Principle‐Based Integrative Therapy with Couples: Theory and a Case Example

The Principle‐Based Integrative Therapy (PBIT) framework harnesses the principles of change underlying each theoretical model within integrative couple therapy treatments. PBIT has commonalities with other integrative approaches, and additional advantages stemming from its four tenets that guide therapists in combining strengths across models and overcoming each of their deficiencies. Tenet 1 advises that each model adds a core principle or mechanism of action that other models do not automatically address. Tenet 2 focuses on how techniques of one model may actualize the principles of other models. Tenet 3 ensures complementarity and a lack of conflict across principles. A case study and common case considerations are presented to illustrate how Tenets 1–3 can work in integrating Cognitive‐Behavioral, Multicultural, and Emotionally Focused Therapy models in working with a couple. Finally, Tenet 4 advocates for the use of models and empirically supported principles that also have received empirical support with diverse populations. Prerequisites and training implications for PBIT, and future clinical and research directions to further the utility of PBIT are discussed.     

Common factors of change in couple therapy

Though it is clear from meta-analytic research that couple therapy works well, it is less clear how couple therapy works. Efforts to attribute change to the unique ingredients of a particular model have consistently turned up short, leading many researchers to suggest that change is due to common factors that run through different treatment approaches and settings. The purpose of this article is to provide an empirically based case for several common factors in couple therapy, and discuss clinical, training, and research implications for a common factors couple therapy paradigm. Critical distinctions between model-driven and common factors paradigms are also discussed, and a moderate common factors approach is proposed as a more useful alternative to an extreme common factors approach.     

Benchmarking Community-Based Couple Therapy: Considering Measurement Reactivity

Couple therapy has been shown to be effective in randomized clinical trials; however, results from naturalistic couple therapy have been less consistent. This study utilized a benchmarking approach to compare the effectiveness of couple therapy in a community-based setting with findings from efficacy treatments, such as treatment within randomized clinical trials. The current study is the largest couple therapy sample published to date (N = 3,347 couples). Clients in couple therapy were asked to provide initial and weekly ratings of symptomology on the Outcome Questionnaire (OQ-45.2). We found that treatment effect sizes found at community clinics were smaller than efficacy studies (i.e., the benchmark). However, when taking into account measurement reactivity, the effect sizes were comparable. This is the first benchmarking study for community-based couple therapy, allowing for meaningful comparisons and understanding of outcomes in real-world couple therapy. Implications for the field are offered in terms of evaluating community-based psychotherapy studies with benchmarking for couple therapy. Results of this study provide clinicians and researchers a way to meaningfully compare couple therapy outcomes, accounting for differences in community-based practices and randomized clinical trials. This benchmark also underscores the impact of measurement sensitivity, an issue commonly overlooked in psychotherapy research and practice.     

Integrating Sex Therapy Interventions with Couple Therapy

This conceptual/clinical paper presents a couple, integrative, psychobiosocial model of assessment, treatment, and relapse prevention for common sexual dysfunctions. The goal is to encourage couple therapists to integrate sexual permission-giving, scientifically and clinically relevant sexual information and guidelines, and specific sexual suggestions/interventions into their couple work. The artificial barriers between couple and sex therapy is to the detriment of couples who need to address intimacy and sexuality problems.     

Evidence-based approaches to assessing couple distress

This article describes a conceptual framework for couple-based assessment strategies grounded in empirical findings linking couple distress to a broad range of both individual and relationship characteristics. These characteristics can contribute to, exacerbate, or result from relationship problems. On the basis of these findings, the authors articulate specific targets of clinical inquiry reflecting relationship behaviors, cognitions, and affect as well as features of individual distress. Guided by this framework, empirically supported assessment strategies and techniques emphasizing relationship functioning across diverse methods are proposed, including the clinical interview, analog behavioral observation, and both self- and other-report measures. Discussion concludes with specific recommendations regarding clinical assessment of couple distress and directions for further research.     

Dialectical Behavior Therapy and Motivational Interviewing: Conceptual Convergence,Compatibility, and Strategies for Integration

Dialectical behavior therapy (DBT) and motivational interviewing (MI) are two widely used and efficacious psychosocial interventions. An immense and growing number of studies examine DBT, MI, or adaptations of these approaches across diverse treatment contexts and across various clinical populations. Because DBT and MI are in high demand, it is probable that trainees and established practitioners will encounter one or both treatments over the course of their careers. Although MI and DBT initially evolved in distinct contexts for different populations, these approaches share a number of common fundamental principles. Each provides distinct and complementary strategies for enhancing clients’ motivation and ability to change. For some, an integrative or sequenced application of MI and DBT may enhance client care. The present article highlights areas of divergence, convergence, and opportunities for integration, and offers practical tips for applying DBT and MI in conjunction.     

