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International Journal of
Environmental Research
and Public Health
Article
An Integrative Behavioral Couple Therapy (IBCT)-Based
Conflict Prevention Program: A Pre-Pilot Study with
Non-Clinical Couples
Jorge Barraca 1, * , Elvira Nieto 2and Thomas Polanski 3
Citation: Barraca, J.; Nieto, E.;
Polanski, T. An Integrative Behavioral
Couple Therapy (IBCT)-Based
Conflict Prevention Program: A
Pre-Pilot Study with Non-Clinical
Couples. Int. J. Environ. Res. Public
Health 2021,18, 9981. https://
doi.org/10.3390/ijerph18199981
Academic Editors:
Cristina Petisco-Rodríguez, Laura
C. Sánchez-Sánchez, José
Manuel García-Montes and Paul
B. Tchounwou
Received: 2 August 2021
Accepted: 18 September 2021
Published: 23 September 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
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iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1Department of Psychology, Universidad Camilo JoséCela, Calle Castillo de Alarcón 49, Urbanización
Villafranca del Castillo, 28692 Madrid, Spain
2Private Practice, Calle Goya 83–3º Derecha, 28001 Madrid, Spain; elviranietopsicologia@gmail.com
3Private Practice, Mariano Paredes N70-122 and Moisés Luna Andrade, Quito 170303, Ecuador;
polanskij@gmail.com
*Correspondence: jbarraca@ucjc.edu
Abstract:
Integrative Behavioral Couple Therapy (IBCT) has demonstrated its efficacy treating severe
couple conflict. Nevertheless, its capacity to prevent such conflicts before they appear has not been
analyzed. The following empirical study examines the effectiveness of a conflict prevention program
based on IBCT’s main therapeutic strategies (empathic joining, unified detachment). A sample of
12 individuals (six couples) from the Community of Madrid completed the DAS (Spanier, 1976;
Martín-Lanas et al., 2017), IBCTQ (Barraca et al., 2017), and ASPA-A (Carrasco, 1996) pre-treatment,
posttreatment, and at a three-year follow up. Three of these couples were randomly assigned to
the experimental group, in which they received five, 120-minute sessions of an IBCT-based conflict
prevention program. The three remaining couples were assigned to a control group and received no
treatment. Results indicated that the experimental couples grew in their acceptance of differences and
significantly improved their level of empathic joining and unified detachment; they also manifested
greater satisfaction in their total DAS score. At the three-year follow up, neither group showed
significant changes with regard to their posttreatment scores. Although the data are based on a
small number of couples and should be replicated, the results suggest that a program based on IBCT
strategies can help prevent couple conflict up to three years after its application.
Keywords:
couple conflict; couple therapy; Integrative Behavioral Couple Therapy; prevention programs
1. Introduction
Most couples seek therapy only when experiencing high levels of distress and nu-
merous conflicts, with the corresponding risk of relationship dissolution [
1
,
2
]. This
assumption—that couples should only go to therapy after presenting severe problems—is
dangerous. The higher the level of conflict when the couple initiates therapy, the greater the
possibility of therapeutic failure and the greater the risk of one or both partners developing
symptoms of anxiety, depression, substance abuse, or other behaviors that jeopardize their
health, up to and including suicide [
3
,
4
]. If generic risk factors for couple conflict were
tackled earlier, their appearance could be prevented or diminished, resulting in greater
relationship satisfaction and psychological well-being both in the medium and long-term.
Such prevention would also alleviate the pressure on legal and health services, avoiding
the personal, social, and economic costs that accompany relationship deterioration [5,6].
In spite of this, the development of couple conflict prevention programs is scarce,
and their empirical evaluation shows that existing programs suffer from important prob-
lems, especially with regard to limitations in their design. A study by Christensen and
Heavy [
7
] on the efficacy of three of the most well-known prevention programs of the
1960s, 1970s and 1980s—the Couples Communication Program [
8
], the Relationship Enhance-
ment Program [
9
], and the Prevention and Relationship Enhancement Program [
10
,
11
]—found
Int. J. Environ. Res. Public Health 2021,18, 9981. https://doi.org/10.3390/ijerph18199981 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021,18, 9981 2 of 15
little evidence that they had medium or long-term positive effects. At the same time, the
theoretical heterogeneity of these interventions, which included systemic, humanist (in the
line of Carl Rogers), social learning, and mixed (learning and cognitive behavior theory)
models made it difficult to glean which components or processes were responsible for
the programs’ results. More specifically, while Christensen and Heavy’s work showed
that these interventions can change couple behavior and produce short to medium-term
improvements in communication, self-revelation, empathy, stability, and relationship ad-
justment [
12
–
17
], an exhaustive examination of the meta-analysis conducted by Giblin
et al. [
14
] and Hahlweg and Markman [
16
] seemed to indicate that these effects dissipate
with time. Upon analyzing the programs as a whole, Christensen and Heavy concluded
that the Couples Communication Program obtained the best results in comparison with the
others but that the Prevention and Relationship Enhancement Program was the only one that
continued to show some benefit beyond six months posttreatment.
In 2004, Carroll and Doherty [
18
] carried out a systematic review of premarital pre-
vention and education programs. Taking into account twelve experimental studies—again
heterogeneous in theoretical orientation (systemic, social and behavioral learning, social
exchange theory, and diverse psychoeducational perspectives)—results showed that these
programs are generally effective in producing immediate and short-term gains in inter-
personal abilities and relationship quality. Nevertheless, because of the lack of extensive
follow-up research, conclusions about long-term effectiveness could not be reached. At the
same time, the diversity of theoretical orientations and measurement instruments made it
difficult to determine which treatment elements were useful and efficacious.
A study by Ledermann et al. [
19
] of their well-controlled Couples Coping Enhancement
Training showed similar results. They randomly assigned a large sample of 100 couples to
experimental and control groups. The program produced positive effects immediately after
completion, but these progressively disappeared at six-month and one-year follow ups.
More recently, Rogge et al. [
20
] tested their Compassionate and Accepting Relationships
through Empathy (CARE) program against the aforementioned Prevention and Relationship
Enhancement Program.CARE is designed to strengthen relationships by teaching couples
abilities to better empathize with and support one another. These abilities are partially
based on aspects of Integrative Behavioral Couple Therapy (IBCT) [
21
] with components of
empathic joining, expressing soft emotions, acceptance, perspective change, and psycholog-
ical distancing. In addition to forming part of either of these programs, couples could also
be randomly assigned to a group that received one session of instruction on the importance
of being more aware of the relationship or to a control group. All of the 174 participating
couples were engaged or recently married and were not experiencing significant stress in
their relationship. Results showed that at the end of the training, there were no significant
differences among the three experimental groups, but all fared better than the control group,
which had a higher probability of relationship dissolution within the following three years.
In order to explain the lack of differences among the experimental groups’ results, the
authors hypothesized that the programs did not have sufficiently distinct components, that
the measurement instruments were not ideal (and had only consisted of self-completed
questionnaires), or that the sample was not sufficiently heterogeneous with respect to
economic situation or relationship status (engaged and recently married couples).
