I
Integrative Behavioral Couple
Therapy
Lisa A. Benson1 and Teresa P. Nguyen2
1
Harbor-UCLA Medical Center, Los Angeles,
CA, USA
2
University of California, Los Angeles, CA, USA
Introduction
Integrative Behavioral Couple Therapy (IBCT) is
an empirically supported treatment with wide dis-
semination in both in-person and online modes.
IBCT was developed in the early 1990s by
Andrew Christensen of the University of Califor-
nia, Los Angeles, and Neil Jacobson of the Uni-
versity of Washington in response to a growing
body of research on the limitations of existing
behavioral couple therapies. It emphasizes
acceptance – that is, changing how partners
respond to each other’s behavior – rather than
behavior change alone, which provides new
options for couples to improve their relationships.
Two small clinical trials and one large multisite
trial support the efficacy of IBCT in producing
clinically significant improvement in relationship
satisfaction.
It is noteworthy that IBCT was chosen by the
U. S. Department of Veterans Affairs (VA) as one
of the empirically supported treatments it is pro-
moting for its clinicians. In the last few years, the
VA has sponsored a 4-day IBCT training for
# Springer International Publishing AG 2018
J.L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy,
https://doi.org/10.1007/978-3-319-15877-8_109-2
30–50 clinicians approximately every 6 months.
Participants are then required to participate in
weekly phone supervision, see at least two cases,
and audio record at least 20 therapy sessions that
will be rated for adherence and competence. VA
clinicians have typically been successful at
attaining adherence and competence in IBCT at
the end of this training period.
IBCT is also being disseminated into the com-
munity through the development of
OurRelationship.com, a web-based version of
the intervention that couples can complete from
their own homes. OurRelationship.com is
intended for a less severely distressed population
of couples than IBCT but relies on the same prin-
ciples for intervention and is accessible to a wider
range of couples due to being completed at home.
OurRelationship.com uses interactive videos,
activities, and questionnaires to help couples
develop an IBCT-based conceptualization of
their relationship. Through approximately 6 h of
these guided activities, couples help each other
use IBCT interventions to improve their relation-
ship. Research on OurRelationship.com indicates
that couples find it appealing and it is efficacious
in improving their relationship satisfaction (Doss
et al. 2016).
Theoretical Framework
IBCT is based on a well-developed conceptuali-
zation of relationship distress, grounded in third-
2 Integrative Behavioral Couple Therapy
wave behavioral principles, and inclusive of five
key principles common to empirically supported
couple therapies.
The conceptualization of distress used in IBCT
is based on the fundamental idea that minor dif-
ferences and disagreements exist for every couple;
severe relationship distress occurs when the part-
ners become “polarized” around these differences.
As both partners become more bothered by their
differences and attempt to change one another’s
points of view, their way of communicating about
the differences becomes more rigid and each
resists the other more. Ultimately, both partners
become “trapped” in a pattern in which each keeps
attempting to solve the relationship problem using
ineffective communication strategies, which
unfortunately only make the problem worse
(Christensen et al. 2014).
More specifically, IBCT therapists conceptual-
ize this process for each couple in terms of differ-
ences, sensitivities, stressors, and patterns of
communication, referred to as a “DEEP
Understanding”:
1. Natural Differences are personality differences
between the partners, such as introversion ver-
sus extroversion or a tendency to be more
economical versus more extravagant. These
differences in themselves do not necessarily
cause relationship problems; indeed, they
may attract partners to each other. A spender
may appreciate a saver’s ability to help the
couple achieve long-term goals, while a saver
may appreciate how a spender emphasizes
enjoying the moment.
2. Emotional Sensitivities are experiences from
either partner’s family or relationship history
that make these differences more difficult for
them to deal with. For example, if the saver
comes from a family that was chronically in
poverty due to an alcoholic parent’s spending,
he may be more sensitive to his partner’s
(comparatively less severe) tendency toward
spending. If the spender was previously mar-
ried to an abusive partner who controlled her
access to money, she may be more sensitive to
any attempts to change her spending habits.
Emotional Sensitivities help explain why
some of the personality differences between
partners result in relationship difficulties and
others do not.
3. External Stressors can then make these chal-
lenges more acute. For example, early in their
relationship, this couple was both earning high
salaries, so their sensitivities around money did
not result in serious arguments. Then, the spen-
der lost her job, significantly reducing the cou-
ple’s income, so their differences around
money became much more distressing.