Psychotherapy integration in the treatment of personality disorders: a commentary

Whereas research on the treatment of personality disorders over the past several decades has focused primarily on comparing the efficacy of various treatment packages associated with different theoretical models, there is increasing evidence that the field would benefit from focusing more attention on developing integrative treatments that are both informed by research and capable of scientific verification. The articles assembled for this special section each propose a different approach to integrative treatment for personality disorders. In this commentary, we outline a number of reasons for making such a shift to more integrative treatments, consider some of the potential challenges to integration, and discuss the different approaches to integration illustrated in these articles. We highlight some of the difficult tradeoffs that must be made in developing an integrative approach and discuss similarities and differences in the response to such challenges by the contributors to this special section. Finally, we point to several areas for future research that we believe will contribute to the development of increasingly effective treatments for individuals with personality disorders.     

The Integrative Revolution in Couple and Family Therapy

A quiet revolution has resulted in significant movement toward integrative practice in couple and family therapy. This article examines the present status of integrative methods, highlighting the factors that have led to their broad acceptance, issues surrounding the definition of integration and the nomenclature used, the content of recent approaches, and specific conceptual developments and directions.     

Secrets or No Secrets: Confidentiality in Couple Therapy

This paper discusses secrecy in couple therapy from ethical and clinical perspectives. The author explains what secrets mean in terms of therapy and then moves to what controversies are raised by revealing or withholding secrets. The author reviews and evaluates current approaches to handling secrets in couple therapy regarding the use of informed consent. Additionally, the manner of implementation serves as another variable. In this paper, the author presents several scenarios which are widely used. The article ends with a call for further research on how the change of formats in therapy affects confidentiality.     

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.     

Couples treatment for major depression: critique of the literature and suggestions for some different directions

Current couples approaches to the treatment of depression show considerable promise for some couples, but have substantial room for improvement – in terms of efficacy as well as applicability and acceptability to a broader population. Although conjoint approaches have been shown to be efficacious in reducing couple distress and are possibly efficacious in ameliorating depression that co-occurs with couple distress, methodological problems hamper generalization from the published findings. Therefore, it is not clear that most depressed persons are likely to benefit from currently available conjoint formats. Most basically, there may often be obstacles that prevent or delay partner involvement, highlighting the need for treatments that can enhance relationship functioning without relying on a conjoint format. Existing treatment delivery systems may also fail to reach a considerable segment of the population. Developing a more flexible set of options for implementing couple-focused treatment, as well as rethinking dominant assumptions about depression, may be integral to extending the viability of couples therapy for depression.     

Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis

During the last two decades a number of therapies, under the name of the third wave of cognitive behavior therapy (CBT), have been developed: acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), cognitive behavioral analysis system of psychotherapy (CBASP), functional analytic psychotherapy (FAP), and integrative behavioral couple therapy (IBCT). The purposes of this review article of third wave treatment RCTs were: (1) to describe and review them methodologically, (2) to meta-analytically assess their efficacy, and (3) to evaluate if they currently fulfil the criteria for empirically supported treatments. There are 13 RCTs both in ACT and DBT, 1 in CBASP, 2 in IBCT, and none in FAP. The conclusions that can be drawn are that the third wave treatment RCTs used a research methodology that was significantly less stringent than CBT studies; that the mean effect size was moderate for both ACT and DBT, and that none of the third wave therapies fulfilled the criteria for empirically supported treatments. The article ends with suggestions on how to improve future RCTs to increase the possibility of them becoming empirically supported treatments.     

Common factors in the enhancement of dyadic coping

Stress and coping are important constructs in understanding the dynamics of close relationships. Couple therapy and marital distress prevention approaches have become increasingly focused on these variables to gain knowledge of how stress and coping may impact the quality and stability of close relationships. In this paper, we outline couple's coping enhancement training (CCET) and the coping-oriented couple's therapy (COCT); both, couple interventions derived from stress and coping research. We address specific features of each approach and report data on their efficacy and effectiveness. We also examine both the common and specific factors that may play a role in the effectiveness of these approaches.     

“Revolving Doors and Brief Encounters: Dare We Do Inpatient Groups?” Reflections on Being an AGPA Conference Panelist

Participating as an American Group Psychotherapy Association (AGPA) conference panelist is an impactful and noteworthy experience. The purpose of this article is to discuss the experience in the context of providing a brief update to the conversation regarding rapid turnover in inpatient groups. We aim to highlight and summarize the far-reaching impact of ongoing clinical discussions and research found in both the literature and the conference experience. From an integrative perspective, clinical discussion between colleagues is an essential component in the discipline of psychology. It aids in appropriate edification as a clinical psychologist. Rather than emphasizing a one-size-fits-all therapeutic model, if we remain open to a diversity of approaches while clarifying and fine-tuning the most valuable commonalities, we will subsequently facilitate increased professional and patient satisfaction.     

