Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples.
ABSTRACT A randomized clinical trial compared the effects of traditional behavioral couple therapy (TBCT) and integrative behavioral couple therapy (IBCT) on 134 seriously and chronically distressed married couples, stratified into moderately and severely distressed groups. Couples in IBCT made steady improvements in satisfaction throughout the course of treatment, whereas TBCT couples improved more quickly than IBCT couples early in treatment but then, in contrast to the IBCT group, plateaued later in treatment. Both treatments produced similar levels of clinically significant improvement by the end of treatment (71% of IBCT couples and 59% of TBCT couples were reliably improved or recovered on the Dyadic Adjustment Scale; G. B. Spanier, 1976). Measures of communication also showed improvement for both groups. Measures of individual functioning improved as marital satisfaction improved.
- SourceAvailable from: Julia C Babcock[Show abstract] [Hide abstract]
ABSTRACT: This study tested moderators of treatment outcome of the ‘Art and Science of Love (ASL) Workshop’, a couples' group psycho-educational intervention with 80 distressed married couples. Couples were randomly assigned to one of four conditions: (1) friendship enhancement alone, (2) conflict management alone, (3) combined friendship enhancement + conflict management or (4) bibliotherapy. Three outcomes were assessed: (1) relationship satisfaction, (2) friendship quality and (3) destructive conflict at pre-, post- and one year following the intervention. All conditions led to increased marital satisfaction and decreased problems with friendship and destructive conflict at one-year follow-up. Examining exposure to the components of the ASL workshop in a 2×2 design – friendship enhancement (yes/no) vs. conflict management (yes/no) – revealed differential impact for men's and women's relationship outcomes over time. Results suggest that the combined condition produced the greatest changes in marital satisfaction and the greatest decreases in problems in friendship and conflict, particularly for men. Practitioner pointsA combination of friendship enhancement and conflict management is recommended to maximize outcomes.Bibliotherapy alone may be effective for significantly distressed couples without co-morbid problems.Psycho-education is recommended before a course of more intensive couple therapy.Men and women have different needs and respond to particular aspects of the programme.Women particularly value the component concerning how to deal with conflict constructively and require more than the friendship enhancement component of the programme.Journal of Family Therapy 08/2013; 35(3). · 0.94 Impact Factor
- Journal of Pediatric and Adolescent Gynecology 04/2012; 25(2):e31-e32. · 1.81 Impact Factor
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ABSTRACT: This study examined differences in marital satisfaction between first and second marriages and how additional factors can help explain satisfaction differences between the marriage types. Participants in first marriages reported higher levels of satisfaction than remarried individuals. Regression analyses demonstrated marriage type to be a moderator of satisfaction in second marriages; as education increased, satisfaction also increased. Length of marriage was found to significantly influence satisfaction in first marriages, but not second marriages. In both first and second marriages, participants currently in counseling reported lower satisfaction scores. The need to understand remarriages' distinct characteristics apart from first marriages is discussed.Journal of Divorce & Remarriage 01/2013; 54(1):78-93.
Traditional Versus Integrative Behavioral Couple Therapy for Significantly
and Chronically Distressed Married Couples
University of California, Los Angeles
David C. Atkins, Sara Berns, and Jennifer Wheeler
University of Washington
Donald H. Baucom
University of North Carolina, Chapel Hill
Lorelei E. Simpson
University of California, Los Angeles
A randomized clinical trial compared the effects of traditional behavioral couple therapy (TBCT) and
integrative behavioral couple therapy (IBCT) on 134 seriously and chronically distressed married
couples, stratified into moderately and severely distressed groups. Couples in IBCT made steady
improvements in satisfaction throughout the course of treatment, whereas TBCT couples improved more
quickly than IBCT couples early in treatment but then, in contrast to the IBCT group, plateaued later in
treatment. Both treatments produced similar levels of clinically significant improvement by the end of
treatment (71% of IBCT couples and 59% of TBCT couples were reliably improved or recovered on the
Dyadic Adjustment Scale; G. B. Spanier, 1976). Measures of communication also showed improvement
for both groups. Measures of individual functioning improved as marital satisfaction improved.
Over the past 30 years, dozens of clinical trials have demon-
strated the efficacy of couple therapy for improving relationship
satisfaction (see Baucom, Shoham, Mueser, Daiuto, & Stickle,
1998; Christensen & Heavey, 1999, for recent reviews). The
results were summarized well by Jacobson and Addis (1993): “in
no published study has a tested model failed to outperform a
control group. In virtually every instance in which a bona fide
treatment has been tested against a control group, the treatment has
shown reliable change” (p. 85). Not only does couple therapy
improve relationship satisfaction, couple therapy also has been
shown to be efficacious as an adjunctive treatment and as a
treatment in its own right for several Diagnostic and Statistical
Manual of Mental Disorders conditions, such as anxiety disorders,
depression, alcoholism, and sexual disorders (Baucom et al.,
There are several different types of couple therapies that are
empirically supported. Nine studies have provided empirical sup-
port for emotionally focused couple therapy (Johnson, Hunsley,
Greenberg, & Schindler, 1999) and Baucom et al. (1998) desig-
nated this treatment as “efficacious and possibly specific.” They
designated several additional therapies with more limited empiri-
cal support, such as cognitive and cognitive–behavioral couple
therapies, as “possibly efficacious” treatments. However, behav-
ioral marital therapy, or what we call traditional behavioral couple
therapy (TBCT),1is the only couple treatment that meets the
highest criterion of empirical support, that of an “efficacious and
specific treatment” (Baucom et al., 1998; Chambless & Hollon,
1998). This designation means that it has been shown to be more
effective than no treatment and to an alternative treatment (a
placebo intervention or a bona fide therapy) in at least two inde-
pendent research settings. Indeed, far more studies have been
conducted on TBCT than on any other couple therapy.
Although many practitioners use the term behavioral to describe
their work, our definition of TBCT is based on the procedures used
in clinical trials of behavioral approaches, particularly the treat-
ment manual of Jacobson and Margolin (1979), the most com-
monly used behavioral treatment manual. The focus in TBCT is on
making positive changes in each partner’s behavior so that they
provide one another with less punishing and more rewarding
interactions. The therapeutic strategy is directive and prescriptive
(or “rule governed”; Skinner, 1966). TBCT therapists first assess
the couple’s problems and strengths, provide feedback to them
about the assessment, and discuss the goals and procedures of
treatment. Therapists then assist couples in identifying positive
1The change from “marital therapy” to “couple therapy” reflects a
broadening of the emphasis from heterosexual married couples to all
romantically involved couples. The addition of “traditional” is intended to
distinguish this treatment from other behavioral approaches.
Andrew Christensen and Lorelei E. Simpson, Department of Psychol-
ogy, University of California, Los Angeles; David C. Atkins, Sara Berns,
and Jennifer Wheeler, Department of Psychology, University of Washing-
ton; Donald H. Baucom, Department of Psychology, University of North
Carolina, Chapel Hill.
This research was supported by National Institute of Mental Health
Grants MH56223, awarded to Andrew Christensen at the University of
California, Los Angeles (UCLA), and MH56165, awarded to Neil S.
Jacobson at the University of Washington (UW), for a two-site clinical trial
of couple therapy. After Jacobson’s death in 1999, William George served
as principal investigator at UW. The authors are grateful for the enormous
contributions of Neil Jacobson to this research. We also acknowledge the
excellent work of the therapists on the project: Alfreddo Crespo, Shelly
Harrell, Megan Sullaway, and Anthony Zamudio at UCLA and Peter
Fehrenbach, Carol Henry, Christopher Martell, and Debra Wilk at UW.
Correspondence concerning this article should be addressed to Andrew
Christensen, Department of Psychology, University of California, Los
Journal of Consulting and Clinical Psychology
2004, Vol. 72, No. 2, 176–191
Copyright 2004 by the American Psychological Association
actions they could take toward one another and direct them to
engage in these positive behaviors. Through instruction, modeling,
behavior rehearsal, and feedback, TBCT therapists teach partners
how to communicate and problem solve around their difficulties.
As couples make positive changes in their relationship, TBCT
therapists becomes less directive, with the expectation that couples
will begin to generalize skills learned in therapy to their daily lives.
The fact that TBCT has garnered the most research and the
highest classification of empirical support says little about its
power to effect change. For that, one must look at effect sizes and
rates of clinically significant change. In a meta-analysis of 17
TBCT studies, Hahlweg and Markman (1988) found an overall
effect size of .95 for TBCT, which is generally considered a large
effect size and certainly comparable to effect sizes found for
individual therapy. However, rates of clinically significant change
have been disappointing. For example, in an examination of 4
studies of TBCT that included a total sample of 148 participants,
Jacobson et al. (1984) found that 54.7% of couples showed reliable
improvement immediately after treatment. However, only 35.3%
of couples in the 3 clinical studies were recovered (reliable im-
provement and movement into the nondistressed range). Only
16.7% were recovered in an analogue study.
Unfortunately, not only is the immediate success of TBCT
disappointing, but there is also evidence of deterioration over the
long term. Studies have generally indicated maintenance of treat-
ment gains from 3 to 6 months following treatment with mixed
results for up to 1 year after treatment (Hahlweg & Markman,
1988; Jacobson et al., 1984). However, the only two studies in the
literature that have looked beyond a year after treatment find
substantial deterioration. Jacobson, Schmaling, and Holtzworth-
Munroe (1987) assessed 12 couples 2 years after TBCT and found
that 25% had deteriorated below their pretest functioning and 9%
had separated or divorced. In perhaps the most comprehensive
investigation to date of marital therapy, Snyder and his colleagues
(Snyder & Wills, 1989; Snyder, Wills, & Grady-Fletcher, 1991)
found that couples in TBCT were superior to the control condition
at termination and substantially maintained their improvement at
6-month follow-up. However, at the next assessment at 4 years
posttreatment, 38% of couples in TBCT were divorced. One pos-
sible explanation for these dramatic findings is that the changes
induced by behavioral marital therapy could not be maintained by
the couple and led to alienation and breakup.