4. Patterns of Communication about these issues
further polarize the couple. If the economical
partner tends to deal with disagreements by
approaching his partner and demanding they
talk about it, it may increase her likelihood of
evading these attempts and avoiding talking
about purchases, which further exacerbates
his demandingness. This cyclical pattern may
lead them to become increasingly frustrated.
Each partner is likely to now have a blaming,
judgmental view of the other (“he’s a control
freak,” “she only cares about herself and get-
ting whatever she wants”). What began as a
small difference in tendencies about money
results in a significant conflict.
To address this polarization, IBCT uses strate-
gies common to the “third wave” of behavioral
therapies, emphasizing acceptance as well as
change (McGinn et al. 2010). It departs from
previous behavioral couple therapies in its empha-
sis on altering couples’ reactions to each other’s
behavior – that is, becoming more accepting –
rather than only changing behavior directly. This
approach is effective because many relationship
problems are essentially unsolvable. Couples can-
not change the fact that they have different per-
spectives on money, family, sex, etc., but they can
learn to approach these disagreements differently.
Much like other third-wave therapies such as
Acceptance and Commitment Therapy and Dia-
lectical Behavior Therapy, IBCT emphasizes the
function of behavior rather than the content of the
behavior. The behavior in one partner that bothers
another has some function based on that partner’s
learning history and previous experiences. Con-
sider the example above: the spender learned in
Integrative Behavioral Couple Therapy
her previous marriage to have an intense reaction
of frustration and anger when asked to spend less
money. This reaction served a useful function at
the time – it helped motivate her to leave an
unacceptable situation. Although her current rela-
tionship is different, the spender continues to have
a learned association between being asked to
change her spending habits and anger. Therefore,
it can be possible for the other partner to under-
stand and become accepting of the function of that
angry reaction, seeing it as understandable even if
they disagree.
IBCT is also similar to these treatments in its
emphasis on experiential learning. Rather than
prescribe behavior outside session, IBCT thera-
pists first try to create the conditions for new
learning and new behavior in session. For exam-
ple, rather than instruct one partner not to criticize
another, the therapist encourages the partner to
express her emotional experience in a “soft,” non-
blaming way. The therapist then helps the other
partner validate this experience. The first partner
is likely to find the validation reinforcing and
therefore be more likely to disclose in a non-
blaming way in future.
It is worth noting that IBCT also includes the
five Common Principles of Couple Therapy, a
unified protocol incorporating currently
established evidence-based couple therapies
(Benson et al. 2012). IBCT therapists (1) “alter
the couple’s view of the presenting problem to be
more objective, contextualized, and dyadic” by
collaborating with the couple to develop the
DEEP analysis. Understanding and helping them
identify how problems that come up each week fit
this conceptualization. IBCT therapists
(2) “decrease emotion-driven, dysfunctional
behavior” and (3) “elicit emotion-based, avoided,
private behavior” by directly intervening in ses-
sion to encourage emotional disclosure and vali-
dating responses. Through multiple sessions of
coaching partners to respond to each other in
these more effective ways, IBCT therapists help
partners reinforce these more effective behaviors
in each other, resulting in (4) “increasing con-
structive communication patterns.” Lastly, IBCT
therapists (5) “emphasize strengths and reinforce
gains” through direct-change interventions later in
3
the course of treatment. Therefore, IBCT is also
grounded in this overarching theoretical frame-
work for effective couple therapy.
Rationale for the Intervention
Prior to the creation of IBCT, traditional behavior
couple therapy (TBCT) was a widely applied
behavioral treatment for couple distress. TBCT
is a change-oriented treatment that primarily
includes skills training in behavior exchange,
communication, and problem-solving. Partners
receive practical advice on how to increase the
ratio of positive to negative couple behaviors
(e.g., physical affection), improve their listening
and nonaccusatory expression, and effectively
define and resolve relationship problems. Despite
the fact that many investigators found TBCT to be
effective, further analysis showed that the treat-
ment was unsuccessful among a subset of couples
and for a subset of relationship difficulties. Spe-
cifically, only 54.7% of couples experienced reli-
able improvements in marital satisfaction
immediately after treatment, and by 6 months
later, only 47.8% of couples showed improve-
ments (Jacobson et al. 1984). Couples who were
older, more distressed, emotionally disengaged,
suffering from other psychopathology, and held
widely different marital values were less likely to
benefit from TBCT (Jacobson and Addis 1993 as
cited by Christensen et al. 2015). As Jacobson and
Christensen noted in their clinical observations, a
common theme among these couples was an
inability to forge compromise, flexibility, and
emotional acceptance in the face of natural differ-
ences (Christensen et al. 2015).
