
5.
Do arguments ever involve hitting, pushing,
shoving or the use of weapons
a.
Written reports reveal more than verbal
Goal setting
Three broad goals of
1.
Understanding
2.
Acceptance
3.
Collaboration
Staying together can often put pressure on one partner to
the other to change, which can maintain the couple’s distress.
Processes, techniques and strategies of IBCT
Three types of strategies
1.
Acceptance
a.
Empathic joining
b.
Unified detachment
2.
Tolerance
a.
Let go of the effort to change the other
3.
Change
a.
Behaviour exchange
b.
CPT: communication and problem solving training
Acceptance through empathic joining
Both partners are in pain and they express it through
accusation and blame. This exacerbates their pain. Pain plus accusation equals
marital discord, pain minus accusation equals acceptance. Empathetic joining,
means in a disagreement to understand both sides in terms of their history,
each in their own logic makes sense and isn’t an attack on the other.
Another strategy is to encourage soft rather than hard
disclosure. Hard emotions are anger, resentment and put one in a dominant
position to the other. To find this out, ask what other feelings are around
apart from anger. Listen for the part of what they say that refers to the hurt
that moves quickly onto anger. Sometimes express what the therapist might feel.
Sometimes it can be helpful to point out mutual vulnerabilities.
Soft and hard are functional descriptions, so whilst
sadness, upset generally function softly it’s not always the case, e.g. when
the husband gets angry about the wife’s depression. The wife’s sadness might be
making her the dominant one, the person to be looked after.
For couples to be more empathic it’s not always soft emotions
that get there, softness is a function not an absolute.
Acceptance through unified detachment
Get distance from the problem by naming it, referring to it
as an it with its own being. This helps deescalate blame and accusation. This helps detached and descriptive
discussions rather than emotionally laden ones.
Unified detachment can also be helped by getting the couple to look for
patterns in their behaviour, or in certain incidents. To become scientists, to
become psychologists
Likewise to compare and contrast incidents, give them both a
history and a context. You might in this area refer to the client as the
relationship and get both of the couple to help and understand. Imagine your
problem is sitting in a chair. Also during between session arguments they can
nominate a chair for the therapist of things they would like to say but find
difficult to say to their partner.
Tolerance building
Let go of fruitless struggles to change the other. These are
used where the therapist doesn’t believe the struggle offers the ability to get
greater intimacy for the couple. Tolerance is focussed on behaviours which are
not destructive and are not likely to change.
Pointing out positive aspects of negative behaviour
So what is a positive aspect of your partner’s negative behaviour?
In the relationship does the behaviour not balance out other aspects? What
happened if the partner was like you? The therapist should look at the function
of behaviour not some silver lining.
Practicing negative behaviour in the therapy session
Aim here is to desensitise one partner to the others
behaviour.
Faking negative behaviour at home between sessions
Do the negative behaviour only when you don’t feel like
doing it. The other partner won’t know
if it’s real or faked, but after faking it for a couple of minutes both debrief
to see what they noticed and what the consequences of behaviour are.
Promoting tolerance through self-care
I.e. don’t rely entirely on your partner to provide your
needs but rather look to care for yourself.
Change techniques
Behavioural exchange
People are better at changing themselves than other
people. Write down a list of behaviours
that would bring pleasure to the other. These behaviours should be positive,
specific, behavioural and observable. By
positive this means do something that bring pleasure rather than takes away
pain. Eventually partners can ask for
additions to the list of their partner.
Do this at home bring into session and read out the other
partner rates the amount of pleasure this would give. Ask the couple if they
would like to do any of them during the week, or put aside a specific caring
day when they aim to do a few.
Communication\problem solving
Communication is about getting partners to level with
feelings, edit out unnecessary negative comments and to validate one another.
Communication
Validate, levelling and editing
1.
When talking about the other, to avoid blame,
always use I
2.
Avoid generalising
3.
Stay specific
4.
The listener summarises what has been said to
the speakers agreement then adds their bit
Problem solving
Take a collaborative approach
1.
Accept their role in problem
2.
Define problem clearly
3.
Look for solutions
a.
Brainstorm
4.
Decide on solution
5.
Contract with each other to implement
Sequencing guidelines
Use more acceptance than tolerance and change techniques.
Start with empathic joining and unified detachment, when
couples appear stuck use tolerance techniques.
End the cycle of persist and resist.
Acceptance and tolerance techniques can lead more to change
techniques. Sometimes change techniques can stall in the resist and persist
cycle and therefore more acceptance is needed. If there’s strong collaboration then change
interventions are more appropriate, if there isn’t collaboration then
acceptance first and then tolerance.
BE is more directive, empathic joining and unified
detachment teach couples new skills that can be used in their environment to
change the interactions.
Empathic joining is about both partners feeling heard
Unified detachment, this can be helped by empathic joining
to start off with. It can also show a
shared problem
Tolerance:
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