Another more recent marriage prevention program is the Marriage Check-up [
22
]. Based
on both motivational interviewing and IBCT principles, it consists of an assessment session
and a feedback session; the first lasts three to four hours and the second lasts around two
hours. A pilot study (n= 29) showed that positive effects lasted two years after application;
however, there was no control group with which to compare results, and the sample may
have contained a mix of distressed and non-distressed couples [
23
]. Most subsequent
studies such as Cordova et al., Trillingsgaard et al., and Gordon et al. [
24
–
26
] also show
positive effects, and benefit from the use of control groups and larger samples. However,
they only collect short-term follow-up data. An exception is the study of Cordova et al.
(n= 215) [27] on annual marriage check-ups, which included a second marriage check-up
Int. J. Environ. Res. Public Health 2021,18, 9981 3 of 15
one year after the first and data collection at a two-year follow-up. Treatment couples
showed significant gains in relationship satisfaction, intimacy, and acceptance after the
first check-up, usually with an initial spike followed by a tapering effect that was still
significantly better at the one-year follow up than at pretreatment levels. The second
marriage check-up seemed to help maintain these gains for the two-year follow-up, again
contributing to an initial spike in all variables followed by a tapering effect. Unfortunately,
results were not disaggregated for distressed and non-distressed couples, and the mix
of motivational interviewing and IBCT-based components make it difficult to determine
which treatment elements were efficacious.
A small aside must also be made to recognize efforts by Andrew Christensen and
Brian Doss to make an IBCT program available to a wide variety of couples through their
online adaptation of IBCT therapy called Our Relationship Program. While the program’s
design seems as though it could be easily adapted for use with non-distressed couples, the
only published data on its effectiveness pertains to its use with distressed couples [28,29].
The objective of the current investigation is to begin to correct some of the limitations
of earlier studies by creating a conflict prevention program that: (1) is based on a single
theoretically and experimentally sound model; (2) possesses stricter and better-defined
content to help identify effective prevention components, and (3) demonstrates potential
to generate significant long-term positive effects. Pilot studies are generally carried out
to test whether interventions merit further investigation and/or to guide the design of
larger, definitive trials. They can do the former by demonstrating treatment tolerance
and providing initial efficacy data, and the latter by calculating population variance and
recruitment and retention rates, which help to estimate the required sample size for a
definitive trial [
30
,
31
]. The current investigation concentrates on the first aspect looking
to demonstrate tolerance and preliminary evidence of effectiveness for an IBCT-based
conflict prevention program. Given the positive results that IBCT has shown in a large,
rigorous, randomized clinical trial [
32
,
33
], the development, application, and quantitative
and qualitative evaluation of an IBCT-based couple conflict prevention program is con-
sidered to be of investigative and clinical interest. The current study was carried out in
Spain with an urban population in the city of Madrid. While cultural differences between
this population and the groups studied in other relationship prevention programs (usually
couples from the United States) could influence IBCT’s effectiveness, IBCT therapy has
been carried out during various decades in Spain with positive results, and we believe that
its main elements (especially acceptance) are universal with regard to increasing well-being
in couples, which is an opinion that seems to be shared by the therapy’s original authors
who have years of experience working with multi-cultural couples [34].
2. Materials and Methods
2.1. Participants
The sample was composed of 6 couples (12 individuals) who were recruited using an
ad placed on social media. The ad contained the following information: “Prevent future
couple conflicts. A free, individualized course is being offered by psychology professionals
for couples that want to strengthen the quality of their relationship. You can obtain more
information by calling the following number: 671XXXXXXX. What does the course consist
of? In this course you will learn to: (1) better understand your partner (their behaviors,
thoughts and emotions); (2) communicate more effectively with them (to express what
you both feel and think adequately); (3) prevent future couple conflict; and (4) nourish the
strengths that unite you and your partner. How many days? 5 days (1 day a week, total:
5 weeks
). How much time? 1 h and 30 min per session.” Eight couples replied to the ad,
but two were discarded—one because of scheduling conflicts and the other because one of
the partners expressed little commitment to the program—resulting in a 75% recruitment
rate. Three of the couples were randomly assigned to the experimental group and three
were assigned to the control group. Inclusion criteria required that: (1) participants be over
18 years of age, (2) neither partner have a mental disorder, (3) the couple not currently be
Int. J. Environ. Res. Public Health 2021,18, 9981 4 of 15
in, nor have attended in the past, any form of couple therapy, and (4) the couple not be in
the process of separating. The presence of a current mental disorder was discarded using a
clinical interview, and all couples scored within a normal range for relationship satisfaction
on the Dyadic Adjustment Scale [
35
,
36
], the properties of which are discussed in the next
section. The sample’s sociodemographic characteristics are presented in Table 1.
Table 1. Sociodemographic characteristics of participants (n= 12).
Characteristic Category n(%)
Sex Men
Women
6 (50)
6 (50)
Age, mean (SD) 39.08 (13.49)
Education level
Low (Primary–Secondary)
Moderate (Bachiller–Some Trade School)
High (University)
2 (16.66)
2 (16.66)
8 (66.66)
Civil status Couple (no legal union)
Married
4 (33.33)
8 (66.66)
Relationship duration
years
15 years
36–38 years
6 (50)
2 (16.66)
4 (33.33)
Previous romantic partners
None
1
2
3
5
4 (33.33)
3 (25)
3 (25)
1 (8.33)
1 (8.33)
Living together Yes
No
8 (66.66)
4 (33.33)
Number of children 0
2
8 (66.66)
4 (33.33)
Occupation Working
Student
8 (66.66)
4 (33.33)
Previously attended couple therapy No 12 (100)
2.2. Instruments
2.2.1. Quantitative Measures
Dyadic Adjustment Scale–DAS—[
35
,
36
]. This 32-question, Likert-style measure evalu-
ates the quality of a couple’s relationship using a global scale for dyadic adjustment and
four subscales: (1) consensus; (2) satisfaction; (3) affectional expression, and (4) cohesion.
The Spanish adaptation has shown good internal consistency (0.88, 0.88, 0.69, and 0.85 for
each subscale), and factor analysis has demonstrated the construct validity of the instru-
ment. The correction and interpretation of results is carried out by transforming the direct
scores into T scores.
Integrative Behavioral Couple Therapy Questionnaire—IBCTQ [
37
]. A 68-question, Likert-
style instrument designed to measure the main concepts of IBCT. It includes four dimen-
sions: (1) acceptance; (2) empathic joining; (3) unified detachment, and (4) tolerance. The
higher the score in each dimension, the better the couple’s situation with regard to that
variable (and the higher their resilience to conflict), according to IBCT’s theoretical model
and intervention strategies. Examples of items for each dimension include “I find it positive
that my partner and I are different”, “When my partner does something that hurts me,
I try to express to them how I feel without attacking them”, “My partner and I try to
resolve problems maintaining a united front”, and “When my partner does something that
annoys me, I try to see the positive side of their behavior”. In a preliminary study with
485 subjects, interdimensional correlations were elevated and significant and the internal
consistency of the subscales was adequate to good (Cronbach’s alpha of 0.88, 0.85, 0.90, and
0.61 for each subscale and 0.93 for the entire instrument). Construct validity was tested by
correlating results with the DAS,CSI,ESFA, and ASPA, producing significant correlations
Int. J. Environ. Res. Public Health 2021,18, 9981 5 of 15
in the expected directions. The instrument is corrected by comparing the direct scores with
population scores.
Couple Assertiveness Questionnaire (Cuestionario de Aserción en la Pareja (ASPA)) [
38
].
