Behavioral marriage therapy in the 1980's: The challenge of integration

Abstract

Only two years ago, my colleagues and I participated in a published debate over the sufficiency of a predominantly behaviorally oriented approach to marital therapy (Gurman and Kniskern, 1978c; Gurman and Knudson, 1978; Gurman et al., 1978; Jacobson and Weiss, 1978). This debate has stimulated a good deal of discussion (e.g., Colapinto, 1979; Taggart, 1979), presumably because it focused attention on a number of issues which are fundamental to how clinicians conceive of marital conflict and treatment, which had not received enough of a public airing for some time. In that debate, my colleagues and I argued that a single-minded application of behavioral principles to marriage therapy was insufficient for effective clinical practice. While behavioral marital therapy (BMT) was the focus of that particular interchange, in several other places I have taken the position that psychodynamically oriented and systems-oriented methods, when applied monolithically to marital problems, are also subject to serious criticism on both theoretical (Gurman, 1978; 1979; Gurman and Klein, 1980) and empirical (Gurman and Kniskern, 1978a; 1978b; 1980a; Kniskern and Gurman, 1980a; 1980b) grounds.     

Behavioral marriage therapy. III. The contents of Gurman et al. may be hazardous to our health

This paper was written as a reply to a critique of behavioral marital therapy (BMT) by Gurman, Kniskern, and Knudson (6, 7). The reply is divided into four sections. First, the paper addresses the critics' comments on the conceptual model put forth by BMT, correcting and clarifying various misconceptions, and restating some of the basic ideological principles in the behavioral model. Second, the paper discusses behavioral change techniques and technology, along with extratechnological treatment considerations. Again, misrepresentations of BMT are corrected. Third, an analysis of the literature investigating the therapeutic efficacy of BMT is reviewed, and the conclusion is reached that BMT is demonstrably effective, at least for a substantial number of mildly to moderately distressed couples. Criticisms are made of the analysis of the same literature conducted by Gurman et al. We conclude that, contrary to the spirit of the paper by Gurman et al., BMT is a viable framework for conceptualizing and treating relationship problems and that the commitment of its adherents to experimental investigation promises continued evolution, refinement, and improvement.     

Behavioral marriage therapy: I. A psychodynamic-systems analysis and critique

After briefly summarizing the major theoretical premises and treatment strategies of Behavioral Marriage Therapy (BMT), five major clusters of implicit assumptions in BMT are identified and critically examined: I. "The Rational Observing Ego Shall Conquer All"; II. "Behavior Should Not Mean, But Be"; III. "What's Sauce for the Goose is Sauce for the Gander"; IV. "Repression Is Good for Your Marital Mental Health"; V. "The Folly of the Therapist as Technician." Throughout this analysis, the conceptual and clinical limitations of a strictly or predominantly behavioral approach to couples therapy are described, and BMT is reconsidered in the light of object relations theory and communication theory perspectives on marital dysfunction and its treatment.     

Neuere Entwicklungen in der kognitiv-verhaltenstherapeutischen Paartherapie

This article focuses on relevant modifications in behavioral marital therapy. Two main topics are addressed: (a) relevant new techniques in marital therapy and (b) important new aims in the prevention of marital problems. Whereas in the first part most essential new techniques such as the acceptance work proposed by Jacobson and Christensen, emotion-focused approaches and the strengthening of marital knowledge are presented, the second part deals with the importance of the prevention of marital problems. The goals of modern cognitive behavioral therapy should focus not only on repairing marital problems but even more on prevention and a broader dissemination of empirically founded knowledge about marital functioning.     

Behavioral Marriage Therapy: II. Empirical Perspective

Two recent published reviews of research on behavioral marriage therapy stimulated us to supplement these accounts with additional relevant data. First, we place research on behavioral couples therapy in the broader context of outcome research on nonbehavioral marital therapy. We then summarize the results of 23 studies of behavioral couples therapy not included in these previous reviews and conclude that these additional data on controlled and comparative studies do little to enhance the current empirical status of the efficacy of behavioral marriage therapy and in no case do they establish the superiority of social learning approaches. It is concluded that an open mind to all sources of data on the efficacy of marital therapy is needed if the field is to make meaningful advances.     