Because of these limitations of TBCT, Christensen and Jacob-
son developed an alternative treatment program, integrative be-
havioral couple therapy (IBCT; Christensen, Jacobson, & Bab-
cock, 1995; Jacobson & Christensen, 1998), that builds on TBCT
but includes an emphasis on emotional acceptance. IBCT assumes
that there are genuine incompatibilities in all couples that are not
amenable to change, that partners’ emotional reactions to each
other’s behavior are at least as problematic as the behavior itself,
and that a focus on change can often lead to a resistance to change.
Therefore, emotional acceptance between partners is as much or
more a goal of intervention as is active change in the partner’s
behavior. Not only is the therapeutic focus of IBCT different from
that of TBCT, the treatment strategy is also different. Rather than
having a primary reliance on prescriptive, rule-governed changes,
IBCT emphasizes nondirective, “contingency-shaped” changes
(Skinner, 1966). Through a series of strategies that are described
later, IBCT therapists try to alter the context in the therapy session,
moving the partners from adversarial confrontation to collabora-
There have been three small empirical studies of IBCT. Wim-
berly (1998) demonstrated that 8 couples randomly assigned to a
group format of IBCT were significantly more satisfied than 9
wait-list couples at the end of therapy. In an unpublished study of
29 depressed women who were maritally distressed, Trapp, Pace,
and Stoltenberg (1997, cited in Christensen & Heavey, 1999)
showed that IBCT was as effective in reducing depression as
cognitive therapy for depression. Finally, in a clinical trial of 21
couples that served as a basis for the current clinical trial, Jacob-
son, Christensen, Prince, Cordova, and Eldridge (2000) demon-
strated that TBCT and IBCT could be distinguished when deliv-
ered by the same therapists according to independently coded
measures of adherence. Because of the small sample size of this
preliminary study, no statistical tests were conducted comparing
the two treatments. However, the effect size data and clinical
significance data favored IBCT. In combination, these three stud-
ies suggest that IBCT is a different therapy than TBCT and is a
viable treatment for marital discord.
The primary purpose of the current study is to examine the
overall and comparative efficacy of TBCT versus IBCT. To in-
crease the chances of finding a difference between these treat-
ments, we used the largest sample of couples in a randomized
clinical trial: 134 couples total, with 66 in IBCT and 68 in TBCT.
This contrasts sharply with the average of 10 couples per treatment
condition that Shadish et al. (1993) found in their review of marital
and family treatment studies. It is also greater than the 25–30
participants per condition that Chambless and Hollon (1998) rec-
ommended to show “a reasonably stable estimate of the effects of
treatment” (p. 9).
In addition, we selected only seriously and stably distressed
couples. Previous research has found that the greater the relation-
ship distress, the poorer the outcome in treatment (Halford, 2001;
Jacobson & Addis; 1993; Snyder, Mangrum, & Wills, 1993). We
reasoned that treatments would show their relative power most
clearly when faced with difficult cases. To be included in the
study, couples had to repeatedly report substantial relationship
distress. We wanted to exclude not only those couples who were
mildly distressed but also those couples whose scores in the
moderately to severely distressed range were unstable (e.g., a
couple who was especially distressed after a recent argument but
who would soon return to a higher and more typical level of
satisfaction). To examine the impact of severity on outcome, we
stratified these couples into severe and moderate levels of distress
and randomly assigned them to treatment within these levels.
Because most outcome studies of couple therapy assess couples
prior to treatment and at the end of treatment, little information is
available on change during the course of couple therapy. We do
not know, for example, whether improvement occurs gradually
and steadily over the course of treatment or whether there is a more
variable course, with perhaps surges early or late in treatment.
Halford (2001) has argued that change during TBCT often takes
place early in treatment, soon after assessment, feedback, and goal
setting. Some of his studies have included intrasubject analyses
and have shown that change occurs early in treatment with little or
no change later in treatment (e.g., Kelly & Halford, 1995). On the
basis of his work, we might predict that change in both types of
couple therapy, but particularly TBCT, would come early in treat-
TRADITIONAL VERSUS INTEGRATIVE COUPLE THERAPY
ment with lesser change later in treatment. In the current study, we
examine the impact of treatment both during and after treatment
Not only do most studies assess participants only at pre- and at
posttreatment, they examine average dyad scores rather than indi-
vidual partner or spouse scores (Dunn & Schwebel, 1995). There-
fore, we know little about the relative impact of treatment on men
versus women. However, we do know that women are more likely
to seek couple therapy than men (Doss, Atkins, & Christensen,
2003) and that men and women show many other differences on
relationship variables (Eldridge & Christensen, 2002). Further-
more, in a reexamination of the data from the outcome study by
Snyder and his colleagues, Kashy and Snyder (1995) found that
behavioral couple therapy was more effective for husbands but
insight-oriented couple therapy was more effective for wives.
Therefore, in the current study, we examine differential treatment
effects for husbands and wives.
Couples typically seek treatment to improve their happiness in
the relationship and to prevent separation and divorce. Similarly,
the most common outcome variables in research on couple ther-
apy, and possibly in research on couples in general, are satisfaction
and stability. Couple therapies, particularly behavioral therapies,
try to achieve these goals by improving communication, in part
because communication is a common presenting complaint. There-
fore, another common relationship outcome measure is communi-
cation. Some studies also assess individual functioning because
improvements in relationship satisfaction may also stimulate gen-
eral adjustment. In the current study, we examine all of these
outcome measures, including relationship satisfaction, stability,
communication, and individual adjustment.
On the basis of these considerations from the previous literature,
the current study has the following five hypotheses: (a) Both
TBCT and IBCT will lead to improvement in relationship and
individual outcomes; (b) these treatments will have their greatest
impact early in treatment with lesser impact later in treatment; (c)
IBCT will have a greater impact than TBCT on relationship and
individual outcomes; (d) these treatments will show the greatest
impact on moderately rather than severely distressed couples; and
(e) husbands and wives will respond differently to couple treat-
ment, with husbands possibly benefiting more from TBCT than
One hundred thirty-four seriously and chronically distressed married
couples were recruited for a therapy program in Los Angeles (71 couples)
and Seattle (63 couples). Newspaper advertisements, radio and TV an-
nouncements, and letters and brochures sent to clinics and practitioners
described a free therapy program for unhappy couples who wished to
improve their relationship.
The first 18 couples in Los Angeles and the first 8 couples in Seattle
were part of a pilot study to train therapists, to evaluate assessment
procedures, and to determine an optimal cutpoint for separating moderately
versus severely distressed groups of couples. Later, we describe procedures
for the study proper and note in a special section how a few procedures for
the pilot phase were different.
To be included in the study, all couples had to be legally married and
living together, had to request couple therapy, and had to meet criteria for
serious and stable marital distress. These distress criteria (described later)
are based on three measures of marital satisfaction that were completed at
three different time points prior to random assignment and treatment. As
evidence of the chronicity of the marital distress of these couples, approx-
imately half reported previously attending marital therapy with their cur-
To be included in the study, both partners had to have a high school
education or its equivalent, both had to be between the ages of 18 and 65,
and both had to be fluent in English. Each spouse was given a diagnostic
interview, but only diagnoses that might directly interfere with treatment
were excluded: current Axis I disorders of schizophrenia, bipolar disorder,
or alcohol/drug abuse or dependence or current Axis II disorders of
borderline, schizotypal, or antisocial personality disorder. To avoid con-
founding therapy results with the presence of alternative treatments, neither
partner could be in psychotherapy or, if he or she was, treatment needed to
be stopped for the duration of the marital therapy. Partners could be on
psychotropic medication if they had been taking the medication for a
minimum of 12 weeks, were on at stable dose for a minimum of 6 weeks
prior to the pretreatment assessment, and their physician, when contacted
by the project, did not anticipant changing medication or dosage. To ensure
that our sample did not include battering men, wife reports of violence
were used to eliminate couples in which husbands had engaged in danger-
ous levels of violence
The mean age of wives was 41.62 years (SD ? 8.59), and the mean age
of husbands was 43.49 years (SD ? 8.74). The mean number of years of
education (counting kindergarten) was 16.97 (SD ? 3.23) for wives and
17.03 (SD ? 3.17) for husbands. Couples had been married a mean of
10.00 years (SD ? 7.60) and had an average of 1.10 (SD ? 1.03) children.
Most of the participants were Caucasian (husbands: 79.1%, wives: 76.1%).
Other ethnicities include African American (husbands: 6.7%, wives:
8.2%), Asian or Pacific Islander (husbands: 6.0%, wives: 4.5%), Latino or
Latina (husbands: 5.2%, wives: 5.2%), and Native American or Alaskan
Native (husbands: 0.7%).
There were no treatment group, distress level, or site differences for age,
education, income, years married, or number of children. Pilot and study
proper participants were equivalent on these variables. Although there were
no treatment group differences for participants’ ethnic identity, there were
site differences. In particular, the ethnic composition of the husband
sample was not significantly different between the two sites, but the
composition of the wife sample did vary by site, ?2(4, N ? 134) ? 15.43,
p ? .01. Wives at the University of Washington (UW) site were more
likely to be Caucasian and less likely to be from a minority group than
wives at the University of California, Los Angeles (UCLA) site (Caucasian
wives: n ? 57 at UW, n ? 45 at UCLA).
All couples participated in a three-stage screening process that included
(a) a phone interview to assess basic demographic eligibility and marital
satisfaction, (b) a mailed packet of questionnaires to assess marital satis-
faction and domestic violence, and (c) an in-person intake evaluation to
assess marital satisfaction and conduct individual psychiatric interviews.
The length of time between the initial phone interview and the intake
evaluation averaged 6 weeks because of time taken by couples to return
mailed questionnaires and scheduling difficulties.
2After the first 35 cases, we began asking couples whether they had had
previous marital therapy. Of these 99 cases, in 45 couples both partners
agreed they had had previous marital therapy, 15 partners reported marital
therapy that was not corroborated by the other (perhaps because it was not
conjoint therapy), and 39 couples agreed that they had not had previous
marital therapy. Thus, a majority of those assessed in our sample had tried
marital therapy before, but it had not been successful in leaving them in an
enduring state of satisfaction.
CHRISTENSEN ET AL.
Marital Adjustment Test (MAT; Locke & Wallace, 1959).
a commonly used, well-validated self-report measure of marital satisfac-
tion. Potential participants were given a phone version of the MAT at Stage
1 of the screening process. If partners scored an average of less than 100,
a common cutoff for marital distress, then they were eligible to advance to
the next stage of screening.
