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Behavior Therapy 43 (2012) 13 24


www.elsevier.com/locate/bt

Integrative Approaches to Couple Therapy: Implications for


Clinical Practice and Research
Douglas K. Snyder
Christina Balderrama-Durbin
Texas A&M University

receiving treatment (Shadish & Baldwin, 2003).


Although meta-analyses affirm that various treatments for Indeed, the overall mean effect size for couple
couple distress produce statistically and clinically significant therapy (0.84) is generally comparable to or larger
outcomes, research findings also indicate that a large than those obtained in randomized clinical trials of
percentage of couples fail to benefit or subsequently individual therapy or medical interventions. How-
deteriorate following current therapies. Based on these ever, tempering enthusiasm from this overall con-
findings, we advocate potential advantages of integrative clusion are additional findings that in only 50% of
approaches to couple therapy. We distinguish among treated couples do both partners show significant
assimilative, transtheoretical, and pluralistic approaches to improvement in relationship satisfaction, and that
integration and describe exemplars of each. Integrative 3060% of treated couples show significant deteri-
approaches to couple therapy are compared to distillatory oration at 2 years or longer after termination
or common factors approaches emphasizing common (Snyder, Castellani, & Whisman, 2006).
elements of treatment components, therapist characteristics, As noted in the introduction to the special section
and client or relationship attributes. We argue that clinical (Halford & Snyder, 2012-this issue), empirical
practice of integrative approaches to couple therapy requires findings from randomized clinical trials support the
conceptual and clinical decision-making skills transcending efficacy of six different couple-based treatments for
those of any one theoretical modality and emphasizing the couple distressincluding traditional behavioral,
selection, sequencing, and pacing of diverse interventions in cognitive-behavioral, integrative behavioral, emo-
a coherent manner. We conclude with implications of tionally focused, integrative systemic, and insight-
integrative couple-based treatments for future research. oriented couple therapy approaches (Snyder, Castel-
lani, et al., 2006). However, meta-analyses provide
little evidence of differential effectiveness across these
Keywords: Couple therapy; integrative therapy; marital therapy; different theoretical orientations to couple therapy,
pluralism; common factors
particularly once other covariates (e.g., reactivity of
measures) are controlled. This lack of differential
META-ANALYSES OF COUPLE THERAPY affirm that
effectiveness across couple treatment approaches,
various approaches to treating couple distress
combined with suboptimal rates of improvement and
produce statistically and clinically significant im-
deterioration after 2 years, have fostered two alter-
provement for a substantial proportion of couples,
native lines of attack to treating couple distress:
with the average couple receiving therapy being
(a) distillation and emphasis on common factors or
better off at termination than 80% of couples not
universal processes hypothesized to contribute to
beneficial effects across singular or pure treat-
Address correspondence to Douglas K. Snyder, Department of ment approaches, and (b) integrative models incor-
PsychologyMS 4235, Texas A&M University, College Station, TX porating multiple components of diverse treatment
778434235; e-mail: d-snyder@tamu.edu.
approaches.
0005-7894/xx/xxx-xxx/$1.00/0
2011 Association for Behavioral and Cognitive Therapies. Published by In this article we advocate potential advantages
Elsevier Ltd. All rights reserved. of integrative approaches to couple therapy. We
14 snyder & balderrama-durbin

distinguish among assimilative, transtheoretical, tion of specific interventions with a given client at a
and pluralistic approaches to integration, and given moment. There are numerous approaches to
contrast these with distillatory or common factors integration that vary in their emphasis on tech-
approaches. We advocate a hierarchical, pluralistic nique versus theory, and their goal of assimilating
model of couple therapy that potentially informs existing techniques or theoretical constructs into an
the selection, sequencing, and pacing of diverse existing predominant theoretical or conceptual
interventionsand we then propose general guide- framework versus generating a new incorporative
lines for implementing this approach. Finally, we theoretical approach. Below we contrast three of
articulate four implications of couple therapy these approachesassimilative, transtheoretical,
integration for clinical practice, along with four and pluralisticand briefly describe exemplars of
implications for future research. each.