The ASPA is a two-part, Likert-style instrument with 40 questions per section. In the first
section (Form A), the subjects evaluate themselves, and in the second section (Form B), they
evaluate their partner’s behavior. The instrument evaluates four types of communication
that are common in couples’ daily experience: (1) assertive; (2) aggressive; (3) submissive,
and (4) passive aggressive. Direct scores are transformed to percentiles, and the percentage
of each type of communication is calculated. The greater the percentage of assertive
communication compared to the other three styles, the better the emotional situation and
conflict resolution capacity of the couple. Psychometric study of the instrument was carried
out with 418 couples. The instrument showed good internal consistency (Cronbach’s alpha
of 0.83, 0.81, 0.75, and 0.84 respectively, with a total value of 0.89 for Forma A and 0.90
for form B). Factor analysis and correlation with the DAS questionnaire showed good
construct validity.
2.2.2. Qualitative Measures
Satisfaction Questionnaire (CS). A short, ad hoc questionnaire was designed to evaluate
the participant’s satisfaction with the prevention program. It consisted of seven Likert-
style items scored from 0 (very low) to 4 (very high), each measuring a different aspect
of satisfaction: (1) general satisfaction regarding the individual’s expectations for the
program; (2) interest in the topics covered; (3) interest in the strategies presented; (4) the
possibility of applying these strategies; (5) perception that these strategies would be helpful
for addressing future marital problems; (6) level of satisfaction regarding the professional
who had imparted the program, and (7) recommendation of the program to other couples.
This questionnaire’s psychometric properties have not been evaluated; thus, it is considered
to be a qualitative measure.
In-session notes. During program sessions, experimental couples’ verbalizations in
relation to program content were registered as evidence of their subjective reactions to
IBCT strategies and exercises.
Treatment tolerance was evaluated by taking into account both quantitative and
qualitative relationship and program satisfaction measures to ensure that the program was
well-accepted by couples without causing unintended iatrogenic effects.
2.2.3. Procedure
All of the subjects signed a consent form approved by the Universidad Camilo José
Cela’s Ethics Committee. The study was conducted according to the guidelines of the Dec-
laration of Helsinki and approved by the aforementioned committee (13_CEI; 26/04/2021).
The prevention program’s content was delivered in five sessions and based on diverse
IBCT manuals [
21
,
39
,
40
] and articles [
1
,
41
–
43
]. The content of each session and program
details are described in Table 2. The prevention program was designed to help in the early
stages of possible couple conflict.
The aforementioned evaluation instruments were applied to the control and experi-
mental groups before beginning the program (pre-program evaluation), at the end of the
program (post-program evaluation), and three years after program completion (follow-
up evaluation).
The program was applied by the same therapist to all couples in order to guarantee a
similar application and fidelity to content. The therapist was a certified psychologist with
experience and a master’s degree in clinical psychology. She was an expert in IBCT, trained
through courses, workshops, and direct supervision. She did not have any interests in nor
receive any benefits tied to the type of results obtained. Interventions were carried out in a
private office.
Int. J. Environ. Res. Public Health 2021,18, 9981 6 of 15
Table 2. Sessions, objectives, content, techniques, and homework for the IBCT-based conflict prevention program.
Session Objectives Content Techniques Homework
1
- To present the program.
- To collect general data on
the couple.
- To explore the beginning
of the couple’s
relationship.
- To describe the couple’s
current relationship and
concerns regarding it.
- To facilitate the couple’s
understanding of the
origins of their conflicts.
- Explanation of the
preventative, empirical nature
of the program and its
objectives.
- Review of sociodemographic
information.
- Positive and negative aspects,
and differences noticed at the
beginning of the relationship.
- Positive and negative aspects,
and differences noticed
currently in the relationship.
- Couple’s concerns regarding
their relationship.
- Origins of couple conflicts
according to IBCT.
- Semi-structured
interview.
- Psychoeducation.
- Reinforcement of
the behaviors on
which IBCT is
based.
- Feedback at the end
of the session.
- Completion of
self-reports.
- Documentation of
the couple’s doubts
and questions.
2
- To explore the couples’
feelings and appreciation
of important relationship
events since the last
session.
- To review the previous
session’s content and
resolve doubts and
questions about it.
- To learn about and
identify the couples’
spontaneous solutions to
conflict.
- To resolve doubts and
consolidate the session’s
main therapeutic points.
- The couples’ feelings and
appreciation of important
relationship events since the
last session.
-
Content shared in the previous
session.
- Discussion of the couples’
spontaneous solutions to
conflict, and their: (1) fit with
each other, (2) level of
attraction, (3) personality
styles, (4) use of conflict
resolution skills, and (5)
stressful situations they are
facing.
- Unstructured
interview.
- Psychoeducation.
- Reinforcement of
the behaviors on
which IBCT is
based.
- Feedback at the end
of the session.
- Documentation of
the couple’s doubts
and questions.
3
- To explore the couples’
feelings and appreciation
of important relationship
events since the last
session.
- To review the previous
session’s content and
resolve doubts and
questions.
- To facilitate
understanding and
internalization of
empathic joining as an
acceptance strategy.
- To resolve doubts and
consolidate the session’s
main therapeutic points.
- The couples’ feelings and
appreciation of important
relationship events since last
session.
-
Content shared in the previous
session.
- Strategies that strengthen
acceptance in the couple, part
I: empathic joining. Focusing
on: (1) definition, (2)
implications, (3) what it looks
like, and (4) how it is
accomplished. The couple is
asked to select a situation to
which they can apply this
strategy and practice it in
session.
- Unstructured
interview.
- Psychoeducation.
- Role playing.
- Reinforcement of
the behaviors on
which IBCT is
based.
- Feedback at the end
of the session.
- Documentation of
the couple’s doubts
and questions.
Int. J. Environ. Res. Public Health 2021,18, 9981 7 of 15
Table 2. Cont.
Session Objectives Content Techniques Homework
4
- To explore the couples’
feelings and appreciation
of important relationship
events since the last
session.
- To review the previous
session’s content and
resolve doubts and
questions.
- To facilitate
understanding and
internalization of unified
detachment as an
acceptance strategy.
- To resolve doubts and
consolidate the session’s
main therapeutic points.
- The couples’ feelings and
appreciation of important
relationship events since last
session.
-
Content shared in the previous
session.
- Strategies that strengthen
acceptance in the couple, part
II: unified detachment.
Focusing on: (1) definition, (2)
implications, (3) what it looks
like, and (4) how it is
accomplished. The couple is
asked to select a situation to
which they can apply this
strategy and practice it in
session.
- Unstructured
interview.
- Psychoeducation.
- Role playing.
- Reinforcement of
the behaviors on
which IBCT is
based.
- Feedback at the end
of the session.
- Documentation of
the couple’s doubts
and questions.
5
- To explore the couples’
feelings and appreciation
of important relationship
events since the last
session.
- To review the previous
session’s content and
resolve doubts and
questions.
- To facilitate
understanding and
internalization of
tolerance strategies.
- To resolve doubts and
consolidate the session’s
main therapeutic points.
- To consolidate content
from all five sessions and
to resolve any final doubts
regarding the material.
- The couples’ feelings and
appreciation of important
relationship events since last
session.
-
Content shared in the previous
session.
- Strategies that strengthen
tolerance. Focusing on: (1)
definitions, (2) implications,
(3) what they look like, and (4)
how they are accomplished.