Thus, as the name indicates, IBCT was devel-
oped as an integration of traditional behavioral
therapy and acceptance (i.e., an integration
between strategies for change and for acceptance).
While TBCT focuses on changing an offending
partner’s behavior (e.g., decreasing husband’s
defensiveness), IBCT focuses on the recipient of
the behavior (e.g., wife’s reaction to husband’s
defensiveness). As Christensen et al. (2015) out-
line, there are multiple reasons for the emphasis
on the recipient. First, focusing on the recipient’s
4 Integrative Behavioral Couple Therapy
emotional response to the behavior is helpful for
forging compromise in relational issues that are
“unsolvable” because the offending partner can-
not make changes. Second, because partners’
reactions to an offense can be just as problematic
as the offense itself, placing equal or greater focus
on the recipient may be necessary to alleviate their
distress. Third, increasing the receiving partner’s
level of acceptance of her partner’s behavior can
paradoxically change the offending partner’s
behavior (Jacobson and Christensen 1996). The
absence of intense pressure to change and the
experience of being accepted by his partner may
inadvertently make him less rigid or defensive,
and thereby increases his chances of making
those changes.
Another defining difference between TBCT
and IBCT is that while TBCT focuses on “rule-
governed behavior,” IBCT focuses on
“contingency-shaped behavior.” The former
establishes a defined meaning of positive behav-
iors in the relationship, and partners are asked to
enact these behaviors (e.g., do not criticize part-
ner, help with chores weekly, etc.). Partners are
then evaluated on whether they performed such
behavior, and IBCT hypothesizes that such good
behavior may be experienced as less genuine and
a result of imposed demands rather than natural
motives or intent.
In IBCT, contingency-shaped behaviors are
ones in which a partner’s positive behaviors
occur naturally based on their environment. For
example, rather than the therapist instructing the
couple to overtly withhold criticisms in session,
the therapist creates different opportunities for
partners to experience noncritical disclosure and
allow the partners to feel the spontaneous, positive
consequences of those disclosures (e.g., greater
responsiveness from their partner). It is hypothe-
sized that these contingency-shaped behaviors –
which are facilitated by the therapist shifting the
couple’s environment – are experienced as more
authentic because they arise from a partner’s nat-
ural concern for the other’s pain. The underlying
assumption is that couples’ distress is not a result
of a skills-deficit, but a lack of contingent oppor-
tunities that promote the skills that they already
possess.
Empirical Support
Multiple randomized clinical trials have shown
the efficacy of IBCT in treating clinically dis-
tressed couples (for review, see Christensen et al.
2015). In particular, one large-scale study com-
pared the effects of TBCT and IBCT on 134 chron-
ically distressed couples who received 26 sessions
of couple therapy. Couples were randomly
assigned to receive either TBCT or IBCT, and
couples in both treatments showed substantial
improvements in their relationship distress, and
2 years after treatment, 69% of IBCT couples and
60% of TBCT couples still had clinically signifi-
cant improvements (Christensen et al. 2006).
Over the course of the following 2 years, IBCT
couples showed significantly higher relationship
satisfaction than TBCT couples (Christensen et al.
2006). It should be noted, however, that the out-
comes for the two treatments converged after
5 years post-treatment such that 50.0% IBCT cou-
ples and 45.9% of TBCT couples show clinically
significant improvements (Christensen et al.
2010). In addition to increases in relationship
satisfaction, couples were observably less nega-
tive and withdrawn during discussions of a rela-
tionship problem (Baucom et al. 2011) and made
gains in their parenting behavior (Gattis
et al. 2008).
Description of the Intervention
IBCT is a semi-structured treatment that can flex-
ibly respond to the needs of the couple (Jacobson
and Christensen 1996). It occurs in three primary
phases: assessment, feedback, and intervention.
First, the therapist asks both partners to describe
the concerns bringing them into therapy, how they
began their relationship, and what it was like
before these problems arose. Both partners also
complete standard measures of relationship satis-
faction (e.g., Couples Satisfaction Index [Funk
and Rogge 2007]). The second and third IBCT
sessions are individual sessions between one part-
ner and the therapist, in which each partner is
encouraged to elaborate on their understanding
of the current problems, as well how truly
Integrative Behavioral Couple Therapy
committed they are to the relationship and
whether any affairs or violence are occurring.