Integrative Approaches to Couple Therapy assimilative approaches


Couple therapists confront a tremendous diversity In assimilative integration, specific interventions or
of presenting issues, marital and family structures, constructs from one or more theoretical approaches
individual dynamics and psychopathology, and are translated and incorporated into some alterna-
psychosocial stressors characterizing couples in tive, existing predominant theoretical framework.
distress. Because the functional sources of couples The goal is to combine the advantages of a single,
distress vary so dramatically, the critical mediators coherent theoretical system with the flexibility of a
or mechanisms of change should also be expected to broader range of technical interventions from
varyas should the therapeutic strategies intended multiple systems (Norcross, 2005). Assimilative
to facilitate positive change. Even within the more integration can occur at either the technical or
restricted domain of individual interventions, grow- theoretical level. Both technical and theoretical
ing recognition of unique strengths and limitations integration are distinguished from their eclectic
of competing theoretical approaches has fueled a counterparts by the number and explanatory power
burgeoning movement toward psychotherapy inte- of linkages among interventions or their theoretical
gration (Norcross, 2005). For example, advocates substrates.
of various integrative models of psychotherapy have Among the first integrative couple therapies to be
emphasized the strengths of psychodynamic ap- articulated was Gurman's (1981, 2008) depth-
proaches for identifying enduring problematic behavioral integrative approach drawing on prin-
interpersonal themes, the benefits of experiential ciples of social learning theory, object relations
techniques for promoting emotional awareness, theory, and general systems theory. Gurman
gains from cognitive interventions targeting dys- emphasizes the critical interrelation of intrapsychic
functional beliefs and attributional processes, and and interpersonal factors in couples interactions
advantages of behavioral strategies for promoting and defines the goal of couple therapy as the
new patterns of behavior (Bongar & Beutler, 1995). loosening and broadening of each spouse's implicit
Thus, couples may benefit most from a treatment matrix of assumptions, expectations, and require-
strategy drawing from both conceptual and technical ments of intimate interpersonal contact. This is
innovations from diverse theoretical models relevant accomplished through interpretation, cognitive
to different components of a couple's struggles. That restructuring, and creation of therapeutic tasks to
is, therapeutic impact may be enhanced when the promote each spouse's exposure to those aspects of
couple therapist has a solid grounding across diverse him- or herself and his or her partner that are
theoretical approaches, has acquired a rich repertoire blocked from awareness.
of intervention techniques linked to theory, engages Although Gurman's (1981, 2008) integrative
in comprehensive assessment of the marital and approach to couple therapy has been consistently
family system, and selectively draws on intervention assimilative, its relative emphasis on psychodynamic
strategies across the theoretical spectrum in a manner versus behavioral theory as the home theory in
consistent with an explicit case formulation (Snyder, which to assimilate competing constructs has changed
Schneider, & Castellani, 2003). significantly over the past 25 years. For example,
Integrative approaches strive to reduce the risk of Gurman (1992) argued that, the most appropriate
haphazard, disjointed, or contradictory interven- theoretical foundation for an integrative understand-
tions resulting from an eclectic borrowing of diverse ing of marital interaction, dynamics, and change is to
principles or techniques without regard for their be found in psychodynamic thinking, especially in a
potential inconsistency or adverse interaction. That focused use of certain concepts originating in object
is, integrative approaches emphasize the impor- relations theory (p. 453). From this perspective, such
tance of theories and principles that guide the selec- behavioral techniques as teaching partners to rely on
integrative approaches to couple therapy 15

positive reinforcement for modifying their spouse's classes of therapeutic change mechanisms: (a) the
behavior may be reconceptualized as a direct inhib- therapeutic bond, (b) problem activation, (c) resource
itor of [partners] proclivities to engage in projective activation, (d) mastery and coping, and (e) motiva-
identification (Gurman, 1980, p. 90). More recently, tional clarification. For example, problem-focused
however, Gurman's depth-behavioral integrative interventions are viewed as inducing short-term
approach emphasizes the centrality of functional increases in inconsistency by directing clients atten-
behavior analytic theoryoverlapping with but tion toward information inconsistent with underly-
distinct from enhanced cognitive-behavioral couple ing emotions or cognitions regarding the problem;
therapy (Epstein & Baucom, 2002) and integrative this initial inconsistency subsequently encourages
behavioral couple therapy (IBCT; Jacobson & accommodative changes in maladaptive regulation
Christensen, 1996). patterns to ensure higher levels of consistency in the
As its name implies, IBCT adopts social learning long term. Concurrent resource activation serves to
theory as its primary theoretical foundation (empha- strengthen the healthy patterns of clients functioning
sizing communication and behavior-exchange skills), while also increasing tolerance for short-term in-
but also incorporates additional strategies aimed at creases in inconsistency and related stress involved in
promoting acceptance. Acceptance techniques are changing the more problematic patterns. Couple
viewed as essential when direct efforts to change are therapy guided by consistency theory incorporates
blocked by incompatibilities, irreconcilable differ- individual, concurrent, or conjoint sessions based on
ences, and unsolvable problems (Jacobson & assessment of partners respective emotional, cogni-
Christensen, 1996, p. 11). Partners are taught to tive, and behavioral resources and their expression in
develop tolerance for differences in interpersonal the couple relationship (Grawe-Gerber, 2010).
preferences and to appreciate and use such differ- An alternative transtheoretical approach is re-
ences to enhance their relationship. Incorporating flected in Pinsof's (1995, 2005) integrative problem-
additional interventions not unlike those in emotion- centered therapy. This systems-oriented approach
focused couple therapy (EFCT; Johnson, 2004), this interrelating family, individual, and biological
integrative approach encourages empathic joining by interventionsbegins the treatment of most disor-
facilitating soft disclosures by the partner or by ders with a focus on the behavioral patterns (or
reformulations of partners harsher exchanges by the problem maintenance structure) that prevent a
therapist. Results from a large randomized clinical couple from solving their presenting problems. If
trial of IBCT demonstrate that about 70% of couples interventions at that level are not effective, therapy
show clinically significant improvement, and that progresses to an exploration of the affective and
about 50% demonstrate sustained improvement at cognitive components of the maladaptive patterns. If
5 years following termination (Christensen, Atkins, interventions at this experiential level fail, the
Baucom, & Yi, 2010). treatment progresses to a developmental perspective
focusing on family-of-origin patterns and specific
transtheoretical approaches historical determinants of enduring maladaptive
Transtheoretical integration incorporates specific relationship patterns. Concurrent with this progres-
constructs from diverse theoretical approaches in a sion across theoretical orientations is a progression
synergistic manner as to generate some new across intervention contextsbeginning with a broad
metatheory not derivable from the respective original familycommunity contextand then addressing
approaches separate from one another. The goal is to couple-relationship and individual contexts. That is,
create an emergent theory that is more than the sum the overall progression in this assimilative approach
of its parts (Norcross, 2005, p. 8). Grawe's (2002) is from the interpersonal to the individual, and from
consistency theory represents a transtheoretical the here-and-now behavioral to the historically
integrative approach well suited to couple-based linked intrapsychic (Pinsof, 2005).
interventions. According to consistency theory,
incongruence between individual perceptions and pluralistic approaches
goals reduces well-being and increases the risk for the Pluralism recognizes the validity of multiple systems
development and maintenance of psychopathology. of epistemology, theory, and practice and draws on
Hence, therapeutic interventions should strive to these as intact units (as distinct from eclecticism),
reduce the level of incongruence in the long term, although not necessarily concurrently or from a
while potentially inducing inconsistency in the short transtheoretical perspective. Pluralism is similar to
term to promote changes more likely to lead to constructs of empirical pragmatism, systematic
healthy self-regulation and enduring consistency. treatment selection, and prescriptive eclecticism
Based on empirical findings from the psychother- characterized by drawing on effective methods
apy literature, Grawe (1997) extracted five broad from across theoretical camps (eclecticism), by
16 snyder & balderrama-durbin