Strategies: (1) highlight the
positive aspects of a negative
behavior, (2) fake negative
behaviors at home, (3)
promote self-care.
- Review of content from the
entire program.
- Unstructured
interview.
- Psychoeducation.
- Role playing.
- Reinforcement of
the behaviors on
which IBCT is
based.
- Feedback at the end
of the session.
- Completion of
self-reports.
2.2.4. Design and Data Analysis
A quasi-experimental design was used. As a result of the small sample size (n= 12)
and the lack of normal distribution for variables, non-parametric statistical tests were used
for data analysis. The Wilcoxon signed-rank test was employed to evaluate differences in
pre-intervention, post-intervention and follow-up scores in the experimental and control
groups (intragroup measure). The Mann–Whitney U-test was used to measure significant
differences between the experimental and control groups at the pre-intervention, post-
intervention, and follow-up measurement points (intergroup measure). One experimental
couple did not reply to the three-year follow-up measures since they had separated during
that period; thus, a missing data approach was incorporated into follow-up analyses.
All statistical calculations were carried out using IBM’s Statistical Package for the Social
Sciences (SPSS v. 21, IBM, Armonk, NY, USA).
3. Results
As can be observed in Table 3, the control group showed no significant change during
the experimental group’s intervention period, whereas the experimental group showed
significant positive increases (Wilcoxon Z,p
≤
0.05) in their DAS scores for the global index
of dyadic adjustment (Z=
−
1.897; p= 0.02) and for two subscales: dyadic satisfaction
(
Z=−2.032
;p= 0.02) and affectional expression (Z=
−
1.761; p= 0.03). Near significant pos-
itive increases were found for dyadic consensus (
X
pre = 46.67;
X
post = 48.67;
Z=−1.511
;
p= 0.06
) and dyadic cohesion (
X
pre = 13.83;
X
post = 15.33; Z=
−
1.355; p= 0.08). The
Int. J. Environ. Res. Public Health 2021,18, 9981 8 of 15
only near significant change for the control group, regarding dyadic satisfaction, was in a
negative direction.
Table 3.
Wilcoxon Z and associated probability (p) results pre–post and post-follow-up for experi-
mental and control groups (DAS,IBCTQ, and ASPA-A).
Experim. Gr. Wilcoxon Control Gr. Wilcoxon
Scale Dimension Moment XSD Z P XSD Z p
DAS
DC
Pre 46.67 3.141 −
1.511
−
0.182
0.06
0.85
54.50 4.324 −
0.135
−
1.992
0.44
0.50
Post 48.67 4.502 54.33 3.830
3-year 49.25 12.527 41.00 9.230
DS
Pre 33.83 4.070 −
2.032
−
1.841
0.02 *
0.06
39.67 5.007 −
1.890
−
1.572
0.06
0.12
Post 38.33 3.061 38.83 4.355
3-year 34.25 3.594 28.83
12.189
AE
Pre 7.00 2.098 −
1.761
−
1.000
0.03 *
0.32
9.17 1.329 0.000
−
1.753
10.00
0.08
Post 9.00 0.632 9.17 1.329
3-year 8.75 0.500 5.67 4.033
DCH
Pre 13.83 2.714 −
1.355
−
.368
0.08
0.71
17.33 5.274 −
.447
−
1.265
0.32
0.21
Post 15.33 3.327 17.50 4.370
3-year 17.25 2.872 14.00 6.986
TOTAL
Pre 101.33 7.367 −
1.897
−
0.535
0.02 *
0.59
120.67 11.021
−
0.542
−
1.782
0.29
0.07
Post 111.83 7.360
119.83 12.287
3-year 109.50 16.258 89.50
30.723
IBCTQ
A
Pre 63.33 8.548 −
1.363
−
0.365
0.08
0.71
69.67
11.911
−
0.742
−
1.753
0.22
0.08
Post 70.17 9.411 68.83
13.318
3-year 73.00 12.356 59.83
21.236
EJ
Pre 78.33 10.053 −
1.782
−
0.816
0.03 *
0.41
83.67
11.130
−
0.850
−
1.892
0.19
0.06
Post 84.33 4.884 82.67
12.356
3-year 85.00 6.218 70.50
20.197
UD
Pre 36.83 11.907 −
2.201
−
1.289
0.01 *
0.19
46.83 7.705 −
1.134
−
1.682
0.12
0.09
Post 45.50 8.142 47.50 7.662
3-year 46.00 6.218 42.17
12.922
T
Pre 55.67 23.367 −
1.363
−
0.365
0.08
0.71
61.50 4.506 −
0.841
−
0.946
0.20
0.34
Post 62.00 10.770 62.50 8.019
3-year 63.00 6.055 59.00
11.832
TOTAL
Pre 234.14 37.032 −
1.997
0.000
0.02 *
10.0
261.67 33.827
−
0.542
−
1.572
0.30
0.12
Post 262.00 24.658
261.50 39.773
3-year 267.00 25.626
231.50 65.056
ASPA-A
CAs
Pre 45.17 8.909 −
1.843
−
0.730
0.06
0.46
53.00 5.733 −
0.736
−
0.674
0.23
0.5
Post 48.83 5.419 52.33 4.131
3-year 45.25 7.805 49.00 9.529
CAg
Pre 23.17 9.600 −
1.089
−
1.461
0.13
0.14
23.50 9.854 0.000
−
1.153
0.50
0.25
Post 18.50 5.505 23.50
10.407
3-year 16.25 3.594 30.83
16.376
CS
Pre 23.17 10.610 −
.315
−
0.365
0.37
0.71
15.17 3.710 −
0.946
−
1.363
0.17
0.17
Post 24.17 9.196 17.50 6.317
3-year 25.75 13.150 23.17 8.612
CPA
Pre 24.67 7.488 −
0.962
−
1.604
0.16
0.11
20.50
10.193
−
1.633
−
2.023
0.06
0.04 *
Post 22.67 8.287 21.50 9.935
3-year 21.00 6.976 31.83
14.932
*p
≤
0.05. Note: DAS = Dyadic Adjustment Scale, DC = Dyadic Consensus, DS = Dyadic Satisfaction,
AE = Affectional Expression
, DCH = Dyadic Cohesion; IBCTQ = Integrative Behavioral Couple Therapy Ques-
tionnaire, A = Acceptance, EJ = Empathic Joining, UD = Unified Detachment, T = Tolerance; ASPA-A = Couple
Assertiveness Questionnaire—Form A, CAs = Assertive Communication, CAg = Aggressive Communication,
CS = Submissive Communication, CPA = Passive-Aggressive Communication.
A similar pattern was observed in the IBCTQ data. The experimental group showed
statistically significant increases in empathic joining (Z=
−
1.782; p= 0.03), unified detach-
ment (Z=
−
2.201 p= 0.01), and their global IBCTQ scores post-intervention (Z=
−
1.997
p= 0.02). Positive changes in acceptance and tolerance were near significant (Z=
−
1.363
p= 0.08 for both subscales). These results imply that couples who completed the conflict
prevention program had improved their ability to perceive negative situations in their
relationship to be more a result of natural differences than intentional efforts to hurt one an-
other and to contemplate relationship problems from a more descriptive and objective (i.e.,
Int. J. Environ. Res. Public Health 2021,18, 9981 9 of 15
less judgmental) perspective. The control group showed no significant nor near-significant
differences in IBCTQ variables during the experimental group’s intervention period.