Marital Satisfaction Inventory—Revised (MSI–R; Snyder, 1997).
MSI–R is a well-normed questionnaire that provides 2 validity scales, 1
global distress scale, and 10 scales assessing specific domains of marriage.
The Global Distress Scale (GDS) of the MSI–R is a measure of overall
dissatisfaction in the relationships and served as both a screening measure
and an outcome measure in this research. As part of the Stage 2 screening,
partners completed the full MSI–R. At the Stage 3 screening (the intake
session), partners completed only the GDS of the MSI–R as a final
verification of the stability of their distress. To be eligible for the study, at
least one partner had to attain a T score of 59 or higher on the GDS at both
Stage 2 and Stage 3 screenings.
Dyadic Adjustment Scale (DAS; Spanier, 1976).
and the GDS, the DAS is a widely used self-report measure of marital
satisfaction and perhaps the most widely used measure of couple treatment
outcome. At Stage 3 of screening (the intake assessment), at least one
spouse had to score at least one standard deviation below the population
mean (? 98) for the couple to be included in the study.
Conflict Tactics Scale—Revised (CTS–2; Straus, Hamby, Boney-McCoy,
& Sugarman, 1996).
Respondents reported verbal, sexual, and physical
aggression and physical injury that they had both inflicted and received
from their spouses on the CTS–2. On the basis of previously developed
criteria for defining male battering (Jacobson & Gottman, 1998; Jacobson
et al., 1994), we excluded couples with moderate to severe husband-to-wife
domestic violence from our study and referred them for specific, violence-
related individual treatment.
Structured Clinical Interview for DSM–IV (SCID).
graduate students conducted SCID interviews for Axis I (First, Spitzer,
Gibbon, & Williams, 1994) and Axis II (Spitzer, Williams, Gibbon, &
First, 1994) disorders and audio- or videotaped the interviews for interrater
reliability analyses. These graduate students assessed for both present and
past Axis I disorders, except for past substance abuse and dependence. To
calculate the reliability of these interviews, we randomly selected 41 tapes,
approximately 15% of these SCID interviews, ensuring that every inter-
viewer had at least one tape in this sample. Each of these taped interviews
was rated by an interviewer at the alternative site. Raters reached 88%
overall agreement on the presence or absence of a current diagnosis (? ?
.66, p ? .001) and 85% agreement on the specific diagnosis (? ? .57, p ?
.001). Raters reached 90% overall agreement on the presence or absence of
a past diagnosis (? ? .75, p ? .001) and 90% agreement on the specific
diagnosis (? ? .72, p ? .001).
As a result of these screening criteria, 94 couples were excluded because
they did not meet our criteria of marital distress (not sufficiently dis-
tressed); 101 couples were excluded because the husbands were too vio-
lent; and 3 were excluded because they met criteria for exclusionary
The MAT is
Along with the MAT
Our outcome measures assessed relationship satisfaction, relationship
stability, communication, spouses’ individual functioning, and client reac-
tions to treatment. At the intake assessment, at 13 weeks after intake, and
at 26 weeks after intake couples came to UW or UCLA for an evaluation
session and completed all of the outcome measures described later except
for the client reaction measures. At the end of the fourth therapy session,
clients completed the Short Therapeutic Bond measure (described in the
Therapeutic bond section) and sent it by mail to the project office. At
the end of the final treatment session, the therapist gave each couple the
relationship satisfaction and client evaluation of services measures. The
couple completed these measures and mailed them to the project.
ously, were the primary methods of assessing change in relationship
satisfaction. Each was administered at all four assessment sessions: intake,
13 week, 26 week, and final session.
The Marital Status Inventory (MSI; Weiss &
Cerreto, 1980) consists of 14 true–false items that measure steps toward
separation/divorce, ranging from thoughts (e.g., thinking of separation/
divorce after an argument), to tentative steps (e.g., talking to a friend), to
actual separation/divorce actions (e.g., moving out). Scores range from 0 to
14 depending on the number of steps the respondent has taken toward
divorce. Research has shown that the MSI can identify couples at risk of
divorce (Crane, Newfield, & Armstrong, 1984). The MSI was administered
at the intake and at 13-week and 26-week assessments. At intake couples
completed the questionnaire for their entire relationship. At 13 and 26
weeks, couples completed the measure with regard to the time period since
the last assessment.
Two subscales of the MSI–R were used to assess the
couples’ self-report of their communication: problem solving communica-
tion (PSC) and affective communication (AFC). The 19 true–false items on
the PSC reflect three domains: difficulty resolving minor differences, lack
of problem-solving skills, and inability to discuss sensitive issues. The 13
true–false items on the AFC reflect two dimensions: lack of support and
affection and limited disclosure of feelings or lack of understanding.
Snyder (1997) describes the extensive validation conducted on the MSI–R
and its subscales.
The Compass Outpatient Treatment Assess-
ment System (Sperry, Brill, Howard, & Grissom, 1996) includes three
self-report scales that evaluate patient functioning: Subjective Well-Being,
Current Symptoms, and Current Life Functioning. The Mental Health
Index (MHI) is the combination of these three scales converted into a T
score. The MHI has been evaluated on thousands of adult outpatients, has
an internal consistency of .87, and a 3–4-week test–retest stability of .82.
The scale is scored such that a higher score represents a more adaptive
status. In comparisons between a community and patient sample, T scores
of 60 or below characterized the patient sample. In addition to the MHI, we
also examined the Current Symptoms (CS) subscale. Like the MHI, the CS
has been evaluated on thousands of adult outpatients, has an internal
consistency of .94, and a 3–4-week test–retest stability of .85. Currently it
is scored such that higher T scores indicate more symptoms. In compari-
sons between an outpatient and community sample, a T score of 40 or
above characterized the patient sample. All T scores were calculated on the
basis of recent normative data provided by Kenneth Howard and his staff
(personal communication, May 28, 1998).
The DAS and the GDS, discussed previ-
Client Reactions to Treatment
items designed to assess working alliance, empathic resonance, and mutual
affirmation (2 items for each). It is based on a 12-item Therapeutic Bond
Scale (Sperry et al., 1996), which in turn was based on the original, 50-item
Therapeutic Bond Scale (Saunders, Howard, & Orlinsky, 1989). The sum
of the 6 items is converted into a T score, based on results from a large
population of 1958 outpatients. Alpha on this measure from that population
Client evaluation of services.
The Client Evaluation of Services Ques-
tionnaire included the eight-item Client Satisfaction Questionnaire (CSQ-
8), which is a brief version of a larger Client Satisfaction Questionnaire
(Nguyen, Attkisson, & Stegner, 1983). On 4-point scales, clients rate the
effectiveness and their satisfaction with the services they received. The
scale has an alpha of .93. In a sample of several thousand clients at various
psychiatric facilities, the average total score on the CSQ-8 was 27.09 with
a standard deviation of 4.01.
To optimize honest reporting on both of these measures, we had couples
mail their questionnaires directly to the project, and we told couples that
their therapist would not see their answers.
The Short Therapeutic Bond Scale consists of 6
TRADITIONAL VERSUS INTEGRATIVE COUPLE THERAPY
After couples had successfully completed the three-stage screening
procedures (the last stage of which was the intake), they were given the
name of a project therapist and instructed to schedule their first appoint-
ment. After scheduling their first appointment with the therapist, couples
were randomly assigned to one of the two treatment conditions. A total of
68 couples were assigned to TBCT and 66 to IBCT.
Criteria for the stratification into moderately and severely distressed
groups were obtained from the pilot portion of the study on the basis of
average scores of husband and wife on the DAS and GDS. The average
DAS scores were first converted to a T score, and then the GDS and the
DAS were averaged so that higher scores would indicate greater distress.
A median split of the pilot sample created the criteria (T ? 66) for the two
groups. Mean scores for the moderately distressed couples were 62.7,
whereas the mean scores for the severely distressed couples were 70.6.
Snyder (1997) found that couples with an intake GDS T score of 66 or
higher who received treatment had a 45% chance of eventually divorcing,
suggesting that our severely distressed couples are at high risk for divorce,
even with treatment.
During the study-proper phase of the study, couples were randomly
assigned to TBCT or IBCT within the two strata of moderately or severely
distressed couples. Combining pilot and study-proper couples, there were
66 moderately distressed couples and 68 severely distressed couples. A
chi-square analysis of the number of moderately and severely distressed
couples in TBCT and IBCT was nonsignificant. An analysis of the com-
bined DAS and GDS T scores indicated, as expected, a major significant
effect of stratification (p ? .001) but no significant effect of therapy
condition and no significant interaction of Therapy Condition ?
In both treatment conditions, couples completed a four-session sequence
of evaluation and feedback. In the first session, attended by both husband
and wife, the therapist inquired about the presenting problems and obtained
a brief relationship history of the couple. The next two sessions were
individual contacts with the husband and wife separately, in no predeter-
mined order. In these sessions, the therapist obtained more information
about the presenting problems and obtained an individual history from each
partner. Finally, in the fourth session, the therapist obtained any additional
needed information and provided the couple with feedback, appropriate to
their treatment condition, about their problems and about their upcoming
treatment. The remaining sessions were devoted to treatment procedures
and, toward the end, preparing for termination. Because of the level of
distress, both treatments were designed to allow for a relatively lengthy
course of treatment, if needed. Couples were told that they could have a
maximum of 26 sessions but could end earlier if they felt their problems
were sufficiently resolved. These sessions would normally occur once a
week but had to be completed within a year.
The mean number of sessions was 22.9 (SD ? 5.35; median and mode
were 26), and the median length of time to complete these sessions was 36
weeks. Mean number of sessions was not significantly different in IBCT
(M ? 23.5, SD ? 4.7) than in TBCT (M ? 21.7, SD ? 6.9), nor were they
significantly different in moderately (M ? 22.4, SD ? 6.7) and severely
distressed (M ? 22.7, SD ? 5.3) conditions. In previous research on couple
therapy, 10 has been the mean and modal number of sessions (Vu &
Christensen, 2003). Therefore, given that some couples ended their treat-
ment prior to the maximum number of sessions we allowed and given our
desire to include as a treatment completer all couples who had completed
a substantial number of sessions, we used 10 or more sessions as our
definition of “treatment completer.” Of the 134 couples, 126 (94%) were
considered “completers.” Of the 8 couples who did not complete therapy,
1 was in IBCT and 7 were in TBCT (Fisher’s exact test probability ?