matching those methods to particular cases on the member, or similar concerns that, until resolved,
basis of psychological science and clinical wisdom preclude development of new relationship skills and
(prescriptionism), and by adhering to an explicit progress toward emotional intimacy. Because some
and orderly model of treatment selection. . . . couples initially present with overwhelming nega-
(Norcross & Beutler, 2000, p. 248). Because a tivity, the therapist may need to instigate behavior
pluralistic approach is less constrained than theo- change directly before assisting the couple to
retically integrative approaches forced to reconcile develop behavior-exchange and communication
competing constructs, it potentially offers greater skills of their own. Along with promoting general
opportunity to accommodate diverse theoretical relationship skills, the couple therapist may need to
perspectives. assist partners in acquiring a prerequisite knowl-
Snyder (1999) advocated a pluralistic approach to edge base and competence in specific domains such
couple therapy conceptualizing therapeutic tasks as as sexuality, parenting, finances, or time manage-
progressing sequentially along a hierarchy compris- ment.
ing six levels of intervention from the most funda- A common impediment to behavior change in-
mental interventions promoting a collaborative volves misconceptions and other interpretive errors
alliance to more challenging interventions addressing that individuals may have regarding both their own
developmental sources of relationship distress (see and their partner's behavior; interventions targeting
Table 1). Because couple therapy often proceeds in a partners relationship beliefs, expectancies, and
nonlinear fashion, the model requires flexibility of attributions aim to eliminate or restructure cognitive
returning to earlier therapeutic tasks as dictated by processes interfering with behavior change efforts.
individual or relationship difficulties. However, not all psychological processes relevant to
The most fundamental step in couple therapy couples interactions lend themselves to traditional
involves developing a collaborative alliance be- cognitive interventions. Of particular importance are
tween partners and between each partner and the partners developmental relationship experiences
therapist by establishing an atmosphere of therapist resulting in enduring interpersonal vulnerabilities
competence as well as therapeutic safety around and related defensive strategies interfering with
issues of confidentiality and verbal or physical emotional intimacy, many of which operate beyond
aggression. Subsequent interventions may need to partners conscious awareness. Hence, when couple
target disabling relationship crises such as substance distress persists despite system-restructuring, skills-
use, psychopathology, illness or death of a family building, and cognitive interventions, then

Table 1
Intervention Levels and Sample Indicators for a Hierarchical Pluralistic Approach
Level Description Sample Indicators
6 Examine development sources of Promoting understanding of enduring maladaptive
relationship distress relationship patterns
Promoting empathic joining and reduced reactivity to covert
sources of each partner's interpersonal anxieties
5 Challenge cognitive components Addressing issues of selective attention, attribution biases,
of relationship distress expectancies
4 Promote relevant relationship skills Promoting communication skills: decision making;
emotional expression and responsiveness
Developing requisite skills in specific domains such as sexuality,
parenting, finances
3 Strengthen the couple dyad Promoting healthy boundaries relative to children, extended family,
work, and community
Facilitating positive behavior exchanges; negotiating
individual and collaborative agreements
2 Contain disabling crises Preventing aggression against self and others
Containing external stressors and facilitating intermediate solutions
Addressing major psychopathology
Mobilizing appropriate external resources
1 Establish collaborative alliance Establishing trust in therapist's competence and fairness
Clarifying ground-rules regarding confidentiality, structure of sessions
Setting limits on negative exchanges in sessions
integrative approaches to couple therapy 17

interpretation of maladaptive relationship patterns commitment to the relationship as the client.