For the ASPA-Form A, neither the experimental nor the control group showed sig-
nificant differences in communication type (assertive, aggressive, submissive, passive-
aggressive) pre and posttreatment.
At the three-year follow-up, the experimental group’s average scores for the DAS and
IBCTQ were very similar to their post-intervention values with no significant changes in Z
score, implying the maintenance of intervention gains during the three years, although the
dispersion for dyadic adjustment was large, suggesting caution regarding that value. The
control group saw no significant changes in their DAS and IBCTQ scores during the follow-
up period. They did show several near-significant changes in these variables, but all in a
negative direction, possibly indicating a small decline in relationship quality. Interestingly,
they also demonstrated a significant uptick in passive-aggressive communication on the
ASPA-Form A at three-year follow-up, which would corroborate the hypothesis regarding
relationship quality decline.
In order to highlight the existence of differences between the experimental and control
group, a variable was created to reflect the changes between pre- and post-intervention
data, eliminating the intrasubject component. Diverse comparisons were carried out using
Mann–Whitney’s Uin a process similar to a post hoc ANOVA. Table 4displays these results.
Table 4.
Mann–Whitney, Z, and associated probability (p) results comparing pre–post and post-
follow-up changes between experimental and control groups.
PRE–POST Comparison POST-FOLLOW-UP Comparison
Scale Dimen. Group Average
Rank M-W U Z p Average
Rank M-W U Z p
DAS
DC
Exper.
7.75 10.50 −
1.21
0.11 4.13 6.50 −
1.18 0.257
Contr.
5.25 6.42
SD
Exper.
9.33 1.00 −
2.76
0.00 * 4.00 6.00 −
1.29 0.257
Contr.
3.67 6.50
AE
Exper.
8.00 9.00 −
1.61
0.05 3.25 3.00 −
1.98 0.067
Contr.
5.00 7.00
DCH
Exper.
7.67 11.00 −
1.15
0.12 5.50 12.00 0.00
10.00
Contr.
5.33 5.50
TOTAL Exper.
8.58 5.50 −
2.09
0.02 * 3.88 5.50 −
1.39 0.171
Contr.
4.42 6.58
IBCTQ
A
Exper.
7.75 6.50 −
1.85
0.03 * 5.63 11.50 −
0.11
0.914
Contr.
7.25 5.42
EJ
Exper.
9.33 5.50 −
2.01
0.02 * 3.75 5.00 −
1.50 0.171
Contr.
3.67 6.67
UD
Exper.
8.00 1.00 −
2.73
0.00 * 5.25 11.00 −
0.21
0.914
Contr.
5.00 5.67
T
Exper.
7.67 12.50 −
0.88
0.18 4.88 9.50 −
0.53 0.610
Contr.
5.33 5.92
TOTAL Exper.
8.33 6.00 −
1.93
0.02 * 4.63 8.50 −
0.74 0.476
Contr.
4.42 6.08
ASPA-A
CAs
Exper.
8.08 8.50 −
1.55
0.06 6.88 6.50 −
1.17 0.257
Contr.
4.92 4.58
CAg
Exper.
5.92 14.50 −
0.56
0.20 5.00 10.00 −
0.43 0.762
Contr.
7.08 5.83
CS
Exper.
6.42 17.50 −
0.08
0.4 6.63 7.50 −
0.96 0.352
Contr.
6.58 4.75
CPA
Exper.
5.67 13.00 −
0.82
0.2 4.38 7.50 −
0.96 0.352
Contr.
7.33 6.25
*p
≤
0.05. Note: DAS = Dyadic Adjustment Scale, DC = Dyadic Consensus, DS = Dyadic Satisfaction,
AE = Affectional
Expression, DCH = Dyadic Cohesion; IBCTQ = Integrative Behavioral Couple Therapy Ques-
tionnaire, A = Acceptance, EJ = Empathic Joining, UD = Unified Detachment, T = Tolerance; ASPA-A = Couple
Assertiveness Questionnaire—Form A, CAs = Assertive Communication, CAg = Aggressive Communication,
CS = Submissive Communication, CPA = Passive-Aggressive Communication.
Greater changes were observed in the experimental group for each DAS dimension,
with the greatest difference being in dyadic satisfaction. Comparing means with Mann–
Int. J. Environ. Res. Public Health 2021,18, 9981 10 of 15
Whitney’s Urevealed statistically significant differences in dyadic satisfaction (U= 1.000;
Z=−2.766
;p= 0.00) and dyadic adjustment (U= 5.500; Z=
−
2.009; p= 0.02). The ex-
perimental group also showed greater change in all IBCTQ variables, with statistically
significant differences versus the control group for acceptance (U= 6.500;
Z=−1.848
;
p= 0.03
), empathic joining (U= 5.500; Z=
−
2.009; p= 0.02), unified detachment (U= 1.000;
Z=
−
2.732; p= 0.00), and total IBCTQ score (U= 6.000; Z=
−
1.925; p= 0.03), with em-
pathic joining showing the greatest difference between groups. No significant differences
were found in the analysis of changes at follow-up, again indicating the maintenance of
intervention gains.
With regard to the ASPA-Form A, no significant differences were found between the
experimental and control groups.
Analysis of qualitative data revealed satisfaction and a positive evaluation of the
conflict prevention program by program participants. In accordance with the 5-point
scale established to measure subjective perception of different aspects of the program,
members of the experimental group had the following mean scores: general satisfaction
regarding the individual’s expectations for the program—3.8; interest in the topics covered—
4; interest in the strategies presented—3.8; possibility of applying these strategies—3.6;
perception that these strategies would be helpful for addressing future marital problems—
3.3; level of satisfaction regarding the professional who had imparted the program—4;
and recommendation of the program to other couples—4. General satisfaction with the
program received was 26.33 out of a 28-point maximum possible score.
In-session notes of experimental couples’ verbalizations seem to note changes in their
patterns of interaction as a result of the intervention program. In the first session, comments
tended to focus on couples’ desire to prevent or better manage conflict: “Being able to
prevent discussions caught my attention”; “If we would do something before [things get
out of hand], that would be great”; “We tend to have big arguments from time to time
and I would like to know what to do”; “Sometimes I’m badly affected when we fight”. By
the second session, couples were starting to be more aware of their differences and the
tendency to polarize: “This week, I’ve focused more on our differences”; “I’ve focused more
on the differences that annoy me”; “I see that we have a lot of differences”; “In a discussion
we had on Saturday, each of us became rigid in their point of view”; It’s difficult to get
outside of your point of view when you’re emotionally altered, but having talked about
it last session at least it makes you think”. The third session showed greater awareness
of spontaneous conflict resolution techniques that were functional for the couple: “We
complement each other well; each one knows how to calm the other”; “This week when my
partner got angry, I went to give them a hug”; “I can’t deny him a hug when he’s altered,
that’s how we resolve things”; “We looked at the most useful way in which we deal with
conflict: humor”. In the fourth session, couples began to comment on the tendency to attack
each other instead of expressing soft emotions and their efforts to implement empathic
joining: “I used last week’s strategy without having to think about it”; “The psychologist
told us that we could express ourselves without attacking each other”; “It’s difficult to
not attack each other when we’re emotionally altered, but it’s true that it complicates
things”; “The other day I saw how we got stuck in a vicious circle because of this”; “I
became aware of how much we criticize each other underneath everything.” In the fifth
session, couples mentioned the helpfulness of analyzing problems more objectively as a
team through unified detachment: “We tend to try and see problems objectively”; “I really
liked what you said, that if a one of us has a problem and it affects both of us, then it’s
our problem together”; “It’s logical that if we look at problems as a team it will be easier
to resolve them”; “Being a team is very important”; “We’ve stopped somewhat being [a
team] since a while ago”; “I also [believe] that if you’re not [a team], then what are you?”.