Couples were recruited sequentially in five cohorts of about 12 couples
at each site (with more couples in the last cohort) between November 1997
and February 2001. The first cohort consisted of the pilot cases.
through direct instruction and skill training. During the feedback session,
the therapist emphasizes the strengths of the couple and delineates specific
problem areas that could be the target for later communication and
problem-solving efforts. During treatment the therapist relies on three
primary treatment strategies: behavioral exchange, communication train-
ing, and problem-solving training. In behavioral exchange, the therapist
structures direct efforts to increase mutual, positive behavior exchange. For
example, the therapist might engage each spouse in generating a list of
specific, positive, noncontroversial behaviors that they could do for the
partner. This list might then be enhanced with input from the partner. When
both partners have a list of positive actions, the therapist might encourage
each spouse to perform activities from the list in an effort to increase
mutual positive reinforcement. In communication-skills training, the ther-
apist teaches partners both speaking and listening skills. Speaking skills
might include a focus on “I” statements and teaching partners to specify
their emotions and behavior (for example, learning to say “I feel disap-
pointed when you come home late without calling” vs. “You are so selfish
and inconsiderate”). Listening skills emphasize each partner learning to
paraphrase or summarize the other’s message. In training problem-solving
skills, the therapist teaches couples how to define problems, to generate
positive alternatives to current problem behavior, to evaluate the pros and
cons of those alternatives, to negotiate alternatives, and to implement and
evaluate planned change.
The treatment manual for TBCT is Jacobson and Margolin’s (1979)
classic monograph, supplemented by a shorter, updated, more succinct
treatment manual (Jacobson & Christensen, 1994). Couples were also
given a communication guide by Gottman, Notarius, Markman, and Gonso
(1977), which they read, in part, during the communication-training seg-
ment of the therapy.
IBCT was designed to enhance TBCT by adding a focus on
emotional acceptance. This focus is based on several assumptions: All
close relationships are characterized by some genuine incompatibilities, the
reactions to problem behavior are often as problematic as the behavior
itself, and direct change efforts are often as much a problem for couples as
they are a solution. Therefore, IBCT focuses more on the emotional
reactions of partners to the difficulties they encounter in their relationships
and less on the active solutions they can take to resolve these difficulties,
especially for what seem to be insoluble problems. During the feedback
stage, the therapist focuses on broad themes in the struggle between
spouses rather than on particular problematic issues. The therapist offers a
formulation of the couple’s difficulties in terms of the differences between
them, the understandable though often ineffective or self-defeating actions
that each has taken, and the natural emotional reactions that each experi-
ences. The therapist also describes the realistic strengths the couple has and
offers the possibility that, through an examination of their daily emotional
hurts and struggles, they may come to a greater understanding and appre-
ciation of each other’s emotional reactions and to a greater closeness.
During the treatment phase, the focus of the sessions is usually on a
salient incident that recently occurred (e.g., an argument last night), will
soon occur (e.g., a trip to her mother’s this weekend), or is now occurring
(e.g., a spouse feels invalidated by the other’s reaction in the session). The
therapist uses three major strategies to promote emotional acceptance:
empathic joining around the problem, unified detachment from the prob-
lem, and building tolerance to some of the responses that the problem can
trigger. To facilitate empathic joining around the problem, the therapist
attempts to elicit vulnerable feelings from each spouse that may underlie
emotional reactions to the problem. The therapist encourages partners to
express and elaborate these feelings, and he or she communicates empathy
for having these understandable reactions. By taking this stance toward
both partners, the therapist may also elicit empathy between the partners
for each other. To facilitate unified detachment from the problem, the
therapist helps the couple to step back from the problem and take a
descriptive rather than evaluative stance toward the problem. The therapist
The goals of TBCT are to promote positive change in couples
CHRISTENSEN ET AL.
may engage the couple in an effort to describe the sequence of actions they
take during their problematic pattern, to specify the triggers that activate
and escalate their emotions, to consider variations of their patterned be-
havior and what might account for these variations (e.g., a typical struggle
over their child was less intense because they had felt close to each other
earlier), and to generate a name for their problematic pattern. To facilitate
tolerance building, the therapist engages the couple in an analysis of the
positive functions as well as the negative functions of their differences and
their problematic behavioral patterns. The therapist might encourage the
couple to deliberately engage in the problem behavior during the session or
at home, so that each partner can become more aware of the pattern and
take it less personally. The IBCT therapist is also free to use the direct
change efforts of TBCT described previously. Some of the specific strat-
egies of IBCT are similar to strategies described by other approaches, such
as those of Wile (2002) and Johnson and Denton (2002).
The treatment manual for IBCT was a book by Jacobson and Christensen
(1998), which was supplemented by a chapter by Christensen et al. (1995).
Couples were also given a self-help book about IBCT by Christensen and
Jacobson (2000) to read during treatment.
Ensuring Treatment Quality and Integrity
Therapist selection, training, and supervision.
licensed, and experienced therapists practicing in the community. Four
doctoral-level clinical psychologists in Los Angeles and three in Seattle, all
with between 7 and 15 years experience postlicensure, were selected on the
basis of their expertise and reputation.3Therapists were trained in the
protocol by (a) reading the treatment manuals and (b) attending a workshop
by either Christensen or Jacobson. They then began treating cases. The first
four cases that each therapist saw were deemed training cases and are part
of the pilot sample (described later).
It was important to ensure that therapists received expert supervision in
both TBCT and IBCT. Two of the supervisors, Christensen and Jacobson,
were experts in TBCT and had published outcome research and reviews on
TBCT. Jacobson in particular had a long record of clinical research in
TBCT, having written perhaps the its most widely used treatment manual
(Jacobson & Margolin, 1979). Christensen and Jacobson had also devel-
oped IBCT together and written the treatment manuals for it (Christensen
et al., 1995; Jacobson & Christensen, 1998). A third supervisor, Peter
Fehrenbach, was a therapist on the initial study of TBCT and IBCT
(Jacobson et al., 2000) and was considered an expert on both. When
Jacobson died, Don Baucom, an expert on TBCT who had published
extensively on behavioral approaches with couples, was brought in to
supervise many of the TBCT cases.
Intense supervision of therapists was maintained throughout the project
to ensure adherence to treatment protocol and competence in treatment
delivery. Throughout the study, therapists sent audio- and/or videotapes of
their sessions to the supervisors each week. The supervisors observed the
sessions and provided feedback to therapists prior to their next meeting.
For the first half of the study, but particularly during the pilot phase,
supervisors listened to almost all of every tape from every session and then
talked on the telephone with the therapist prior to the next session. During
the second half of the project, supervisors often listened to only parts of
sessions or skipped occasional entire sessions on the basis of feedback
from the therapists. Commentary was provided by e-mail as well as phone.
However, even during this phase, the supervisor observed a majority of the
therapy and provided commentary between most sessions.
Measures of therapy adherence.
the preliminary study of TBCT and IBCT (Jacobson et al., 2000), includes
eight items reflecting change-oriented interventions and nine items reflect-
ing acceptance-oriented interventions. One case from each of the five
cohorts was randomly selected from each of the seven therapists with
alternation across cohorts between TBCT and IBCT cases. This procedure
yielded 35 cases (26% of all cases). Within each case at least one early, one
middle, and one late therapy session was randomly selected from the
We sought well-trained,
Our adherence scale, developed for
sessions following the first four sessions (assessment and feedback), gen-
erating a total of 115 sessions (16% of the possible sessions). Three senior
graduate students independently coded each of these sessions for adherence
to treatment protocol.
Our experience in our initial study (Jacobson et al., 2000), as well as in
the current study, demonstrated that graduate students cannot remain
uninformed as to treatment assignment. Knowing IBCT and TBCT, they
can immediately determine from observing the tapes which condition the
couple has been assigned. Therefore, we also used undergraduate observers
who had no knowledge of IBCT or TBCT as adherence raters. Over the
course of the study, 11 undergraduate observers rated the 35 cases de-
scribed above, but coded two early, two middle, and two late therapy
sessions, a total of 208 or 30% of possible sessions that were randomly
selected. Prior to rating these tapes, these undergraduate observers were
extensively trained in a coding system that was based on the system
described but only included four 9-point scales: the extent to which
therapists (a) set and followed an agenda, (b) engaged in change oriented
strategies, (c) engaged in acceptance based strategies, and (d) assigned and
checked homework (Jacobson et al., 2000).
Measures of therapist competence.
fair test in the current study, an outside consultant who had no other
connection with the project, Gayla Margolin, was hired to assess compe-
tence. As the coauthor of our treatment manual for TBCT (Jacobson &
Margolin, 1979), she was the best available judge of competence. She used
the Behavioral Couple Therapy Competence Rating Scale (Jacobson et al.,
2000) to evaluate one randomly selected case from each of the seven
therapists. This manual describes 10 skills essential to good TBCT (9 are
rated on 6-point scales, 1 is rated on a 12-point scale). Competence cannot
be judged on isolated sessions; it can only be judged with an understanding
of the case. Therefore, for each case, Margolin observed the first four
sessions (the first joint session and the two individual sessions, which
constituted the evaluation sessions, and the 4th session, which was the
feedback session) to get an understanding of the case. Then she observed
and rated a randomly selected sequence of three consecutive sessions from
the first half of treatment and a randomly selected sequence of three
consecutive sessions from the second half of treatment. Her ratings were on
consecutive sessions so that she could see the continuity between sessions.
Thus, she observed 70 sessions of TBCT but rated only 42 sessions for
To ensure that TBCT received a
Procedures for Pilot Cases
Therapists were trained and procedures were developed on the first 26
couples, who were designated as pilot cases. Each therapist saw two
couples in each condition and was supervised by all three supervisors.