Marriage Counseling: A Christian Approach to Counseling Couples

An approach to marriage counseling aimed at Christian couples is described. The theoretical bases of the approach are cognitive behavioral therapy and structural and strategic marital therapies. Techniques are drawn from various schools of marriage therapy. Shared Christian values between counselor and clients are used to promote increased marital commitment, marital satisfaction, and personal spiritual growth. Marital satisfaction might be increased through helping the couple increase their intimacy, enhance their communication, improve their conflict management, and forgive each other for past and present hurts.     

Religion,Spirituality, and Marriage and Family Therapy: A Study of Family Therapists' Beliefs about the Appropriateness of Addressing Religious and Spiritual Issues in Therapy

For many years the literature in the field of family therapy was silent as to the religious and spiritual aspects of clients' lives. During the past five years, however, many voices have come forth calling attention to the importance of bringing spirituality and religion into our conversations with clients. The result of these new voices has been a significant increase in attention to spirituality in journal articles, books, and presentations at national conferences. While there appears to be a strong movement in favor of bringing spirituality and religion into the therapy room, there have been no published studies in marriage and family therapy journals that explore marriage and family therapists' beliefs about the appropriateness of addressing spiritual issues in therapy. The purpose of this study was to fill this gap in the literature by examining the beliefs of a random sample of clinical members of AAMFT in respect to this issue.     

Visual Motor Behavior Rehearsal. The Basic Technique

The past decade has witnessed a significant shift toward a more cognitive emphasis in our understanding and treatment of obsessive‐compulsive disorders (OCD). This article discusses the shortcomings in more standard behavioral treatment of OCD, which despite its demonstrated efficacy, led to the recent cognitive‐behavioral approaches to the disorder. Current cognitive behavior therapy for OCD is described and a short critical review of the comparative treatment outcome literature on cognitive behavior therapy vs exposure and response prevention is provided. The article concludes that although the clinical utility of a more cognitive approach to OCD has not been consistently demonstrated, it would be premature to abandon cognitive formulations until some key research questions have been addressed.     

The Limits of Reciprocity in Behavioral Marriage Therapy

This reexamination of the values underlying Behavioral Marriage Therapy (BMT) focuses on the central theoretical concept of reciprocity. It is suggested that BMT's emphasis on individuality and instrumental exchange may not be suitable for all couples. An alternative perspective, emphasizing a developmental progression in marriage reciprocity defined by mutual understanding, is seen to be more sensitive to the differing value systems of couples in therapy.     

Recent developments in family behavioral marital therapy

This paper reviews recent developments in the area of behavioral marital therapy (BMT). New information is summarized regarding the long-term efficacy of BMT and the identification of predictors of positive response to treatment and to relapse. Finally, new applications of BMT techniques are reviewed (e.g., spouse-involved therapies as the sole treatment for presenting problems in which marital distress is not the primary focus such as anxiety and affective disorders).     

Can depression be de-medicalized in the 21st century: scientific revolutions, counter-revolutions and the magnetic field of normal science

This article is about our scientific investigations of the change mechanisms in cognitive therapy (CT) for depression. In a previous clinical trial, we found that so-called 'cognitive' interventions were not necessary for the success of CT: the behavioral activation (BA) component, a treatment precluding attempts to change thinking, worked as well as the entire CT package, both in maximizing acute treatment response and in relapse prevention over a two year period. We tentatively suggested at the time of publication [Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., Gortner, E. T., & Prince, S. E. (1996). A component analysis of cognitive-behavioral treament for depression. Journal of Consulting and Clinical Psychology, 64, 295-304; Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson, N. S. (1998). Cognitive-behavioral treatment for depression: relapse prevention. Journal of Consulting and Clinical Psychology, 66, 377-384.] that the 'cognitive' components of CT may not only be unnecessary but potentially a liability, since they result in a less parsimonious treatment package that may be not be cost effective. In this article, we not only defend this contention, but counteract the skepticism expressed by some CT advocates that the quality of our CT was deficient. Finally, we describe a study designed to confirm our conclusions from the earlier trial and, in the process, reintroduce a contextual perspective on depression, one which counters the currently dominant defect models reflected in both Beck's cognitive model and in theories that emphasize biological causation.     