The therapist then develops a conceptualiza-
tion of the couple’s difficulties using the DEEP
Framework (Christensen et al. 2014). In the feed-
back session, the therapist reviews this conceptu-
alization with the couple, encouraging them to
collaborate in making changes or additions
throughout. If they agree with the revised concep-
tualization, they can then provide fully informed
consent to proceed with IBCT. The content of
intervention sessions is responsive to whatever
topic the partners bring in that week, preferably
ones related in some way to the conceptualization.
The therapist will use any of the acceptance-
building IBCT interventions – empathic joining,
unified detachment, or tolerance building – in any
sequence that seems most likely to be helpful with
that topic.
Empathic joining is a couple’s experience of
being emotionally connected and feeling empathy
toward each other when discussing a relationship
problem. To promote this, the therapist encour-
ages both partners to disclose their underlying
emotions (e.g., sadness below the anger) to each
other in a vulnerable way. Then, the therapist
coaches each partner in responding to the other
with validation and genuine empathy.
Unified detachment is when a couple is able to
describe the usual course of their disagreements
together in an accurate, nonblaming way. The
therapist helps the couple collaboratively identify
how each new conflict fits into the conceptualiza-
tion until they are able to complete this process on
their own. Often couples find it helpful to develop
a metaphor for their interaction pattern that allows
them to find the humor in it – for example: “uh oh,
we’re back in our district attorney and hostile
witness scenario.” Note that neither empathic
joining nor unified detachment requires the couple
to agree with each other about their area of dis-
agreement, only to change how they interact
around it.
Tolerance building similarly emphasizes
increasing the couple’s acceptance around their
conflicts rather than changing behavior. As ther-
apy goes on, they may identify specific issues
such as one partner making a sarcastic comment
5
when the other comes home with multiple shop-
ping bags. Rather than try to stop either the sar-
casm or the shopping behavior, the therapist might
ask the partners to role-play this interaction in
session. Pretending is likely to result in less emo-
tional distress than actually being in the situation
and may lead to some humorous distance. This
and related strategies can help the couple shift
their responses to each other’s behavior, building
empathic joining and unified detachment.
Once the couple is approaching their disagree-
ments in a more accepting way, the therapist can
also introduce interventions common to other
behavioral couple therapies such as problem-
solving strategies and structured communication
techniques. For example, problem-solving
involves defining the problem in a specific, behav-
ioral way, then brainstorming a list of possible
solutions without any judgment of each one. The
couple would then identify advantages and disad-
vantages of these solutions, pick one to try, and
select a length of time in which to try it. At the end
of that period, they would evaluate the success of
the solution and switch to a different option if
needed.
Case Example
The following example illustrates an IBCT case
formulation and treatment. Sofia and Ty are a
middle-aged multiracial couple who have been
married for 9 years, and Sofia is pregnant with
their first child. Sofia is a lawyer at a prestigious
firm and Ty is a landscape architect. Sofia initiated
their request for therapy, stating that the two were
experiencing conflictual communication regard-
ing household responsibilities.
Assessment and Feedback
During their three-session assessment period, the
couple identified two major conflicts that pro-
mpted them to seek couple therapy. The first inci-
dent was when Ty was laid off from work and
Sofia was supporting them financially. After a
year of unemployment, Ty had still not found a
job. Sofia was frustrated with Ty, believing that he
was not trying hard enough to find work. In the
6 Integrative Behavioral Couple Therapy
second instance, Sofia had an emergency during
her pregnancy in the middle of the night, and
when she woke, Ty was still not at home. Ty had
stayed late at a friend’s birthday party, absent
mindedly forgot to notify Sofia in advance, and
failed to answer her multiple calls because he got
“carried away.” The couple completed relation-
ship quality questionnaires prior to beginning
therapy, and their scores indicated that they were
moderately distressed. Sofia reported greater dis-
tress than Ty.