However, in Los Angeles, four therapists were trained on 18 cases because
two couples had to leave treatment early and therefore two cases were
added. In Seattle only two of the therapists needed training, which required
8 cases (two therapists had worked on the initial study so did not need
training). During the pilot study, we did not have an upper age limit and
included one couple over 65. Also, we excluded potential participants for
substance dependence but not substance abuse and had one couple in which
the husband met criteria for substance abuse. We developed our criteria for
moderate and severe distress on the basis of a median split of the combined
GDS and DAS scores of pilot couples. Therefore, in the pilot study,
classification into severe and moderate levels of distress was done after
randomization to treatment conditions. Finally, some assessment proce-
dures were done differently in the pilot study than in the study proper. For
example, we did not have a separate GDS for the pilot study but only the
3At the Seattle site, one master’s-level family therapist was selected on
the basis of expertise and reputation but left for personal reasons after
treating only two cases, one in IBCT and one in TBCT.
TRADITIONAL VERSUS INTEGRATIVE COUPLE THERAPY
GDS from the MSI–R. Also, the DAS was sent out at the Level 2 screening
(the mailed packet) rather than at intake. Because of these differences
between pilot and study proper cases, we examine whether these differ-
ences led to changes in treatment effectiveness.
graduate students coded 58 sessions of TBCT and 57 sessions of
IBCT. On two major summary scores of IBCT interventions and
TBCT interventions, alpha reliabilities computed across coders
were .93 and .97, respectively. Mann–Whitney’s nonparametric
tests indicated that, as expected, TBCT interventions were much
more likely in TBCT sessions (p ? .001) and IBCT interventions
were much more likely in IBCT sessions (p ? .001). Using a
global coding system, 11 undergraduates rated 101 sessions of
TBCT and 107 sessions of IBCT. Alpha reliabilities for the four
global ratings were .75 for agenda, .93 for change, .92 for accep-
tance, and .83 for homework. Mann–Whitney’s nonparametric
tests indicated that TBCT and IBCT differed in expected ways on
each dimension (p ? .001). In fact, therapists in IBCT engaged in
about three times more acceptance strategies than therapists in
TBCT, who engaged in about three times more change strategies
than therapists in IBCT. Clearly, therapists were performing dif-
ferent treatments, in accord with each treatment protocol, in IBCT
and TBCT sessions.
Across 42 sessions from a total of seven cases,
Gayla Margolin’s ratings on the Behavioral Couple Therapy Com-
petence Rating Scale averaged 52.1 (or a rating between good and
excellent). Average scores for each case ranged from a low of 33.3
(a score midway between mediocre and good) to a high of 60.9 (a
score just under the maximum possible of 66).
Using our detailed adherence coding system, three
To examine the impact of our treatments across our repeated
assessments (intake, 13-week, 26-week, and final session), we
used hierarchical linear modeling (HLM; Raudenbush & Bryk,
2002), which has also been referred to as multilevel modeling
(Snijders & Bosker, 1999) and mixed-effects modeling (Pinheiro
& Bates, 2000). There are several important advantages of HLM
over other common approaches to repeated measures data, such as
repeated measures analysis of variance and analysis of covariance.
Most other approaches assume that all participants are assessed at
identical and equally spaced intervals, an assumption that is rarely
true. In the current study, participants were not assessed at exactly
13 and 26 weeks after treatment began and the final session
assessment varied notably between couples. The maximum likeli-
hood estimation used in HLM allows the data to be unbalanced.
Thus, participants need not be assessed at the same time or provide
data at every time point. Other statistical approaches often drop
participants who have missing data whereas HLM uses all avail-
able data and generates unbiased empirical Bayes’s estimates for
each individual in the analysis. Finally, HLM is uniquely suited for
the dependencies in couple data in which spouses’ data are often
HLM proceeds in two broad stages. It first creates trajectories of
each individual based on the available data from that individual
and describes a linear or curvilinear model of change that fits these
data. For the present data, each individual’s repeated measures
were fit with an intercept, slope, and quadratic. The intercept
estimates the initial level of distress of an individual when he or
she began treatment. The slope estimates the linear change over
time, either constant improvement or deterioration, and the qua-
dratic component captures any acceleration or deceleration in the
change that may occur. Then, each of these Level 1 parameters are
treated as outcome variables to be explained by predictors at
higher levels.4To test our first hypothesis, that change occurs over
the course of treatment, we examine the slope of the trajectories.
To test our second hypothesis, that change slows later in treatment,
we examine the quadratic component of the trajectories to see if
there is a flattening out of change over time. To test our third
hypothesis of differential treatment effects, we examine whether
our two treatments have different effects on the slope and qua-
dratic shape of couples’ trajectories. To test our fourth hypothesis,
that change occurs differently for husbands and wives, we compare
the slope and quadratic shape of husband and wife trajectories. To
test our fifth hypothesis, that change occurs differently for severely
distressed versus moderately distressed couples, we examine
whether the trajectories of these two groups of couples demon-
strate different slopes and quadratics. In addition to these hypoth-
eses, we compare the trajectories of pilot participants versus study-
proper participants (because both are included in the analyses) and
of our two research sites. Univariate analyses were conducted with
SPSS v11.0.1 (SPSS, 2001); HLM analyses were conducted using
the nlme library of functions (Pinheiro & Bates, 2000) in S-Plus
2000 Professional Release 2 (Mathsoft, 1999), and generalized
linear mixed model (GLMM) analyses used the glmmPQL func-
tion in the MASS library (Venables & Ripley, 1997) in R v1.4
(Ihaka & Gentleman, 1996).
We examined the impact of our
treatments on our two measures of marital satisfaction, the DAS
and the GDS. Because previous research by Whisman and Jacob-
son (1992) has shown that the DAS is the more sensitive measure
of change, we examined it first.
Table 1 presents the means and standard deviations for DAS
scores for husbands and wives in TBCT and IBCT. The slope of
4Most HLM analyses with couple data have followed the methods of
Raudenbush, Brennan, and Barnett (1995), in which husbands’ and wives’
trajectories are represented in a two-level multivariate model. For the
present analyses, we used a three-level model with repeated measures,
individuals, and couples as the three levels. For the majority of analyses,
the data were represented well by a random intercept at the individual level
and random effects for intercept, slope, and quadratic at the couple level.
The reason for modeling the present data in this manner is twofold. The
current analyses pertain to a relatively brief period of time in which both
partners are actively engaged in therapy. Thus, partners’ data are extremely
correlated, especially change over time. This led to extreme correlations
among the random effects using Raudenbush et al.’s (1995) approach with
some models. In addition, the three-level model is more parsimonious in its
representation of the random effects. Raudenbush et al.’s (1995) model
uses 22 parameters in estimating the random effects, whereas the three-
level model uses only 8 parameters. Comparisons between the two-level
and three-level representations using Akaike’s information criterion
(Akaike, 1974) and Bayes’s information criterion (Schwarz, 1978) favored
the three-level model in the present analyses.
CHRISTENSEN ET AL.
the trajectory of the DAS across intake, 13-week, 26-week, and
final session assessments was highly significant, B ? 0.365, SE ?
0.078, t(723) ? 4.71, p ? .0001. Overall, couples were improving
in their marital satisfaction over treatment at the rate of 0.37 DAS
points per week.5The pre- to posttreatment effect size of this
overall change during treatment was d ? .86. The quadratic effect
(a deceleration or flattening out of the rate of change over time)
was not significant, B? ?0.002, SE ? 0.002, t(723) ? ?1.126,
ns. Thus, considering both therapies together, there was no evi-
dence that couple therapy had its primary impact early in
There was a significant effect of therapy on the slope,6B ?
0.170, SE ? 0.078, t(723) ? 2.19, p ? .03, d ? .58,7and a
significant effect of therapy on the quadratic, B ? ?0.004, SE ?
0.002, t(723) ? ?2.053, p ? .05, d ? .62. These interactions can
be seen in Figure 1, which plots the predicted DAS values for each
of the two treatments over time. TBCT couples improved more
quickly than IBCT couples but then plateaued while IBCT couples
showed slow but steady improvement across treatment with no
flattening out or deterioration.
There was no effect of gender on the intercept. However, there
was a significant gender effect on the slope, B ? 0.105, SE ?
0.050, t(717) ? 2.11, p ? .05, d ? .37, but not on the quadratic,
B ? ?0.002, SE ? 0.001, t(717) ? ?1.711, p ? .10. Husbands
progressed more quickly in treatment than wives.
As expected, there was a significant effect of stratification8on
the intercept of DAS scores, B ? ?8.536, SE ? 0.727, t(130) ?
?11.742, p ? .0001. There was no significant impact of stratifi-
cation on the slope, but there was a significant impact of stratifi-
cation on the quadratic, B ? ?0.005, SE ? 0.002, t(717) ? ?2.72,
p ? .01, d ? .88. As compared with moderately distressed couples,
severely distressed couples showed a greater slowing or flattening
out of satisfaction over time.
There was no significant effect of pilot versus study proper
cases on the intercept of DAS scores. However, there was a
significant pilot effect on the slope of DAS scores, B ? 0.25, SE ?
0.103, t(717) ? 2.43, p ? .05, as well as a significant pilot effect
on the quadratic, B ? ?0.004, SE ? 0.002, t(717) ? ?2.151, p ?
.05. Compared with study proper cases, pilot cases showed greater
improvement early on in treatment but then showed a greater
deceleration or flattening out later in treatment. There were no
significant effects for site. Nor did we find significant effects for
Next, we computed clinical significance statistics using average
couple DAS scores by treatment condition. We computed clinical
significance using the method described in Jacobson and Truax
(1991). Because there is normative information for the DAS
(Spanier, 1976), we used their “cutoff c” for our calculations,
which is the midpoint between the normative mean and the pre-
therapy mean. With the present data, this yielded a cutoff score of
96.8, which is slightly lower than one standard deviation below the
normative mean. Our categories of clinical significance are dete-
riorated (reliable change in a negative direction; separation, or
dropout of treatment because of doing poorly), no change (no
reliable improvement in either direction), improvement (reliable
5This interpretation of the slope is correct initially (i.e., at the intercept).
However, if there are significant higher order terms in the model, such as
a significant quadratic, the rate of change is affected accordingly.
6Categorical variables were coded using effect contrasts. For therapy,
TBCT was coded as 1 and IBCT was coded as –1. Thus, the coefficient
represents the deviation of each therapy from the overall slope (i.e., IBCT
slope coefficient is 0.195; TBCT slope coefficient is 0.535).