They also emphasized the importance of tolerance strategies such as self-care: “I also look
to my needs”; “Yes, when we’ve had an argument, I know that things will be okay if I
dedicate time to be with friends and practice a sport and calm myself”; “Maybe we’ve
lost time for ourselves [as individuals].” All of these comments are coherent with IBCT
Int. J. Environ. Res. Public Health 2021,18, 9981 11 of 15
strategies (empathic joining, unified detachment, and tolerance) and reveal progress in the
program’s objectives.
Not all couples responded equally to all program elements. Couples showed more
interest in and benefited more from specific IBCT strategies as a function of their interaction
profile. For example, Experimental Couple 1 (EC1) responded more to unified detachment.
They were the youngest of the cohort, had been together the shortest period of time, did
not live together, and were memorable because of each partner’s openness in expressing
emotions and their attempts to attend to each other’s feelings during conflict. Perhaps this
openness was the result of cultural influences given the greater gender equality lived by
current Spanish youth. Nevertheless, they tended to become tied up in these emotions
and suffer growing distress because of the guilt each felt for the emotional pain they
were causing in the other. At the same time, they tended to fuse with the content of their
conflict, blaming each other for their difficulties instead of seeing the conflict as an external
pattern or event that they fall into together. This tended to erode their sense of facing their
problems as a team, once again increasing their level of distress. Unified detachment, a
more analytic IBCT technique, helps to increase intimacy and positive affect toward the
partner by promoting psychological distance from the problem, thus avoiding the blame
game and supporting a more detached, “us vs. the conflict” mentality, all of which helped
this couple to better navigate conflict.
Experimental Couple 2, on the other hand, responded better to empathic joining. They
were a middle-aged couple that had been together longer than EC1 and lived together
without any children. They tended to take a logical approach to the problems that occurred
between them, and when they expressed emotions, they would accuse each other vehe-
mently, resulting in numerous conflicts and emotional distance from their partner and from
themselves. They even understood emotions as problems to be solved. Empathic joining,
which also looks to increase intimacy and positive affect toward one’s partner, helped them
to directly and assertively express both their surface and hidden emotions as well as learn
how to interpret their partner’s emotions by taking into account their behavioral learning
history. They began to stop seeing emotions as a problem that needed to be solved.
Lastly, Experimental Couple 3 responded the most to tolerance strategies. They had
been together for many years, had two children, and showed a manifest resistance to
change. They were aware of this resistance and explained that their many years together
and the prior unfruitful attempts that they had made to change each other were important
reasons for it. Thus, they showed the greatest interest and inclination toward tolerance
strategies, especially being able to see the positive aspects of each partner’s negative
behavior and the emphasis on self-care, the latter of which they had tried before but out of
resignation instead of seeing it as a way of tolerating and accepting the other.
As can be seen through this qualitative analysis, each couple responded more to certain
IBCT strategies in accordance with their personalities and relationship characteristics.
Nevertheless, all showed quantifiable improvement on the DAS and IBCTQ, and several
of these improvements were maintained over three years. It could be concluded that
IBCT contains diverse strategies that benefit each couple in keeping with their specific
relationship characteristics, but that there are also common factors that seem to benefit most
or all couples. These common factors include: (1) an open and uninterrupted expression of
the unpleasant emotions experienced by each partner during and after a conflict; (2) active
listening by each partner in response to the emotions of the other; (3) consciousness raising
between partners regarding each one’s learning history; (4) a more careful and assertive
use of language when revealing emotions, putting emphasis on expressing feelings instead
of criticism; (5) achieving distance from problems, seeing them from a more objective
perspective, and (6) greater introspection and critical reflection toward the behaviors used
by each to manage unpleasant emotions.
Int. J. Environ. Res. Public Health 2021,18, 9981 12 of 15
4. Discussion
The present investigation presents a new IBCT-based conflict prevention program
for couples and conducts a pre-pilot test of its short-term and long-term efficacy with an
experimental and control group. In contrast with previous marriage prevention programs,
a single theoretical base (IBCT) was used to develop program content, and both quantitative
and qualitative measures were used to investigate multiple intervention effects in line
with that theory (changes in level of acceptance, empathic joining, unified detachment,
and tolerance). The study’s follow-up period (three years) is also longer than that of
most other marriage prevention investigations. Results reveal that the program can be
efficacious in increasing relationship quality in the short-term and long-term (although the
dispersion of the results for dyadic adjustment suggest care regarding the interpretation
of that particular value), with the logical caution imposed by the small sample size. More
specifically, the program contributes to increases in relationship satisfaction (mostly short-
term) and affective expression (both short and long-term), which translates as a decrease in
tension and an increase in intimate and sexual communication between partners. Other
dimensions of relationship quality such as cohesion and consensus (DAS) also improve
in couples post-intervention, although such changes only reach near-significance. We
hypothesize that a longer training may favor clearer statistical results in these areas.
With regard to specific IBCT variables, this program helps couples develop a greater
use of empathic joining and unified detachment (IBCTQ). These results suggest that couples
who complete the program are better able to conceive negative situations and actions (or
inaction) by their partner as examples of differences that exist in the couple instead of
personal attacks, just as the IBCT model posits [
21
], which are results that continue to
suggest that the IBCT model applies cross-culturally. Couples also seem to gain a greater
distance or separation from their problems: that is, a more objective and descriptive
perspective of them. Associated measures of acceptance and tolerance also show near-
significant change.
Although slight changes in communication types (assertive, aggressive, submissive,
and passive-aggressive, ASPA—Form A) were observed, none were significant. One possible
reason is that IBCT acceptance and tolerance strategies do not directly focus on couple
communication types but rather approach them transversely.
Both independent (pre–post changes in the experimental and control groups) and
comparative analyses indicate the greatest change in IBCTQ variables, which is congruent
with the program’s focus. This result both confirms that the program’s content really has
followed IBCT principles and that the IBCTQ is sensitive to changes in IBCT variables. This
last finding is of additional interest, since the IBCTQ is a relatively recent instrument that
could be used in the future to measure other IBCT-based interventions. Along this line,
we believe that the results of studies such as Rogge et al. [
20
] might have been different
or clearer in their conclusions if they had benefitted from a more specific instrument for
measuring IBCT variables such as the IBCTQ. It is also possible that a more specific and
in-depth focus on IBCT components in the current program contributed to the different
results between studies.
Qualitative data tend to be more sensitive to subjective interpretation. Nevertheless,
the results in this case are so clear and consistent among participants that there is little
doubt concerning couples’ satisfaction with the program, that the intervention increased
feelings of rapport and understanding between partners, and that participants perceived
that they had acquired useful tools for managing future conflicts. Role-play practice of IBCT
strategies and the therapists’ resulting feedback do not guarantee that empathic joining and
other abilities were fully absorbed by couples. However, follow-up results seem promising,
and the manifest satisfaction of the participants who learned them indicates their likely use.