evolving from developmental processes comprises an While teaching specific relationship skills to trans-
essential treatment component (Snyder & Mitchell, fer responsibility for ongoing relationship interven-
2008). tions over to partners, unanticipated or emergent
This pluralistic approach presumes that couples crises may require reversion to an earlier level of
will vary in the extent to which they require intervention to facilitate intermediate solutions or
interventions at any level of the treatment hierar- mobilize external resources.
chy, but also presumes that higher-order interven- In this manner, tailoring therapeutic interven-
tions (e.g., cognitive or insight-oriented techniques tions to characteristics of individual partners, their
targeting intrapersonal processes) would ordinarily relationship, and extended psychosocial system
not be implemented unless lower-order interven- differs from a priori treatment matching paradigms
tions (e.g., crisis-intervention, relationship strength- in which clients are assigned to predesigned
ening, or skills-building techniques targeting treatment modalities based on initial assessment
interpersonal processes) had already proven insuf- findings. Instead, in an informed pluralistic ap-
ficient. This model also posits that higher-order proach, matching proceeds on a continuous basis
interventions, even if necessary, would not be throughout therapy, based not only on client and
pursued until a foundation of increased positivity extended relationship characteristics but also on
and reduced negativity had already been firmly emergent features of the therapeutic process
established. Indeed, this general sequence is consis- including fluctuations in the therapeutic alliance,
tent with findings from Christensen and colleagues unanticipated disruptions by external stressors, or
comparisons of traditional and integrative behavior interactions of evolving skill sets with enduring
couple therapy demonstrating that changes in belief systems or covert interpersonal anxieties.
targeted behaviors were a powerful mechanism of Although the predominant mode or level of inter-
change early in therapy, whereas interventions vention for a given session or phase of treatment
targeting emotional acceptance were more strongly may be planned ahead of time based on an overall
related to changes in relationship satisfaction later in case formulation, specific interventions within
therapy (Doss, Thum, Sevier, Atkins, & Christensen, session are matched to both therapist and client
2005). characteristics in the moment. Doing so effectively
Although the sequencing of interventions pre- requires keen attention to aspects of the therapeutic
scribed by the pluralistic model presented here process, continuous awareness of both overt and
mirrors the general progression of interventions covert aspects of partners ongoing responses, and
characterizing Pinsof's (1995, 2005) integrative familiarity with a broad range of specific interven-
problem-centered therapy, the two approaches tions and the theoretical underpinnings that guide
differ in subtle ways. First, the pluralistic model their selection and implementation.
articulated here emphasizes the frequent necessity From this perspective, systematic monitoring and
of attending to immediate relationship crises and feedback of couple therapy progress could enhance
distinguishes explicitly between strengthening the therapy outcome by optimizing continual tailoring
dyad through structural interventions versus spe- of interventions across, if not within, sessions (see
cific skill-building interventions. The pluralistic Halford et al., 2012-this issue). For example,
model also draws a sharper distinction between recognizing couples heightened reactivity during
cognitive and affective components of relationship initial phases of exploring developmental origins of
distress and associated interventions, regardless of maladaptive relationship patterns or reversion to
their temporal origins. Finally, although consistent increased frequency of disruptive negative ex-
with techniques of affective reconstruction de- changes between sessions after prior mastery of
scribed here, Pinsof's model does not explicitly communication skills may dictate renegotiation of
address unique benefits of conducting developmen- positive behavior exchanges and either individual
tal interventions in the context of conjoint couple or collaborative agreements by the therapist.
therapy.
Table 1 summarizes general guidelines indicating empirical evidence regarding efficacy
when any specific component of the pluralistic of integrative approaches
model may assume particular salience. For exam- Despite conceptual arguments regarding the poten-
ple, at any given time in the couple therapy, the tial advantages of integrative approaches to couple
collaborative alliance between partners and thera- therapy, empirical evidence regarding their incre-
pist may be strained by misunderstanding of the mental efficacy beyond the individual treatment
partners or therapist's rolesrequiring clarifica- components they draw upon is generally lacking.
tion to restore trust in the therapist's fairness and Of the integrative approaches described above, only
18 snyder & balderrama-durbin

