What Works in Couples Therapy
What are the two most effective couples therapies, and what do they share?
Posted Jan 14, 2020
Two of my prior blog posts, "What Do All Troubled Couples Share?" and "The ABC's of Couple Arguments," revealed the common vicious cycles that all couples in distress share. They noted that the task of all effective couples therapies is to break those cycles. Yet with so many variations in couples therapies available, which have been found to be most effective?
Two Most Effective Couple Approaches: After extensive research on couples therapy, two approaches have emerged as what professionals call "evidence-based" couples therapies.
- The first approach is called Integrative Behavioral Couple Therapy or IBCT (Jacobson & Christensen, 1996; Jacobson et al., 2000).
- The second approach is Emotion-Focused Couples Therapy or EFCT (Greenman & Johnson, 2013; Johnson, 2016).
Different Roots but the Same Tree?
Each of these two approaches is equally effective. However, they grow out of very different conceptual and theoretical roots on the cause and cure for couples' problems. In many ways, their philosophies couldn't be farther apart. IBCT is rooted in behavioral and cognitive ideas. EFCT, on the other hand, has its roots in humanistic and existential theories. IBCT views couples as engaged in quid pro quo behavior exchanges, emphasizing rewards and aversions in sequences framed by couples' assumptions about each other. EFCT views couples as responding to each other based on their histories of prior family of origin bonds or lack thereof.
Yet, both approaches target the same escalating vicious cycles between partners and seek to reverse them through increasing acceptance and vulnerability, and then changing other troubling patterns as trust and collaboration evolve.
The Essence of IBCT
Behavioral couples therapy researchers originally built couples treatments based strictly on ideas of collaborative change in problematic couples patterns. However, they found that not all couples were open to collaboration and compliance as they entered treatment, and even when change did happen, it eroded over time. The researchers thus added what they called an acceptance component to treatment.
Strategies to Build Acceptance
The following is a set of acceptance and tolerance-based strategies employed by the IBCT approach.
- Empathic joining around the problem is one of the first acceptance steps. Therapists emphasize the pain and honest efforts of each partner without accusation. The formulation itself becomes a central vehicle for this joining by casting the couple’s dilemma as flowing from an honest difference that naturally led to polarization and eventually alienation. Therapists emphasize using “soft” rather than “hard” emotion descriptions in their reflections, and they encourage the partners to do the same.
- Encouraging unified detachment, or making the problem an “it” follows from empathic joining. Rather than blaming each other, the problem is externalized and often given a metaphorical name as an “it.” “Two porcupines trying to dance,” is an example.
- Highlighting the positive features of negative behavior relates directly to the dialectical or polar nature of the couple’s dilemma. Complementary differences usually create balance in relationships. These differences can even become a positive aspect of the couple’s relationship and something for them to be proud of and feel close about.
- Role-playing negative behavior during the therapy session is a commonly used technique in IBCT. This entails having the couple act out the pattern via role play in session. The idea is to help the couple to do on purpose what they have been doing reflexively. The intent is for the couple to lower their arousal levels through desensitizing the couple to the pattern. Lowered arousal makes problem-solving in the face of the problem easier.
- Faked incidents of negative behavior at home, or “faking bad” is explained as a way to promote tolerance by desensitizing partners to negative behavior. Partners are asked to deliberately pick fights, or deliberately do or not do something that creates conflict when they would not ordinarily do this. The faker is then asked to observe the process of the vicious cycle—the polarization and pain—to better track and learn from it. It has powerful effects on deescalating fights and reinforcing the formulation of how the conflicts occur.
- Preparation for backsliding is an inoculation used as progress is made. It is basically relapse prevention that inoculates the partners against both assuming that the problem has started again and trying again to fix it using the same old vicious cycle first-order solutions.
- Emotional acceptance through greater self-care has two elements. The first is to have each partner begin doing things for him or herself to feel better and to learn self-soothing. The second is to learn to do self-care during arguments, polarization processes, and other instances of negative behavior.
As greater acceptance is generated, further pattern shifts can then be made.
Emotion-Focused Couples Therapy (EFCT)
EFCT is delivered in three phases. Prior to Phase I there is an assessment to ensure that the couple is suitable for treatment, involving eight tasks. These include the inevitable steps of creating a collaborative therapeutic alliance including bonds, goals, and tasks, and assessing the couple’s response to the therapist. In this process, the therapist also assesses how open and receptive the couple is to the major EFCT frame that their problems rest in their history of bonding and their emotional ways of defending against further vulnerability to wounds and loss.
- Phase I: As in all treatments, the therapeutic alliance is partly contingent on the clients buying into the frame and rationales for treatment. In the first stage, clinicians help couples to see that their problem is not one another but, instead, the problematic pattern of interaction, which is obscuring their true needs. That need is to feel connected and closer to one another. This is a core premise of the EFCT approach. In accordance with attachment theory, EFCT seeks to create more secure attachment bonds between partners, modify perceptions of threat, and create a functional safe haven and secure base for the partners to thrive. Again, fitting this frame to the couple is crucial to moving forward in treatment.
- Phase II: Phase II involves what is referred to as restructuring the couple’s interactions to achieve a secure attachment bond. This involves assisting the demander with softening his or her approach by expressing the soft side feelings that are underneath complaining and anger. (Interestingly, this use of the term “soft emotions” is the same as in the IBCT approach discussed above.) On the other side, the therapist assists the withdrawer with engaging. This involves expressing their own hurts, fears, and needs to be comforted. When attachment is secure, partners can receive positive, soothing responses, while remaining open and responsive to one another’s emotional needs. Through this process, a new way of responding unfolds and replaces the demand-withdrawal pattern.
- Phase III: Finally, in Phase III, gains are consolidated and long-standing conflicts are addressed using the newly learned interactive pattern. Former triggers of the demand-withdraw cycle are also discussed. The therapist then acts as a facilitator of effective problem-solving, and as a process consultant.
Clearly, there are numerous ways that the EFCT approach parallels the IBCT approach in interdicting couples' vicious demand-withdraw cycles, yet the results are achieved from very different assumptions. Each approach, of course, emphasizes empathy and bonding to enhance the therapeutic alliance and helps couples to buy into the frames and rationales of the approach. Each brakes the same classic vicious cycles from different roots but in broadly the same ways.
Which One Is Best? Of course, we are always tempted to ask which one of these two is best. The answer once again turns to the idea of fit. Each couple comes to therapy with different life experiences and beliefs, so the approach that makes the most sense to them, or fits them best, is the one that is likely to work the best.
Jacobson, N. S., & Christensen, A. (1996). Integrative couple therapy: Promoting acceptance and change. WW Norton & Co.
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.
Johnson, S. J. (2016). Emotionally focused therapy for couples: Key concepts. Retrieved from www.holdmetight.com, www.iceeft.com
Greenman, P. S., & Johnson, S. M. (2013). Process research on emotionally focused therapy (EFT) for couples: Linking theory to practice. Family Process, 52(1), 46-61.
Adapted from Fraser, J. S. (2018). Unifying effective psychotherapies: Tracing the process of change. Chapter 9, Couple Problems. A Washington, DC: APA Books.