Although the results of this study are encouraging, limitations exist that suggest
caution in generalizing the results. Due to the small sample size of the experimental and
control groups (n= 12), this investigation should be considered as more pre-pilot than final.
In addition, as previously mentioned, one of the experimental couples did not complete
Int. J. Environ. Res. Public Health 2021,18, 9981 13 of 15
the three year-follow up data, expressing that they had separated. While this might seem
worrisome, other marriage prevention studies indicate that a significant number of couples
drop out or separate despite initial intervention gains [
23
,
26
,
27
]. The couple that separated
also had a shorter relationship (2 years) than most of the others and did not live together,
which seem to indicate a lower level of commitment compared with other participants and
make the separation less surprising. The study’s small sample size also makes statistical
anomalies of this type more probable and is one of the reasons that a follow-up study
with a greater sample size is recommended. There were also temporal limitations to the
IBCT content that could be imparted. Since we did not want this program to exceed other
proposals such as that of Rogge et al. [
20
] in sessions or time, content was presented in
five 120-minute sessions, which restrained the extension and variety of material used. We
believe that complementing the intervention with videos and content summaries would
more clearly illustrate each IBCT strategy.
5. Conclusions
The present investigation has sought to correct some of the limitations of earlier
relationship prevention studies by creating a conflict prevention program that (1) shows
significant long-term positive effects, (2) possesses strict and well-defined content to help
identify effective prevention components, and (3) is based on a single theoretically and
experimentally sound model (Integrative Behavioral Couple Therapy). Results reveal that
the program is efficacious in increasing relationship quality in the short-term, with some
long-term benefits, especially in the area of affectional expression. IBCT-related variables
(empathic joining and unified detachment) showed significant short-term change, which
were maintained at three-year follow-up. Associated measures of acceptance and tolerance
also showed near-significant change. These data suggest that couples who complete the
program are better able to view negative situations and actions (or inaction) by their partner
as examples of differences that exist in the couple instead of personal attacks and gain
a greater distance or separation from their problems, just as the IBCT model posits [
21
].
Both expressed satisfaction levels, and the 100% program completion rate seem to indicate
high tolerance for the intervention, and the quantitative improvements seem to indicate no
iatrogenic effects. While the recruitment rate for the investigation was good (75% of couples
that desired to participate met with inclusion criteria and entered the study), recruitment
itself was weak, with only eight couples responding to initial social media propaganda.
Greater recruitment time and additional recruitment methods will need to be taken into
account when conducting a full-size randomized controlled trial.
While only a pre-pilot study, we believe the present investigation demonstrates the
potential that a purely IBCT-based model has for relationship prevention both short-
term and long-term and recommend its testing in a larger sample. We hope that the
divulgation of empirical studies such as this one will help alleviate the absence of long-
term efficacious conflict prevention programs and help to better define the usefulness of
specific intervention components (in our case, empathic joining and unified detachment)
in avoiding the escalation of serious couple conflict and its grave repercussions.
Author Contributions:
Conceptualization, J.B.; methodology, J.B., E.N. and T.P.; validation, J.B.;
formal analysis, J.B. and E.N.; investigation, J.B., E.N. and T.P.; resources, J.B. and E.N.; data curation,
J.B. and E.N.; writing—original draft preparation, J.B., E.N. and T.P.; writing—review and editing,
J.B., E.N. and T.P.; supervision, J.B.; project administration, E.N. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Universidad Camilo JoséCela’s Ethics Committee
(13_CEI; 26/04/2021). Since this study involves a prevention program, the Ethics Committee of
the Universidad Camilo JoséCela decided that their review was unnecessary for carrying out the
Int. J. Environ. Res. Public Health 2021,18, 9981 14 of 15
investigation. Nonetheless, for practical purposes, the Committee’s approval was again requested
and received shortly after finalizing the study.
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to privacy and ethical reasons.
Conflicts of Interest: The authors declare no conflict of interest.
References
1.
Atkins, C.; Doss, D.; Berns, B.; George, G.; Gattis, K.; Christensen, A. Prediction of response to treatment in a randomized clinical
trial of marital therapy. J. Consult. Clin. Psychol. 2005,73, 893–903. [CrossRef] [PubMed]
2.
Sevier, M.; Atkins, D.C.; Doss, B.D.; Christensen, A. Up and down or down and up? The process of change in constructive couple
behavior during Traditional and Integrative Behavioral Couple Therapy. J. Marital Fam. Ther.
2015
,41, 113–127. [CrossRef]
[PubMed]
3. Barraca, J. Integrative Behavioral Couple Therapy (IBCT) as a third-wave therapy. Psicothema 2015,27, 13–18.
4.
Gurman, A.S. A framework for the comparative study of couple therapy: History, models, and applications. In Clinical Handbook
of Couple Therapy, 4th ed.; Gurman, A.S., Ed.; Guilford Press: New York, NY, USA, 2008; pp. 1–31.
5.
Markman, H.J.; Floyd, F.J.; Stanley, S.M.; Storaasli, R.D. Prevention of marital distress: A longitudinal investigation. J. Consult.
Clin. Psychol. 1988,56, 210–217. [CrossRef]
6.
Whisman, M.A.; Uebelacker, L.A. Impairment and distress associated with relationship discord in a national sample of married
or cohabiting adults. J. Fam. Psychol. 2006,20, 369–377. [CrossRef]
7. Christensen, A.; Heavy, C.L. Interventions for couples. Annu. Rev. Psychol. 1999,50, 165–190. [CrossRef]
8. Miller, S.; Nunnally, E.; Wackman, D. A communication training program for couples. Soc. Casework 1976,57, 9–18. [CrossRef]
9.
Guerney, B.G. Relationship Enhancement: Skill-Training Program for Therapy, Problem Prevention and Enrichment; Jossey-Bass: San
Francisco, CA, USA, 1977.
10.
Markman, H.J.; Stanley, S.M.; Blumberg, S.L. Fighting for Your Marriage: Positive Steps for Loving and Lasting Relationships;
Jossey-Bass: San Francisco, CA, USA, 1994.
11.
Stanley, S.M.; Blumberg, S.L.; Markman, H.L. Helping couples fight for their marriages: The PREP approach. In Preventive
Approaches in Couples Therapy; Berger, R., Hannah, M.T., Eds.; Brunner/Mazel: Levittown, PA, USA, 1999; pp. 279–303.
12. Bagarozzi, D.A.; Rauen, P. Premarital counseling: Appraisal and status. Am. J. Fam. Ther. 1981,9, 13–30. [CrossRef]
13. Cavedo, C.; Guerney, B.G. Relationship enhancement and problem prevention programs: Therapy-derived, powerful, versatile.
In Preventive Approaches in Couples Therapy; Berger, R., Hannah, M.T., Eds.; Brunner/Mazel: Levittown, PA, USA, 1999; pp. 75–103.
14.
Giblin, P.; Sprenkle, D.H.; Sheehan, R. Enrichment outcome research: A meta-analysis of premarital, marital and family
interventions. J. Marital Fam. Ther. 1985,11, 257–271. [CrossRef]
15.
Guerney, B.; Maxson, P. Marital and family enrichment research: A decade review and look ahead. J. Marriage Fam.
1990
,52,
1127–1135. [CrossRef]
16.