7At the present time, there is not a universally accepted approach to
calculating effect sizes in HLM analyses. We have followed the recom-
mendation of Raudenbush and Liu (2001) for binary predictors by dividing
the fixed effect estimate by the square root of the corresponding random
effect (see those authors’ Footnote 4 on p. 391 for differences between their
approach and Cohen’s d).
8Including stratification as a fixed effect predictor of the intercept led to
a huge decrease in the random variation at the intercept. This is to be
expected because the stratification variable is based on pretreatment mar-
ital satisfaction scores. Thus, models with stratification as a predictor have
random effects at the couple level for slope and quadratic but not intercept.
Dyadic Adjustment Scale and Global Distress Scale Scores for Wives and Husbands in
Traditional Behavioral Couple Therapy (TBCT) and Integrative Behavioral Couple Therapy
Pretreatment Week 13Week 26Final session
M SDM SDM SDM SD
Dyadic Adjustment Scale
Global Distress Scale
TRADITIONAL VERSUS INTEGRATIVE COUPLE THERAPY
change in a positive direction but not reaching the normal range),
and recovery (reliable change in a positive direction and reaching
the normal range—i.e., DAS ? 96.8). Table 2 provides these data
on the DAS. In IBCT, 71% of couples showed reliable improve-
ment or recovery. In TBCT, 59% of couples showed reliable
improvement or recovery. A chi-square test examining whether
therapy condition was independent of outcome was nonsignificant,
?2(3, N ? 130) ? 3.32, p ? .34. Not surprisingly, there was a
significant difference in clinical outcome between moderately and
severely distressed couples, ?2(3, N ? 130) ? 13.90, p ? .0030.
For DAS, 73% of the moderately distressed were improved or
recovered, whereas 54% of the severely distressed were improved
Next, we examined the GDS. Table 1 presents the means and
standard deviations for GDS scores for husbands and wives in
TBCT and IBCT. The slope of the trajectory of the GDS across
intake, 13-week, 26-week, and final session assessments was
highly significant, B ? ?.125, SE ? 0.037, t(675) ? ?3.38, p ?
.001.9Overall, couples were decreasing in their global distress
over treatment at the rate of 0.13 GDS T-score points per week.
The pre- to posttreatment effect size of this change was d ? .85.
There was no statistically significant quadratic effect (a decelera-
tion or flattening out of the rate of change over time), B ? 0.000,
SE ? 0.001, t(675) ? ?0.33, ns. Thus, there was no evidence that
couple therapy has its primary impact early in treatment. There
were also no main effects of therapy, no significant Therapy ?
Time effects or Therapy ? Quadratic effects. Couples were im-
proving on the GDS but not differentially by treatment condition.
As with the DAS, we examined the impact of gender of spouse,
stratification into high and moderate distress, pilot versus study
proper cases, and the two sites. There was a significant effect of
gender on the intercept, B ? 1.948, SE ? 0.330, t(131) ? 5.89,
p ? .0001, with men evidencing more distress at the start of
treatment than women. Because this measure is gender normed, it
means that men were more distressed, relative to other men, than
women were, relative to other women. There was also a significant
gender effect on the slope, B ? ?0.061, SE ? 0.027, t(669) ?
?2.28, p ? .05, d ? .22, with husbands showing greater change
over time than wives, but not showing a significant gender effect
on the quadratic, B ? 0.001, SE ? 0.001, t(669) ? 1.74, p ? .10.
As expected, there was a significant effect of our stratification at
the intercept, B ? 2.75, SE ? 0.340, t(128) ? 8.08, p ? .0001.
However, there were no interactions between stratification and
time or stratification and the quadratic. Furthermore, there were no
other significant effects.
In comparing the findings of the DAS and GDS, there are
notably fewer significant findings with the GDS. Moreover, there
were some strong differences between the DAS and GDS HLM
models in the reliabilities of the random effects (not shown). With
both measures, the reliability of the quadratic component was
somewhat lower than the reliabilities for the intercepts and slopes,
which would be expected with only four total data points. How-
ever, the reliability of the random effect of the slope for the GDS
was also quite low. The empirical Bayes’s estimates of the random
effects are “shrunken” toward the mean effects based on the
reliabilities. Thus, the GDS slope and quadratic random effects
were largely determined by the group means leading to very high
correlations among the GDS random effects. In addition, Rauden-
bush and Liu (2001) have shown that the power of a fixed effect
depends on the reliability of the random effect. Thus, the lower
reliabilities for the GDS affect the power to find effects and may
partly explain the differences between the DAS and GDS.
One possible explanation for the low reliability of the GDS
change components pertains to the historical nature of some GDS
items. Some GDS items are historical (e.g., “My partner and I have
never come close to ending our relationship”) and would thus not
be expected to change during therapy. However, it is possible that
9Unlike the DAS, the GDS was not given at all time points to the pilot
couples, which accounts for the slightly lower degrees of freedom for the
Integrative (IBCT) Behavioral Couple Therapy.
Predicted Dyadic Adjustment Scale (DAS) scores over treatment for Traditional (TBCT) and
CHRISTENSEN ET AL.
some participants answered these questions with respect to their
last assessment point. To the extent that some individuals may
have answered historical items in a literal sense, whereas others
answered them relative to their last assessment, this would increase
the measurement error of the GDS, particularly with respect to
change over time, and may have contributed to low reliabilities.
As we did with the DAS, we computed percentages of couples
who achieved clinically significant change on the GDS. Table 2
presents these data. In IBCT, 65% of couples showed reliable
change or recovery; the comparable figure for TBCT was 57%.
Chi-square analyses revealed no significant differences in outcome
between therapy conditions, ?2(3, N ? 130) ? 5.43, p ? .14.
However, as with the DAS, there was a significant difference in
clinical outcome between moderately and severely distressed cou-
ples, ?2(3, N ? 130) ? 19.81, p ? .0001. On the GDS, 67% of the
moderately distressed were improved or recovered while 53% of
the severely distressed were improved or recovered.
Table 3 presents the means, medians,
and standard deviations of the MSI for husbands and wives in
TBCT and IBCT. The MSI was highly skewed; the median MSI at
13 weeks and 26 weeks is 1 in most cases. Thus, most couples are
reducing the number of steps and bottoming out at 0 or 1 step,
which is the normal level, but a few couples are remaining unstable
or becoming more so. This nonnormal distribution of the MSI is
best represented by the Poisson distribution, which is often used
for rate or count variables (Long, 1997). Therefore, we modeled
the changes in MSI using a GLMM with a Poisson distribution and
log link (Breslow & Clayton, 1993; Raudenbush & Bryk, 2002). In
examining the data below, it is important to remember that the
coefficients reported are on the log scale.
Looking at the basic model, we find that the slope of the
trajectory is significantly decreasing over time, B ? ?0.069, SE ?
0.009, t(455) ? ?8.08, p ? .0001. However, there is also a
significant quadratic effect, B ? 0.001, SE ? 0.000, t(455) ? 4.77,
p ? .0001. Because GLMM models are inherently nonlinear, it is
usually recommended that significant effects be portrayed through
plotting the estimated regression line or providing estimates at
meaningful values of the covariates (Long, 1997). The estimated
regression values at pretreatment and 26-week assessment are 3.6
and 1.6, respectively. A plot of the regression line (not shown)
demonstrates that marital instability is decreasing over time, but
the primary decrease occurs during the early stage of treatment and
then “bottoms out.” There were no significant Therapy ? Time or
Therapy ? Quadratic interactions.
We also looked at the impact of gender of spouse, stratification
into high and moderate distress, pilot versus study proper cases,
and the two sites. There was no impact of site, pilot, or gender. As
expected, there was a main effect of stratification, B ? ?0.303,
SE ? 0.055, t(131) ? ?5.52, p ? .0001. Severely distressed
couples were more unstable than moderately distressed couples.
There was a significant Gender ? Stratification interaction on the
quadratic, B ? 0.001, SE ? .000, t(445) ? 2.03, p ? .05. In
severely distressed couples, husbands’ stability flattened out more
so than wives’. This pattern was somewhat reversed in moderately
distressed couples. There were also significant Stratification ?
Therapy interactions on the slope, B ? ?0.207, SE ? 0.009,
Clinically Significant Outcome on the Dyadic Adjustment Scale and the Global Distress Scale
for Couples in Traditional Behavioral Couple Therapy (TBCT) and Integrative Behavioral
Couple Therapy (IBCT)
MeasureDeteriorated Unchanged ImprovedRecovered
Dyadic Adjustment Scale
Global Distress Scale
the Dyadic Adjustment Scale or Global Distress Scale at or near treatment end.
Clinical significance could not be computed for two TBCT and two IBCT couples, who did not complete
The Marital Status Inventory for Wives and Husbands in Traditional Behavioral Couple Therapy
(TBCT) and Integrative Behavioral Couple Therapy (IBCT)
PretreatmentWeek 13 Week 26
M Mdn SDMMdn SDMMdn SD
TRADITIONAL VERSUS INTEGRATIVE COUPLE THERAPY
t(445) ? ?2.326, p ? .02, and on the quadratic, B ? 0.001, SE ?
0.000, t(445) ? 2.39, p ? .05. TBCT and IBCT performed
similarly for severely distressed couples but TBCT performed
somewhat better for moderately distressed couples. However, this
difference seemed to be driven primarily by a tendency toward
pretreatment differences in moderately distressed TBCT and IBCT
We examined both AFC and PSC subscales
from the MSI-R. Table 4 presents the means and standard devia-
tions for husbands and wives in TBCT and IBCT over the three
assessment points for both of these variables. AFC showed im-
provement over time, averaging about 0.11 T-score points per
week, B ? ?0.112, SE ? 0.050, t(490) ? ?2.26, p ? .05. There
was no significant quadratic effect. Furthermore, there were no
main effects of therapy condition or interactions with time or the
Looking at the other predictors, there were no significant dif-
ferences in AFC for site or pilot cases. However, women began
therapy more distressed in AFC than men, B ? ?0.936, SE ?