IBCT has been examined in a randomized clinical treatment components constituting diverse integra-
trial comparing it to traditional behavioral couple tive approaches to couple therapy.
therapy (TBCT). In that study (Christensen et al.,
Integration Versus Distillation: The Common
2010), both treatment conditions produced sub-
stantial effect sizes in seriously and chronically Factors Approach
distressed couples. The integrative treatment incor- The common factors approach argues that shared
porating acceptance-based interventions produced mechanisms of change cutting across the diverse
significantly but not dramatically superior out- couple therapies account for the absence of
comes through the first 2 years after treatment significant differences in their overall effectiveness.
termination, but outcomes for the two treatments Sprenkle and colleagues (Davis, Lebow, & Sprenkle,
converged over longer follow-up periods. More- 2012-this issue; Sprenkle & Blow, 2004; Sprenkle,
over, the empirical evidence supporting efforts to Davis, & Lebow, 2009) have cited five types or
match treatments (or treatment components) to classes of common factors characterizing psycho-
specific client characteristics is mixed, at best. In therapy in general, and four specific to couple or
arguably the largest effort of this sort to date, family therapy. Common factors viewed as generic to
Project MATCH involved more than 1,700 patients psychotherapy include (a) client characteristics (e.g.,
with alcohol-abuse problems and 80 therapists at learning style, perseverance, and compliance with
over 30 participating institutions and treatment instructions or assignments); (b) therapist character-
agencies. Patients were matched to one of three istics (e.g., abilities to foster a therapeutic alliance
treatments (a 12-step facilitation treatment, cogni- and to match activity level to clients expectations or
tive behavioral therapy, or motivational enhance- preferences); (c) dimensions of the therapeutic
ment therapy) based on their pretreatment personal relationship (e.g., emotional connectedness and
characteristics. Although patients in all three congruence between the therapist's and client's
treatment conditions showed major improvement, specific expectations or goals); (d) expectancy or
results failed to provide support for the matching placebo effects; and (e) nonspecific interventions
hypothesis in 15 of 16 instances (Project MATCH promoting emotional experiencing, cognitive mas-
Research Group, 1998). tery, and behavioral regulation. Those common
Both in the study comparing integrative versus factors viewed as specific to couple or family
behavioral couple therapy (BCT; Christensen et al., therapies include (a) conceptualizing difficulties in
2010) and in Project MATCH, individuals were relational terms, (b) disrupting dysfunctional rela-
assigned to treatment protocols administered in tional patterns, (c) inclusion of multiple members of
their entirety. This differs both conceptually and the extended family system in direct treatment, and
strategically from matching specific treatment (d) fostering an expanded therapeutic alliance across
components to client characteristics (including partners or multiple members of the family as a
partners interactions with each other as well as whole.
with the therapist) that emerge over the course of More recently, Christensen and colleagues
therapy. Matching specific interventions to individ- (Benson, McGinn, & Christensen, 2012-this
ual and relationship characteristics that emerge issue; Christensen, 2010) have advocated a unified
over the course of treatment potentially provides a protocol for couple therapy based on an alternative
larger database (extending beyond pretreatment formulation of five central principles of therapeutic
characteristics) on which to prescribe differential interaction, based on evidence-based couple thera-
therapeutic strategies, with such treatment de- pies. These principles include (a) altering the couple's
cisions being more proximal to the timing of the view of the presenting problem to be more objective,
selection indicators. Despite this potential advan- contextualized, and dyadic; (b) decreasing emotion-
tage, research identifying prescriptive indicators of driven, dysfunctional behavior; (c) eliciting emotion-
couple treatment response has been rare. The based, avoided, private behavior; (d) increasing
research comparing IBCT with traditional BCT constructive communication patterns; and (e) pro-
suggested that severely distressed couples may moting strengths and reinforcing gains. Implement-
respond more favorably to BCT than to IBCT ing this unified protocol successfully requires a
during the initial stages of treatment. Additional coherent case conceptualization through functional
analyses from this clinical trial (Atkins et al., 2005) analysis of the couple's interactional pattern.
suggested that sexually dissatisfied couples showed In their expanded treatise on common factors,
slower initial response but overall more consistent Sprenkle et al. (2009) distinguish among contrasting
gains in IBCT versus BCT. Clearly, considerably views of common factorsthat is, viewing these as
more research is necessary to generate evidence- important but not exclusive mechanisms contribut-
based indicators and contraindicators for specific ing to the effectiveness of various therapeutic
integrative approaches to couple therapy 19