Integrating Sex and Couples Therapy: A Multifaceted Case History

Traditionally, sexuality has not been a focus in couples therapy training, research, or practice, although it is an important, often complex issue for many couples. This article tells the story of a couple presenting for sex therapy due to their unconsummated marriage, and is told to exemplify how sex therapy and couples therapy can be integrated in order to best meet the needs of couples. As the story unfolds, the multilayered facets of the presenting issue are revealed. The therapy incorporates and weaves together family of origin history, intrapsychic and cognitive issues, relational dynamics, patterns of interaction, and physiological/medical concerns into a postmodern couples therapy with behavioral interventions. This combined approach recognizes the value of each method on its own and their greater usefulness when blended together.     

The Divorce of Marriage and Parenthood

Marriage is a template for domestic life and the problems that arise in it. The patterned assumptions that traditionally defined marriage gave substance to the family. These assumptions have become less compelling over the course of a century. In this paper, I suggest how and why this has happened. I focus on the meaning of parenthood and its relationship to marriage. In the course of a century, parenthood has been redefined as a rational choice governed by calculation. As a result, childbearing, pregnancy, marriage and parenthood have been redefined. Their relationships to one another have, to varying degrees, been altered. Marriage is an institutionalized way to care for the babies that once came, inevitably, as a result of sexual intercourse. What becomes of marriage when sex no longer produces babies? The answer is that everything about marriage and the family changes. Such changes help explain the rise of professional family therapy and related fields.     

Chasing Prince Charming: Partnering consequences of holding unrealistic standards for a spouse

Although social scientists have generally assumed that people's standards for a spouse shape their marital behavior, systematic investigations of the role of mate standards in partnering have been rare. Using survey data collected from 471 unmarried individuals and their peer informants, this study used a novel, residual‐based approach to quantify the attainability (rather than the absolute stringency) of people's standards for a spouse. Regression analyses using this index of unrealistic criteria revealed that holding less realistic standards for a marriage partner was associated with several indicators of a propensity to delay or forgo marriage, including greater difficulty establishing high‐quality romantic relationships, lower expectations to marry one's current partner, and lower levels of psychological and behavioral investment in marrying.     

The GRIMS. A psychometric instrument for the assessment of marital discord

Research in marital therapy has been disadvantaged by the lack of a good, short and recent psychometric questionnaire to objectively assess the state of a marriage for research, demographic and clinical purposes. The Golombok Rust Inventory of Marital State (GRIMS) is a companion questionnaire to the Golombok Rust Inventory of Sexual Satisfaction (GRISS), and concentrates on aspects other than the sexual in a dyadic relationship between two adults living together. It is a 28 item psychometrically constructed inventory designed to produce a single scale along which changes in a marriage may develop as marital therapy progresses. It has been shown to be valid for this purpose, and to have a good reliability.     

Schematherapie

Schema therapy is a cognitive behavioral therapy (CBT) development mainly for the treatment of personality disorders and other chronic mental disorders. It is characterized by an integration of cognitive, emotional and behavioral intervention methods derived from different therapeutic approaches with an emphasis on a specifically supportive therapeutic relationship. The original approach focused mainly on early maladaptive schemas. Current developments, however, concentrate on the concept of schema modes, describing different schema-associated emotional states. The schema mode approach is also used for specific case concepts for personality disorders. Effectiveness of schema therapy has been shown for borderline personality disorder. Current studies investigate the effectiveness of schema therapy for patients with other chronic mental conditions and as a group therapy approach. This paper provides an overview about case conceptualization and treatment, presents main research findings and discusses open questions and problems.     