In the feedback session, the IBCT therapist
presented her working conceptualization of the
couple’s relationship difficulties using the DEEP
analysis. The primary theme for the couple was
formulated as a struggle over their level of con-
scientiousness and drive for action inside and
outside the relationship. Sofia described herself
as having a high-achieving “Type A” personality
who can be competitive and impatient. On the
other hand, Sofia and Ty agreed that Ty was
more laid back and easy going. This difference
in achievement drive between them drew the cou-
ple together when they first met, as Sofia appreci-
ated Ty’s ability to make her laugh and relax. This
difference became particularly problematic, how-
ever, as they encountered situations that triggered
their emotional sensitivities. Although it was clear
that Sofia became angry when she took additional
responsibilities in their relationship, the DEEP
analysis revealed that the anger stemmed from
her emotional vulnerability of seeing her mother
resentfully run the household alone. During their
arguments, Ty found himself often emotionally
vulnerable and triggered by Sofia’s anger because
of his history of living with a volatile and demand-
ing father. When both partners were employed,
these types of situations were less commonly trig-
gered. However, due to the stress of impending
parenthood and Sofia’s anxiety about their
finances and Ty’s lack of steady income, their
personal differences were exacerbated.
Sofia and Ty’s differences, emotional sensitiv-
ities, and external stressors all contributed to their
pattern of negative interaction. Sofia’s need for
detailed planning for parenthood and her sensitiv-
ity to potentially carrying that burden alone comes
out in any situation where Ty fails to follow
through on a plan (e.g., forgetting to schedule an
appointment with the obstetrician-gynecologist
during pregnancy). Sofia becomes worried that
Ty is unreliable and makes angry accusations
him of not working hard enough or not taking
responsibility. In turn, Ty finds her anger to be
scary and hurtful, particularly because he feels it is
unjustified. Ty reacts by withdrawing from Sofia’s
attacks, which decreases his chances of under-
standing and meeting Sofia’s requests, which fur-
thers her anxiety of being burdened. Through this
demand/withdraw pattern, each partner’s feelings
of anger and hurt are exacerbated and their views
are polarized.
Interventions
Based on the conceptualization, the two primary
interventions for Sofia and Ty were the use of
empathic joining and unified detachment to
break their typical pattern of interaction. For
example, one week the couple discussed the
mounting number of tasks needed prior to the
birth of the baby, including shopping for supplies,
installing safety devices around the home, and
planning for when labor starts. Sofia had made a
detailed list and assigned Ty a portion of the tasks
several weeks ago but recently discovered that he
has not completed all tasks to Sofia’s satisfaction.
To foster empathic joining, the therapist shifted
the focus from blame of Ty to the pain that Sofia
was experiencing. Although Sofia readily
expressed “hard” emotions such as anger, the
therapist helped her explore the more vulnerable
“soft” emotions, including her worry of parent-
hood, and more critically, feelings of abandon-
ment. After this disclosure, Ty was noticeably
more attentive and empathetic of Sofia’s experi-
ence, and squeezed her hand in support as she
became teary eyed.
In a later session, Sofia and Ty discussed that
the stress of Sofia going into labor will likely
make them more vulnerable to their typical pat-
tern. To foster unified detachment, the therapist
engaged the couple in a careful, nonjudgmental
analysis of their pattern of interaction. Sofia and
Ty were asked to predict the likely triggers during
labor and to describe the sequence of events that
typically ensue during these problematic
Integrative Behavioral Couple Therapy
interactions. The discussion occurred in a calm
manner, and the therapist encouraged them to
identify the pattern with a name. When Sofia and
Ty returned at the next session, the couple
commented that the exercise was helpful in seeing
their pattern of interaction as a common enemy
that was removed from either of them. By
detaching themselves from the problem, Sofia
and Ty were able to be more mindful and less
emotionally charged when the next stressor
occurred. The therapist provided feedback on her
observations of their ability to form unified
detachment during conflict, and the couple agreed
that the nature of their disagreements had observ-
ably changed. In fact, by the end of treatment,
Sofia and Ty had several instances where they
verbally labeled the pattern mid-argument,
which immediately deescalated the conflict.
Outcome
By the end of treatment, Sofia and Ty could more
easily communicate soft emotions and empathize
and validate the other’s experience with little pro-
mpting from the therapist. Despite the occurrence
of other stressors such as their newborn falling ill,
Sofia and Ty were able to work as a team such that
Sofia benefited from Ty taking the initiative while
Ty benefited from Sofia collaborating with him
when they needed to troubleshoot errors. Their
improvements were also evidenced in relationship
quality questionnaires, which showed that their
scores were consistently in the satisfied range.
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