approaches versus a more radical view of common selection and modification, attentional deployment,
factors as entirely responsible for treatment effects and stimulus interpretation) and response-focused
and specific treatment approaches as irrelevant to strategies promoting either increases or reductions in
outcome. Even the former, more moderate view is experiential, physiological, and behavioral emotion
not without its critics. For example, Sexton, Ridley, response tendencies. This model readily lends itself to
and Kleiner (2004) have argued that in their current translation into specific couple-based interventions
form, common factors are neither operationally for general couple distress or specific disorders
defined, contextualized within the clinical process targeting both individual and relational processes
into which they might fit, or explicated as to the (e.g., disease-related pain; see Baucom, Porter, Kirby,
mechanisms that might promote their outcome & Hudepohl, 2012-this issue). A common factors
(p. 138). They further argue that common factors, perspective suggests that diverse couple-based treat-
by themselves, fail to offer a road map or set of ments may yield similar outcomes to the extent that
systematic procedures for determining which interv- different specific techniques within each approach
entions or mechanisms are most salient at specific therapeutically impact relevant emotion-regulation
points during the change process. Davis and Piercy processes.
(2007a, 2007b) countered that appreciation of Empirical findings regarding the efficacy of specific
common factors should supplement, not supplant, theoretical approaches to couple therapyand the
providers thorough grasp of diverse models under- review of alternative integrative approaches as well
lying couple therapy. as a common factors perspectiveoffer several
As an alternative to common factors in couple implications for clinical practice and research.
therapy, Sexton and colleagues (2004) proposed com-
mon mechanisms of change to include (a) redefinition implications of integrative approaches
of the presenting problem, (b) impasse resolution, for clinical practice
(c) therapeutic alliance, (d) reduction of within-session Effective Treatment of Couples Often Requires
negativity, (e) improved interactional and behavioral Therapists to Conceptualize and Practice Integra-
competency, and (f) treatment adherence to the tively Across Diverse Theoretical Orientations
specific model being practiced. To date, however, Couple therapy often requires thinking outside the
there has been little research documenting specific parameters of any one theoretical orientationin
treatment effects attributable to proposed common part because theoretical approaches vary in their
factors, common mechanisms, or central principles attention to cognitive, affective, and behavioral
or systematic efforts in designing couple treatment components of intrapersonal and interpersonal
approaches intended to maximize their therapeutic functioning. The more difficult the couple, the
impact. greater the need may be to draw on increasingly
Among client characteristics potentially contrib- diverse intervention strategies to address multiple
uting to similar outcomes across treatment ap- individual and relationship problems. Couple ther-
proaches, there has been increasing emphasis in apists need to develop competence in the principles
recent years on the role of emotion regulation in and strategies of integrative practiceensuring a
health and dysfunction (Snyder, Simpson, & technical understanding of specific therapeutic
Hughes, 2006). Deficits in emotion regulation may techniques, the theoretical context in which these
lead to either the overcontrol or undercontrol of evolved, and their demonstrated efficacy for partic-
affect, with the latter typically receiving the greater ular problems in specific populations.
attention in the clinical literature. Indeed, analysis of Although incorporating diverse treatment strate-
affect-related symptoms in the current Diagnostic gies may enhance efficacy by expanding the range
and Statistical Manual of Mental Disorders (DSM- of potential interventions and tailoring their use to
IV-TR; American Psychiatric Association, 2000) emergent characteristics of partners and the thera-
reveals symptoms of both overcontrol (e.g., con- peutic process, doing so is not without risks. Snyder
stricted or flat affect; emotional coldness or et al. (2003) hypothesized on a theoretical basis
detachment) and undercontrol (e.g., inappropriate, about relative costs and benefits of eclecticism and
labile, or intense affect) related to a broad spectrum integration in low- and high-complexity cases. They
of emotional and behavioral disorders other than predicted that high levels of eclecticism in the
specific mood disorders (e.g., PTSD, schizophrenia, absence of theoretical integration could result in
organic brain syndromes, diverse substance abuse reduced effectiveness due to either (a) the unsyste-
disorders, and most personality disorders). matic or contradictory use of specific interventions,
One widely recognized model of emotion regula- or (b) the dismantling of interventions within
tion (Gross, 2001) distinguishes between antecedent- treatment approaches that rely on the synergistic
focused emotion-regulation strategies (e.g., situation effects of specific components. Paradoxically, the
20 snyder & balderrama-durbin

more difficult the couple, the more likely the teristics that predict response to a particular treat-
therapist may be to draw upon increasingly diverse ment (or response across treatments, irrespective of
intervention strategies to address multiple individ- specific approach) rather than prescriptive indicators
ual and relationship problems. Snyder et al. argued that predict differential response to one treatment
that (a) such risks were potentially diminished by versus another. Even among prognostic indicators,
preserving theoretical integration, and (b) because predictors of treatment response have emphasized
pluralism is less constrained than assimilative or static rather than dynamic variables (e.g., age or
transtheoretical approaches to reconcile competing socioeconomic status). Exceptions include various
constructs, it potentially benefits from greater forms of psychopathology (e.g., depression or
opportunity to accommodate diverse theoretical substance abuse), pretreatment levels of negative
perspectives. To date, however, empirical tests of communication, emotional expressiveness and re-
these hypotheses have not been conducted. sponsiveness, partners power asymmetry, and ther-
apeutic alliance (see Snyder, Simpson, et al., 2006,
Effective Treatment of Individuals and Couples for a brief review)each of which may be responsive
Requires Comprehensive Assessment of Intraper- to tailored interventions addressing these concerns.
sonal and Interpersonal Functioning Throughout
Affective, Behavioral, and Cognitive Domains Differences in Urgency of Individual and Relation-
Across Multiple Levels of the Family And Socio- ship Issues and Their Progression During Therapy
ecological System Require an Organizational Conceptual Framework
Couples presenting with primary complaints of for Selecting, Sequencing, and Pacing Interventions
relationship difficulties often fail to recognize, Although virtually all approaches to couple therapy
understand, or acknowledge the role of individual possess an implicit progression of individual
problems in their interpersonal distress. Similarly, treatment components, couples with interactive
individuals seeking treatment for their own emotion- individual and relationship difficulties demand
al or physical health problems may neglect or special attention to the selection, sequencing, and
minimize the interaction of these concerns with pacing of specific interventions. Treatment of
interpersonal functioning in their intimate or broader particularly difficult couples often requires alter-
social relationships. Hence, both individual and nating attention between partners and their rela-
couple therapists need to assess clients individual tionship with each other or other family members in
and relationship strengths and vulnerabilities as well promoting growth in one individual or relationship
as broader elements of the extended family and social and then working with other members to promote
systemsdrawing on well-validated self-report and their adaptation to this change.
observational techniques (Snyder, Heyman, & Until a comprehensive integrative theoretical
Haynes, 2008). model demonstrates its efficacy in an appropriately
controlled clinical trial, we advocate integration from
Therapy Will Be Most Effective When Individuals a sequential, pluralistic approach. From this per-
and Couples Are Matched to Treatments for spective, moderators influencing both the selection
Which They Possess Prerequisite Attributes and and pacing of interventions would likely include
Are Excluded From Treatments for Which They (a) partners commitment to conjoint therapy
Are Particularly Ill Suited and views toward their own roles in relationship
For assessment to influence treatment, individual problems; (b) acute psychosocial stressors or indi-
differences in intrapersonal and interpersonal vidual crises precluding sustained attention to
functioning need to be linked to alternative models relationship issues; (c) family organization regarding
and modalities of intervention. Clinicians need to patterns of influence and emotional attachment;
be as attentive to exclusionary characteristics (d) partners effectiveness in enlisting support but
influencing treatment selection as they are to limiting intrusion from individuals outside their
inclusionary criteria. Moreover, they need to be relationship; (e) intensity and pervasiveness of
sufficiently trained both in theory and research hostility; (f) levels and resiliency of emotional
methods to be discerning consumers of the litera- warmth and positive regard; (g) communication
ture in evaluating diverse treatment modalities. skills involving emotional expressiveness, listening,
For this treatment implication to be realized, far and decision making; (h) additional relationship
more evidence will need to be accrued linking partner skills in such domains as parenting, money manage-
and relationship characteristics to differential treat- ment, and physical intimacy; (i) disruption of
ment methods and outcomes. Nearly all the literature relationship functioning by unrealistic assumptions
examining predictors of couple therapy outcome or standards, faulty attributions, or related cognitive
emphasizes prognostic indicatorsthat is, charac- processes; and (j) recurrent maladaptive relationship
integrative approaches to couple therapy 21