Topic-focused analysis in a case of integrative psychotherapy with a father fearing his own anger

Even though evidence-based knowledge is considered the foundation of clinical practice, many clinicians question the clinical relevance of published research. Clinicians increasingly define themselves as having an integrative stance, in contrast to the tendency for most research to be based on clearly defined psychotherapies. Qualitative single case studies make it possible to generate knowledge about what actually occurs in integrative therapy. Topic change process analysis (TCPA) is used in the analysis of brief integrative therapy conducted by a very experienced psychotherapist drawing on a complex variety of therapeutic approaches. The client was a man in his late thirties, worrying about his strong anger, particularly related to one of his children. Analysis of topic areas, topic shifts, response patterns within topics and changes in perspective made it possible to identify key processes and key patterns of the therapy which resulted in a very positive outcome for the client. Implications of these findings for practice, and future research, are discussed.     

Intervening with Military Couples Struggling with Issues of Sexual Infidelity

Both the prevalence and adverse impact of infidelity argue for the importance of disseminating evidence-based interventions for couples struggling with this highly disruptive event. We describe an integrative approach for promoting recovery from infidelity drawing on empirically supported treatments for couple distress as well as empirical literature regarding recovery from interpersonal trauma and recovery from relationship injuries. We then describe a structured 8 session adaptation of this protocol tailored to military couples struggling with issues of infidelity. Reaching these high-risk couples requires extending both the availability and efficacy of services delivered by professionals within the military from diverse disciplines. We present initial findings indicating that US Army chaplains receiving training in this structured protocol not only can learn information regarding the conceptual underpinnings and specific interventions comprising this treatment, but also can apply it appropriately in analog clinical situations. We conclude with suggestions for extending dissemination efforts to reduce acute adverse consequences experienced by service members and their partners experiencing infidelity.     

Why using “consciousness” in psychotherapy? Insight,metacognition and self-consciousness

Since its early development, clinical psychology has questioned the impact of “consciousness” on the determination of human responsibility across psychiatric disorders. In recent years, specific clinical approaches have focused on “consciousness” work that could play a key role in psychotherapy. We focused our research on clinical psychology's consciousness-related concepts of insight, self-consciousness, and metacognition. Insight and metacognition, for example, have prompted increased interest in schizophrenia (SZ), bipolar disorder (BD), and, more recently, borderline personality disorder (BPD) treatments as representative of the latest advances in the cognitive and behavioral therapy field. Here we review cognitive, social, and clinical psychology research measuring “consciousness” in BPD, SZ, and BD, exploring the implications of different conceptualizations of consciousness-like concepts for treatment adherence, symptom evolution, and related aspects of psychotherapy. Our results show the overall relevance of using measures of clinical and cognitive insight, emphasizing the more central role of cognitive insight and metacognition in psychotherapy, as it appears that consciousness can remain useful if understood as a cognitive skill. The inclusion of a conceptualization of self-consciousness is important in order to address the social component of psychotherapy, as it does in biopsychosocial approaches. We discuss the implications of such results for global efficacy, for the relevance of the “consciousness” concept to clinical psychology, and for the potential need to keep operationalizing different conceptualizations of it in psychotherapy. We open the debate on the definition of consciousness to motivational aspects of change and to general considerations of both legal and ethical aspects.     

Youth Depression in the Family Context: Familial Risk Factors and Models of Treatment

Research on parent risk factors, family environment, and familial involvement in the treatment of depression in children and adolescents is integrated, providing an update to prior reviews on the topic. First, the psychosocial parent and family factors associated with youth depression are examined. The literature indicates that a broad array of parent and family factors is associated with youth risk for depression, ranging from parental pathology to parental cognitive style to family emotional climate. Next, treatment approaches for youth depression that have been empirically tested are described and then summarized in terms of their level of parent inclusion, including cognitive–behavioral therapy, interpersonal therapy, and family systems approaches. Families have mostly not been incorporated into clinical treatment research with depressed adolescents, with only 32% of treatments including parents in treatment in any capacity. Nonetheless, the overall effectiveness of treatments that involve children and adolescents exclusively is very similar to that of treatments that include parents as agents or facilitators of change. The article concludes with a discussion of the implications of these findings and directions for further research.