0.373, t(130) ? ?2.51, p ? .05. There were no differences
between spouses in the amount of change over the course of
therapy. The analyses also revealed that severely distressed cou-
ples began treatment more distressed in their AFC, B ? 2.428,
SE ? 0.421, t(130) ? 5.76, p ? .0001, and changed less during
therapy, B ? 0.040, SE ? 0.020, t(486) ? 1.99, p ? .05.
PSC changed over time, improving on the average of 0.1
T-score points per week, B ? ?0.106, SE ? 0.052, t(491) ?
?2.05, p ? .05. There was no significant quadratic effect, nor was
there an effect of therapy or any interactions between therapy and
time or therapy and the quadratic. There were no significant effects
of gender, site, or pilot. There was a significant difference based on
stratification such that severely distressed couples began treatment
with poorer PSC than moderately distressed couples, B ? 1.898,
SE ? 0.422, t(491) ? 4.49, p ? .0001.
We examined the overall MHI and CS
from the Compass. Table 5 presents the means and standard
deviations for husbands and wives in TBCT and IBCT over the
three assessment points. On average, both husbands and wives
start out slightly better than typical outpatients in individual ther-
apy. HLM analyses revealed no significant effects of time, the
quadratic, or therapy. Overall, MHI changed very little over the
course of treatment.
Because our treatment was directed at the marital relationship,
we expected improvements in individual functioning only to the
extent that the marital relationship improved. To test this hypoth-
esis, we included DAS scores as a time varying covariate. Follow-
ing the suggestions of Diggle, Liang, and Zeger (1994), two
components of DAS scores were included to reflect the level of
satisfaction and change in satisfaction for each individual. Time 1
DAS scores and the individuals’ deviations from their Time 1
scores were calculated and entered into the HLM models. Pretreat-
ment DAS was not a significant predictor of the MHI, indicating
that DAS scores and MHI scores were unrelated at pretreatment.
However, changes in DAS scores over time were highly associated
with changes in MHI scores, B ? 0.116, SE ? 0.025, t(486) ?
4.70, p ? .0001. For each point increase in DAS, the MHI
increased by 0.116 points. Therefore, to the extent that MHI
changed, it changed only as DAS changed. The only other signif-
icant effect was an effect of stratification on the intercept: Severely
distressed couples scored more poorly on the MHI than did mod-
erately distressed couples, B ? 1.481, SE ? 0.621, t(130) ?
?2.39, p ? .05.
Current symptoms data were highly skewed, showing that the
majority of individuals reported few psychological symptoms with
a smaller number of individuals reporting clinical levels of psy-
chological symptoms. We used Box–Cox’s method to identify an
appropriate transformation (Draper & Smith, 1998; Venables &
Ripley, 1997). The analysis revealed that raising the symptoms
variable to the –3 power (i.e., one over symptoms cubed) yielded
a reasonably normal distribution. As with the analyses of the MHI,
there were no significant effects of time, the quadratic, or therapy.
Overall, current symptoms changed very little over the course of
Following the same logic as used with the MHI, we only
expected improvements in symptom scores to the extent that the
marital relationship improved. To test this hypothesis, we again
Affective and Problem-Solving Communication for Wives and Husbands in Traditional
Behavioral Couple Therapy (TBCT) and Integrative Behavioral Couple Therapy (IBCT)
Pretreatment Week 13Week 26
MSDM SDM SD
CHRISTENSEN ET AL.
included DAS scores as a time-varying covariate. The pretreatment
DAS was not statistically significant, indicating that DAS scores
and symptom scores are unrelated at pretreatment. However, im-
provement in DAS scores over time was highly associated with
improvement in symptom scores, t(490) ? 3.00, p ? .01 (because
these analyses were done with transformed scores, the coefficients
and standard errors are on the inverse-cube scale and thus are not
directly interpretable). Furthermore, after controlling for DAS
scores, there was a significant effect of time, t(490) ? ?2.08, p ?
.05, indicating that symptom scores were improving. There was
also a significant therapy by stratification by time interaction,
t(484) ? 2.37, p ? .05. Graphs of the predicted values indicated
that husbands and wives in severely distressed couples were both
improving in both TBCT and IBCT, but moderately distressed
wives were improving more in TBCT. Because these effects are
found on transformed data after controlling for DAS scores, they
should be interpreted very cautiously.
Client Reactions to Treatment
We obtained two measures of client reactions to treatment: a
measure of the therapeutic bond at the end of the fourth session
(the feedback session) and a measure of client evaluation of
services at the end of the final session. Mean scores on the
therapeutic bond measure in TBCT were 52.73 (SD ? 6.88) for
wives and 51.53 (SD ? 7.38) for husbands. In IBCT, mean scores
were 52.85 (SD ? 6.57) for wives and 51.01 (SD ? 8.07) for
husbands. Mean scores on the client evaluation of services in
TBCT were 27.54 (SD ? 4.80) for wives and 27.65 (SD ? 4.96)
for husbands. Mean scores on the client evaluation of services in
IBCT were 27.85 (SD ? 4.76) for wives and 27.57 (SD ? 4.74) for
husbands. On both measures, clients scored slightly higher than the
normative means for outpatient samples on these measures, indi-
cating that, in general, clients had a good bond with their therapist
and were satisfied with treatment.
Because each of these measures was given at only one occasion,
analysis of variance was used to examine the results. We consid-
ered three 2-level between-groups factors (therapy condition, site,
and cohort [pilot vs. proper]) and one 2-level repeated measures
factor (husband vs. wife). Spouse was considered a repeated mea-
sures factor because of the linkage between husband and wife in
the same marriage. On the therapy bond measure, wives rated their
bond slightly higher than husbands, F(1, 122) ? 4.53, p ? .05.
There were no other significant main effects or interactions. On the
evaluation of services, there were no significant main effects or
Results must always be considered in the context of the sample
from which they are derived. We deliberately sought a sample of
significantly and chronically distressed couples. We excluded 94
couples who wanted treatment but were not sufficiently dissatis-
fied on one of our three measures of marital satisfaction given at
three time points. A brief phone follow-up on these excluded
couples indicated that one half sought therapy elsewhere
(Frousakis, Simpson, & Christensen, 2003). Of the couples who
participated in our therapy study, more than half had received
couple therapy before. Also, about half scored 66 or higher on the
GDS of the MSI–R; Snyder (1997) found that couples with an
intake GDS T score of 66 or higher who received treatment had a
45% chance of eventually divorcing. Thus, these were clearly
seriously distressed couples. We believed that a stably and seri-
ously distressed population would provide the most rigorous test of
marital therapy in general and of IBCT and TBCT in particular.
Heyman and Neidig (1997) noted that “All marital therapists
treat violent couples, whether they know it or not.” Our data
support the truth in that statement. Seventy-three percent of all the
couples that we screened reported at least one incident of physical
violence at some point in their relationship, and 44% reported at
least one incident of severe violence. Using conservative criteria
for male-to-female battering, we eliminated 101 couples and re-
ferred them for treatment targeted at violence. We were concerned
about safety issues for these women and did not believe that
standard marital therapy was the appropriate treatment for batter-
ing (Bograd & Mederos, 1999).
Mental Health Index and Current Symptoms for Wives and Husbands in Traditional Behavioral
Couple Therapy (TBCT) and Integrative Behavioral Couple Therapy (IBCT)
Pretreatment Week 13Week 26
M SDM SDM SD
Mental Health Index
TRADITIONAL VERSUS INTEGRATIVE COUPLE THERAPY
Our first hypothesis addressed the overall impact of marital
therapy on this sample of couples. We found statistically signifi-
cant effects indicating improved relationship satisfaction, stability,
and communication. Not surprisingly, improvements in individual
functioning only occurred to the extent that marital satisfaction
improved. Even though there was no control group for comparison
to these treatment effects, a number of studies have shown that
no-treatment control groups of distressed couples show no im-
provement without treatment and even some deterioration. For
example, across 17 studies, Baucom, Hahlweg, and Kuschel
(2003) found an average effect size for control groups of M ?
?0.06 (SE ? 0.10). In contrast, the effect size of the improvement
in marital satisfaction in this study was large and comparable to or
greater than other studies of marital therapy. For example, the
largest meta-analysis of couple therapy (Shadish et al., 1993)
found an overall effect size of d ? .60 (SE ? .09) for 27 studies
of couple therapies. Our effect sizes of .86 for the DAS and .85 for
the GDS are significantly larger. Also, our rates of clinically
significant change compare favorably with other data. In their
review of several behavioral studies, Jacobson et al. (1984) found
that 54.7% of couples showed reliable improvement. However,
only 35.3% showed reliable improvement and recovery (reaching
a level of satisfaction more similar to nondistressed than distressed
couples). In their meta-analysis, Shadish et al. (1993) calculated
that 41% of 19 studies reviewed brought the average client in the
study to recovery. Even though their strategy calculated percent-
ages across studies rather than across couples, they obtained a
similar percentage of recovery as Jacobson et al. (1984). In the
current study, across both treatments, 65% of couples showed
reliable improvement on the DAS (61% on the GDS), whereas
48% demonstrated recovery on the DAS (45% on the GDS). The
lower the client’s initial satisfaction, the more improvement they
must evidence to reach recovery. In general, our study had more
severe cases than those in the studies reviewed but gave them more
sessions of treatment.
We did not find evidence for our second hypothesis, that satis-
faction improves more rapidly early in treatment than later in
treatment. These results suggest that more treatment may be better
treatment, a finding that may be particularly important for severely
distressed couples, who need to improve substantially.
In contrast to our satisfaction data, our measure of stability
showed greater improvement early on in treatment. However, this
finding is something of an artifact. By the Week 13 assessment,
most couples had reached the normative level of stability on the
MSI, so there was little room for further improvement. Also, no
other measures showed differential change over treatment. Thus,
there was little evidence to suggest that, in general, the impact of
marital therapy is greatest early on in treatment. However, Hal-
ford’s (2001) argument that change takes place early in treatment
was made specifically in regard to traditional behavioral ap-
proaches rather than couple therapy in general. To address that
more specific notion, we need to examine our third hypothesis,
about the relative impact of TBCT and IBCT.
In conducting a comparison between two different psychologi-
cal treatments, one must first ask: Was it a fair comparison?