patterns rooted in early developmental experiences enhanced treatmentsincluding single-case designs,


or operating beyond immediate awareness. analysis of specific treatment components (or inte-
grative modules), and open clinical trials in which the
implications of integrative approaches therapist provides a defined treatment to a series of
for clinical research consecutive cases that meet predefined criteria
Couple Therapy Needs to Move Beyond Existing (Christensen, Baucom, Vu, & Stanton, 2005).
Therapies to Examine Integrative Approaches
Including Indicators for Selecting and Sequencing Studies of Treatment Outcome Need to Be
Specific Treatment Components, Alternative Inte- Complemented by Research on Treatment Processes,
grative Models, and Moderators of Therapeutic Focusing Particularly on Common Factors Related
Effectiveness to Client, Therapist, and Treatment Characteristics
Efforts to decompose couple-based interventions Research on couple therapy process should begin
into their smallest transportable components should with efforts to articulate both common factors in
lead to research on the most effective ways of couple-based interventions and specific components
reassembling these in a manner uniquely tailored to that distinguish one approach from another. To the
couples variation in individual and relationship extent that diverse treatment approaches share
functioning. Each intervention incorporated into an common attributes, this may facilitate shifting from
integrative approach needs to be considered with one therapeutic modality to another to capture
respect to its necessity, sufficiency, and interactive unique techniques specific to that approach when
effects. Issues of necessity involve delineating those working with difficult couples. Because some tech-
individual and couple characteristics for which a niques may require a set of interventions linked
given intervention or set of interventions is essential together in a specific constellation or sequence to be
for reducing distress or promoting well-being. By effective, research on articulating therapeutic com-
comparison, issues of sufficiency involve delineating ponents should identify the smallest unit of interven-
those constellations of individual and relationship tion that can be transported across approaches while
functioning for which a given intervention or set of retaining its efficacy. Research on variations in
interventions are enough to produce some desired treatment process across individual and relationship
therapeutic outcome. Research on intervention factors should be integrated with task analyses of
interactions also needs to identify combinations of how specific intervention components and their
techniques that produce either positive or negative variations are linked to within- and between-session
synergistic effects. Because some treatment compo- responses of each of the participants. That is, process
nents may be interactively inconsistent, contradic- research interfaces with outcome research by em-
tory, neutralizing, or harmful, research also needs to phasizing more immediate, proximal effects of
identify when specific combinations or sequences of therapist interventions on partners behavior and
treatment interventions produce deleterious effects. partners effects on the therapist and each other
Admittedly, the logistic requirements for conduct- (Heatherington, Friedlander, & Greenberg, 2005).
ing such research are daunting. First, identifying Such task analysis has been used successfully to
negative prognostic or prescriptive indicators would examine change processes in both IBCT and EFCT.
potentially require expanding the range of individual In a pilot study with 12 distressed couples randomly
and relationship characteristics of couples admitted assigned to either IBCT or traditional BCT (Cor-
to clinical trialsrelaxing usual exclusionary criteria dova, Jacobson, & Christensen, 1998), gains in
(e.g., concurrent psychopathology, substance abuse, partners constructive detachment (i.e., talking
or physical aggression). Second, the research design about problems without blaming or being com-
requirements for identifying prescriptive indicators pelled to solve themboth indicators of acceptance
are more rigorous than those for identifying promoted in the IBCT condition) from early to late
more general prognostic indicators, particularly as sessions predicted couples gains in relationship
these relate to adequate power for detecting effects satisfaction. A report regarding three task analytic
(Whisman & McClelland, 2005). For example, using studies of EFCT (Greenberg, Ford, Alden, &
Cohen's (1987) power tables, an investigator would Johnson, 1993) showed that (a) couples receiving
need to obtain minimum sample sizes of 26, 55, or EFCT demonstrated more shifts from hostility to
392 participants in order to have adequate power affiliative behaviors than wait-list couples; (b) best
(i.e., power of .80, at = .05) for detecting large, sessions as identified by couples were characterized
medium, or small effect sizes, respectively. by more depth of experiencing and affiliative and
Given these reality constraints, some have argued autonomous statements than were sessions identi-
for alternative smaller-level methods to randomized fied as poor; and (c) intimate, emotionally laden
clinical trials for developing and evaluating new or self-disclosure by one partner was more likely to
22 snyder & balderrama-durbin