Hahlweg, K.; Markman, H. The effectiveness of behavioral marital therapy: Empirical status of behavioral techniques in
preventing and alleviating marital distress. J. Consult. Clin. Psychol. 1988,56, 440–447. [CrossRef]
17.
Sayers, S.L.; Kohn, C.S.; Heavey, C. Prevention of marital dysfunction: Behavioral approaches and beyond. Clin. Psychol. Rev.
1998,18, 713–744. [CrossRef]
18.
Carrol, S.; Doherty, J. Evaluating the effectiveness of premarital prevention programs: A metaanalytic review of outcome research.
Interdiscip. J. Appl. Fam. Sci. 2004,52, 105–118. [CrossRef]
19.
Ledermann, T.; Bodenmann, G.; Cina, A. The efficacy of the Couples Coping Enhancement Training (CCET) in improving
relationship quality. J. Soc. Clin. Psychol. 2007,26, 940–959. [CrossRef]
20.
Rogge, R.; Lawrence, E.; Cobb, R.; Johnson, M. Is Skills Training Necessary for the Primary Prevention of Marital Distress and
Dissolution? A 3-Year Experimental Study of Three Interventions. J. Consult. Clin. Psychol. 2013,81, 949–961. [CrossRef]
21.
Jacobson, N.S.; Christensen, A. Acceptance and Change in Couple Therapy: A Therapist’s Guide to Transforming Relationships; Norton:
New York, NY, USA, 1996.
22.
Cordova, J.V. The Marriage Checkup Practitioner’s Guide: Promoting Lifelong Relationship Health; American Psychological Association:
Washington, DC, USA, 2014.
23.
Gee, C.B.; Scott, R.L.; Castellani, A.M.; Cordova, J.V. Predicting 2-year marital satisfaction from partners’ reaction to a marriage
checkup. J. Marital Fam. Ther. 2002,28, 399–408. [CrossRef]
24.
Cordova, J.V.; Scott, R.L.; Dorian, M.; Mirgain, S.; Yaeger, D.; Groot, A. The marriage checkup: A motivational interviewing
approach to the promotion of marital health with couples at-risk for relationship deterioration. Behav. Ther.
2005
,36, 301–310.
[CrossRef]
25.
Trillingsgaard, T.; Fentz, H.N.; Hawrilenko, M.; Cordova, J.V. A randomized controlled trial of the Marriage Checkup adapted for
private practice. J. Consult. Clin. Psychol. 2016,84, 1145–1152. [CrossRef]
Int. J. Environ. Res. Public Health 2021,18, 9981 15 of 15
26.
Gordon, K.C.; Cordova, J.V.; Roberson, P.N.E.; Miller, M.; Gray, T.; Lenger, K.A.; Hawrilenko, M.; Martin, K. An implementation
study of relationship checkups as home visitations for low-income at-risk couples. Fam. Process 2018,58, 247–265. [CrossRef]
27.
Cordova, J.V.; Eubanks Fleming, C.J.; Morrill, M.I.; Hawrilenko, M.; Sollenberger, J.W.; Harp, A.G.; Gray, T.D.; Darling, E.V.; Blair,
J.M.; Meade, A.E.; et al. The Marriage Checkup: A randomized controlled trial of annual relationship health checkups. J. Consult.
Clin. Psychol. 2014,82, 592–604. [CrossRef]
28.
Doss, B.D.; Knopp, K.; Roddy, M.K.; Rothman, K.; Hatch, S.G.; Rhoades, G.K. Online programs improve relationship functioning
for distressed low-income couples: Results from a nationwide randomized controlled trial. J. Consult. Clin. Psychol.
2020
,88,
283–294. [CrossRef]
29.
Doss, B.D.; Roddy, M.K.; Nowlan, K.M.; Rothman, K.; Christensen, A. Maintenance of gains in relationship and individual
functioning following the online OurRelationship Program. Behav. Ther. 2019,50, 73–86. [CrossRef]
30.
Córdova, J.V.; Warren, L.Z.; Gee, C.B. Motivational interviewing as an intervention for at-risk couples. J. Marital Fam. Ther.
2001
,
27, 315–326. [CrossRef]
31.
Bell, M.L.; Whitehead, A.L.; Julious, S.A. Guidance for using pilot studies to inform the design of intervention trials with
continuous outcomes. Clin. Epidemiol. 2018,10, 153–157. [CrossRef]
32.
Christensen, A.; Atkins, D.C.; Baucom, B.R.; Yi, J. Couple and individual adjustment for 5 years following a randomized clinical
trial comparing traditional versus integrative behavioral couple therapy. J. Consult. Clin. Psychol. 2010,78, 225–235. [CrossRef]
33.
Christensen, A.; Atkins, D.C.; Yi, J.; Baucom, D.H.; George, W.H. Couple and individual adjustment for two years following a
randomized clinical trial comparing traditional versus integrative behavioral couple therapy. J. Consult. Clin. Psychol.
2006
,74,
1180–1191. [CrossRef]
34.
Christensen, A.; Doss, B.D.; Jacobson, N.S. Integrative Behavioral Couple Therapy: A Therapist’s Guide to Creating Acceptance and
Change, 2nd ed.; W.W. Norton: New York, NY, USA, 2020.
35.
Spanier, G.B. Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. J. Marriage Fam.
1976,38, 15–28. [CrossRef]
36.
Martín-Lanas, R.; Cano-Prous, A.; Beunza-Nuin, M.I. DAS—Escala de Ajuste Diádico—Adaptación Española; TEA Ediciones: Madrid,
Spain, 2017.
37.
Barraca, J.; Nieto Fernández, E.; Lozano-Bleda, J.H. Integrative Behavioral Couple Therapy Questionnaire (IBCTQ). In Proceedings
of the Libro de Actas del X Congreso Internacional y XV Nacional de Psicología Clínica, Santiago de Compostela, Spain,
16–19 November 2017
; Ramiro, M.T., Sierra Freire, J.C., Eds.; Asociación Española de Psicología Conductual: Granada, Spain,
2017; p. 234.
38. Carrasco, M. Cuestionario de Aserción en la Pareja (ASPA-A); TEA Ediciones: Madrid, Spain, 1996.
39. Barraca, J. Terapia Integral de Pareja: Una Intervención para Superar las Diferencias Irreconciliables; Síntesis: Madrid, Spain, 2016.
40. Barraca, J.; Sánchez, J.M. Terapia Integral de Pareja Paso a Paso; Grupo 5: Madrid, Spain, 2018.
41.
Baucom, J.W.; Eldridge, A.; Sevier, M.; Doss, B.D. Observed communication in couples two years after integrative and traditional
behavioral couple therapy: Outcome and link with five-year follow-up. J. Consult. Clin. Psychol. 2011,79, 565–576. [CrossRef]
42.
Baucom, B.; Simpson, L.; Atkins, D.; Christensen, A. Prediction of response to treatment in a randomized clinical trial of couple
therapy: A 2-year follow-up. J. Consult. Clin. Psychol. 2009,77, 160–173. [CrossRef]
43.
Jacobson, N.S.; Christensen, A.; Prince, S.E.; Cordova, J.; Eldridge, K. Integrative behavioral couple therapy. An acceptance-based,
promising new treatment for couple discord. J. Consult. Clin. Psychol. 2000,68, 351–355. [CrossRef]