Several safeguards were put in place in the current study to ensure
a fair comparison. First, both investigators were extensively
trained in TBCT and both, particularly Jacobson, had conducted
research and scholarship on that approach. In fact, Jacobson was
the primary author of the primary treatment manual for TBCT.
Second, therapists were provided extensive training and supervi-
sion in both approaches. When Jacobson died, an outside expert on
TBCT, Don Baucom, was brought in to assist with the supervision
of TBCT cases. Third, a detailed and a global coding system were
used to evaluate adherence to treatment protocol. Finally, another
outside expert on TBCT, Gayla Margolin, who coauthored the
treatment manual for TBCT, was brought in to provide compe-
tency ratings for TBCT. In addition to these safeguards, consider-
able data suggest that the comparison was a fair one. First, the
adherence ratings indicated that the two approaches differed in
ways consistent with the treatment protocols for each. Second, the
ratings provided by Margolin indicated that TBCT was compe-
tently delivered. Third, clients’ ratings of the therapeutic bond
indicated that couples in both conditions evaluated their therapists
highly and comparably. Fourth, clients’ ratings at the end of
treatment indicated that couples in both conditions rated their
entire treatment highly and comparably. Finally, outcome in TBCT
was comparable to or exceeded that in other studies of TBCT. For
example, our rates of 59% reliable improvement and 44% recovery
in TBCT on the DAS compare favorably to the review by Jacobson
et al. (1984) with a rate of 55% reliable improvement and 35%
recovery (based primarily on the MAT and the DAS, which are
Assuming a fair test of the two treatments, we then can examine
the results of our third hypothesis about the relative outcome of
IBCT versus TBCT. For the most part, TBCT and IBCT performed
similarly across measures, despite being demonstrably different
treatments. The results are consistent with the idea that IBCT is at
least as efficacious as TBCT in treating relationship distress at the
end of their respective treatments. On the DAS, however, there
were significant effects of therapy on both the slope and quadratic
of the trajectory of change, both of which were moderate effect
sizes. As indicated in Figure 1, TBCT couples improved more
quickly early on in treatment than IBCT couples but tended to
flatten out over the course of therapy, whereas IBCT couples made
steady improvement over the course of therapy. This pattern of
more rapid improvement early in treatment, which is just what
Halford (2001) predicted, is likely due to the early emphasis on
behavioral exchange in TBCT. Early in therapy, prior to training in
communication and problem-solving skills and to a focus on
long-standing problems, TBCT therapists typically focus couples
on improving their positive actions toward each other (e.g., making
lists of positive actions each could do, agreeing to do more of those
actions). These positive actions may create an immediate boost in
satisfaction, but as couples later focus on their enduring problems,
their increase in satisfaction may level off. In contrast, IBCT
provides no quick boost for couples but focuses immediately on
the central themes and issues that trouble the couple and leads to
steady improvement. The important question raised by these in-
triguing differences between TBCT and IBCT is whether the
different trajectories have any implications for follow-up. Is the
flattening out in TBCT a predictor of poorer long-term outcome?
Or is early improvement an indicator of longer maintenance? Only
follow-up data can provide information about the significance of
these different trajectories of change.
Our fourth hypothesis concerns differences between husbands
and wives in their response to treatment. On the gender-normed
GDS T scores, but not on the DAS scores, husbands were more
CHRISTENSEN ET AL.
dissatisfied at the beginning of treatment than were wives. How-
ever, on both measures, husbands tended to improve more quickly
than wives early in treatment. We know that husbands in general
are more reluctant to enter therapy than are wives and that this
finding is true in the current sample (Doss et al., 2003). It may be
that husbands fear they will be criticized by both their wives and
the therapist for their misdeeds and are reluctant to put themselves
in such a situation by coming to therapy. When husbands enter
treatment and find that, contrary to their fears, the therapist takes
an even-handed stance toward both and that therapy may benefit
them as well as their wives, husbands may show a greater rise in
satisfaction than their wives. The only other differences between
spouses occurred with AFC, in which wives started therapy more
distressed than husbands, and with the therapeutic bond, in which
wives rated their therapists more highly than did husbands. Both of
these differences fit gender-role stereotypes, with wives being
more attuned to relationships and to emotional communication
Our final hypothesis concerned the impact of our stratification
of couples into moderately and severely distressed groups. As
expected, there was a significant impact of stratification on the
intercepts for all our variables, but stratification did not affect the
slopes of any variables and only the quadratic of the DAS. Al-
though severely distressed couples evidenced a similar rate of
change as moderately distressed couples, they demonstrated a
greater flattening out on the DAS. Although there were a couple of
inconsistent interactions with other variables, there was, overall,
very little impact of stratification on the rate of change in therapy.
Thus, although severely distressed couples start at a significantly
lower point than moderately distressed couples on most of our
outcome measures, they improve at a comparable rate.
This finding of comparable rates of change in severely and
moderately distressed couples is encouraging. It means that IBCT
and TBCT can be applied to even very severely distressed couples
with a reasonable hope of improvement. However, it is important
to remember that the intercepts of the two groups are still signif-
icantly different. Even though they improve similarly, the severely
distressed couples start out and end up in worse condition. This
fact can be seen when we examine rates of recovery for moderately
and severely distressed couples. Because recovery depends not just
on how much a couple has improved but also on the absolute level
of satisfaction achieved, a moderately distressed couple is more
likely to achieve recovery than a severely distressed couple.
Whether or not a couple achieves recovery (a level of “normal”
satisfaction) may have important implications for maintenance.
There are a number of important strengths of this study. First,
with 134 couples, it is the largest clinical trial of couple therapy to
date. To our knowledge, the next largest is a study by Hahlweg,
Revenstorf, and Schindler (1982) that involved 85 couples. A large
clinical trial gives the researcher the necessary statistical power to
provide a robust test of hypotheses. Second, this is the first study
to require that couples meet repeated criteria for dissatisfaction.
Thus, we generated a group of stably dissatisfied couples and
reduced the impact of regression toward the mean on results.
Because of our recruitment strategies, we have one of the most, if
not the most, severely distressed samples of couples to participate
in a randomized clinical trial. Third, this is probably the most
diverse sample of couples to participate in a clinical trial of couple
therapy. This diversity comes about in part because couples were
recruited from two geographical locations, Los Angeles and Seat-
tle. Also, specific efforts were made to recruit minority couples
(e.g., advertisements in minority outlets, use of minority thera-
pists). In almost one third of the couples in the current study (42
couples), one or both partners were Asian, African American, or
Latino. Most clinical trials of couple therapy have not reported the
percentage of minority couples, but of those that have, this, to our
knowledge, is the highest level of minority participation. Fourth,
we believe our study provides the most rigorous test to date of
different treatments. Because of the use of experienced therapists,
the high level of training and supervision, the measures of adher-
ence and competence, and the measures of therapeutic bond and
evaluation of services, we could provide a high level of compara-
ble service delivery and measure that level of delivery. Fifth, this
is the first clinical trial of couple therapy to use the statistical
strategies of HLM. Because these strategies enable the researcher
to separate (a) initial status (intercept), (b) rate of change (slope),
and (c) change in the rate of change (quadratic), they provide a
more differentiated view of outcome. In addition, these strategies
allow the researcher to consider simultaneously the impact of
treatment on husbands and wives, nested within a marriage. Fi-
nally, this is the first study we know of that systematically exam-
ines the level of initial distress by stratifying couples into severely
and moderately distressed conditions.
There are also limitations of the current study. Because it was an
efficacy rather than an effectiveness study, the emphasis in this
study was on internal rather than external validity. There are
substantial limitations in generalizing our results to the practice of
couple therapy. Although our therapists were licensed practitioners
in the community who saw couples in their private offices, we
selected these therapists on the basis of the quality of their training,
experience, and reputation. They are hardly a randomly selected
group of therapists. They also practiced treatments that are prob-
ably not widely used in the community. IBCT is too new to be
widely adopted. While TBCT has had considerable influence,
some of its strategies, such as communication training, are prob-
ably used with an eclectic mix of other strategies. In addition, we
provided our therapists with extensive training and supervision, a
provision that is not ordinarily a part of usual practice. Our couples
were given free treatment and paid to participate in assessments. It
is unclear how these factors affect outcome. Also, couples were
given a maximum of 26 treatment sessions, which probably ex-
ceeds the amount usually provided by managed care organizations.
In general, our approach was to provide a test of couple therapy
under optimal treatment conditions but with highly distressed
couples. There is little research on the effectiveness of couple
therapy in the community to serve as a comparison to our treat-
ment effects. However, a recent study by Hahlweg and Klann
(1997) evaluated the outcome of couple therapy as implemented
by practicing clinicians in Germany. Their findings indicated an
overall effect size of only .28, which is small compared with our
effect size and with effect sizes for efficacy studies. The compar-
ison suggests that we may have been successful in providing an
optimal test of our treatments. Later research can examine the
extent to which these findings can generalize to less trained ther-
apists, to fewer sessions, and to more mildly distressed couples.
Perhaps the most serious limitation of the current study is that it
provides data only on the immediate outcome of treatment. We
cannot fully evaluate the success of treatment until we look at the
TRADITIONAL VERSUS INTEGRATIVE COUPLE THERAPY
long-term maintenance of treatment gains. Traditional behavioral
approaches to couple therapy have demonstrated disappointing
results at long-term follow-up (Jacobson et al., 1987; Snyder et al.,
1991). IBCT was developed in part to address long-term follow-
up. Specifically, its focus on broad relationship themes rather than
target behaviors, its emphasis on emotional acceptance as well as
change, and its emphasis on contingency-shaped rather than de-
liberate, rule-governed change were designed to lead to greater
maintenance of gains in satisfaction. We are currently assessing
the couples in this study at 6-, 12-, 18-, and 24-month follow-up
periods. A later article will provide results on these follow-up data.
Serious marital distress is all too common. Current estimates are
that half of first marriages will end in divorce and second mar-
riages will fare even worse (Bramlett & Mosher, 2001). Marital
distress and divorce are associated with a number of negative
consequences for spouses and their children (Amato, 2000). There-
fore, any effective treatment for marital distress will likely prevent
a host of damaging effects for both spouses and their offspring.
The current study suggests that couple therapy can be effective, at
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