Textbooks in Accredited Marriage and Family Therapy Programs

Although choices of required textbooks are important decisions in developing a course curriculum, faculty in marriage and family therapy training programs have few convenient resources to guide curriculum development. This article presents results of a survey of textbook selections of accredited marriage and family therapy programs within a regional affiliate of AAMFT. The five programs surveyed listed 108 different titles used in their curriculum. Only 12 texts were used by two programs, and only one text was used by more than two programs. This article presents the textbook selections by the six curricular areas of COAMFTE accreditation standards. The wide variety of textbooks used by programs leads us to conclude that no consensus exists about what textbooks best represent the core knowledge of marriage and family therapy. The body of knowledge taught in accredited marriage and family training programs reflects a distinct and autonomous body of knowledge.     

Idiographic outcome analyses of the clinical significance of two interventions for patients with musculoskeletal pain

This study adopted a perspective of the individual to define domains of everyday life for the analysis of clinically meaningful change. The purpose was to compare the clinical significance of two interventions for patients with musculoskeletal pain, applying an idiographic outcome measure, The Patient Goal Priority Questionnaire, in combination with the Jacobson and Truax methodology [(1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 67 (3), 300-307] for determination of clinical significance. The concurrent validity of the outcome variables behavioral performance, satisfaction with behavioral performance, and fulfilled pre-treatment expectations was also studied. Eighty-two patients, randomized to either individually tailored behavioral medicine treatment (experimental group) or physical exercise therapy (control group) were evaluated at baseline and 3 months post-treatment regarding behavioral treatment goals. The experimental intervention had high impact on participants' performance of their highest ranked everyday life activities, and resulted in larger proportions of clinically significant outcomes compared with controls. The concurrent validity of the outcomes was high for those reporting clinically significant changes, but more generally, there was a moderate agreement across outcome categories. The individual should be the unit for analyses of clinical significance to enhance the ecological validity of the construct. Further development of idiographic outcome measures is necessary, as is the inclusion in pain intervention research.     

Clinically significant but impractical? A response to Hageman and Arrindell

Hageman, and Arrindell [Hageman, W.J., & Arrindell, W.A. (in press). Establishing clinically significant change: increment of precision and the distinction between individual and group level of analysis. Behavior Research and Therapy.] suggest adaptations to the traditional clinical significance model originally developed by Jacobson, Follette, and Revenstorf [Jacobson, N.S., Follette, W.C., & Revenstorf, D. (1984). Toward a standard definition of clinically significant change. Behavior Therapy, 17, 308-311.]. They observe that one must distinguish between analysis at the individual and group level and based upon an alternative decision-making strategy have formulated different procedures for assessing clinically significant change that incorporate the unreliability inherent in testing measures. A comparison of the traditional method with Hageman and Arrindell's suggested approach is conducted utilizing data originally presented by Jacobson and Truax [Jacobson, N.S., & Truax, P., Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19.] and implications of this comparison for the method developed by Hageman and Arrindell's method are discussed. Although this revised method has much to recommend it, it seems to yield results at the individual level that are quite similar to those derived from the traditional method. Given the complexity of the revised method, the traditional model developed by Jacobson, Follette, and Revenstorf (1984) still seems to be preferable.     

Influence of Therapist Behaviors on Therapeutic Alliance

A number of recent studies have investigated the relationship between therapist and client gender and conversation in marriage and family therapy. There has also been recent empirical investigation of therapeutic alliance and its influence on therapy outcome in marriage and family therapy. However, there has been limited investigation of the influence of interactional patterns on therapeutic alliance. It seems probable that therapy conversation (which seems to be influenced by gender) will influence therapeutic alliance and subsequent outcome.