lead to affiliative statements by the other partner search, and Disseminating and Incorporating
than were other randomly selected responses. Findings Germane to Clinical Practice
Finally, a recent task analysis of EFCT by Bradley Therapists allegiance to pure-form therapies has
and Furrow (2004) found that, consistent with diminished over the past few decades. A majority
proposed mechanisms of change in EFCT, specific of therapists now identify themselves as either
therapist interventions linked to softening events eclectic or integrative, with the latter term
involved intensifying a couple's emotional experi- preferred by a margin of nearly 2:1 (Norcross,
ence and promoting intrapsychic awareness and Prochaska, & Farber, 1993). Similarly, the most
interpersonal shifts in attachment-related interac- common theoretical orientation identified in a
tions. recent survey of couple therapists was eclectic
Research on such therapeutic event-related pro- (28%), with an additional 10% not identifying any
cesses also needs to attend to changes in these primary orientation (Whisman, Dixon, & Johnson,
linkages across the course of treatment. For 1997). Hence, researchers would benefit from
example, the effects of interpreting developmental collaborative dialogue with practitioners about
components of interpersonal distress may be very clinical and logistical issues presenting the greatest
different if conducted early in therapy than later in challenges in working with couplesparticularly
treatment once collaborative alliances and con- from an integrative perspective.
structive communication skills are more firmly Researchers also bear responsibility for dissem-
established. Consequently, stages of couple therapy inating their findings in a format relevant to
need to be defined not only by the composition or practitioners. This entails attending to multiple
structure of clinical interventions, but also by their styles and media of communication including
proximal effects on partners responses and the detailed treatment manuals, case-study publica-
therapeutic process. tions, and clinical practice guidelines for selecting
and sequencing specific treatment components
The Conceptualization of Treatment Outcome
linked to particular individual or relationship
Should Extend Beyond Reduction of Couple
characteristics. Research suggests that therapists
Distress to Include Indicators of Individual and
negative attitudes toward evidence-based practices
Relationship Functioning Across a Broad Spectrum
relate to perceived inflexibility, lack of attention to
Most studies of couple therapy have included
the therapeutic alliance, and a lack of emphasis on
measures of partners individual functioning target-
clinical judgment. In one study, therapists attitudes
ing emotional/behavioral disorders, and a few (e.g.,
became significantly more favorable toward evi-
Gattis, Simpson, & Christensen, 2008) have
dence-based practices when provided with more
assessed well-being of partners children. Largely
flexible modular assembly of treatment pro-
absent have been measures targeting such positive
cedures compared to standard treatment manuals
elements as joy, hopefulness, or generosity. More-
(Borntrager, Chorpita, Higa-McMillan, & Weisz,
over, despite widespread recognition that clinically
2009).
favorable outcomes can include terminating an
Clinicians also need to contribute to the scientific
unhealthy marriage, few if any studies have
enterprise by collaborating with researchers in
incorporated measures of success that reflect
articulating issues critical to conducting couple
constructive processes culminating in partners
therapy and by participating in the research
decision to end their marriage and move on
process. The latter may involve willingness to
separately.
administer structured treatments according to a
Admittedly, enhancing a broad range of positive
research protocol in a community setting, assessing
aspects of both individual as well as relationship
couples before and after treatment as usual in a
functioning does not require an integrative approach
treatment-comparison condition, or facilitating
to treatment; nor does expanding the conceptualiza-
integrative approaches by providing videotaped
tion of treatment success among separating or
treatment sessions for task analyses linking thera-
divorce couples. However, the explicit consideration
pist and client behaviors to within-session processes
and measurement of diverse individual, relationship,
and outcomes.
and broader systemic outcomes may be encouraged
Similar to couple interventions promoting the
by integrative approaches addressing a wider spec-
respective strengths of each partner, so too the field
trum of treatment domains.
of couple therapy will advance when clinicians and
Clinicians and Researchers Need to Pursue More researchers collaboratively encourage each other's
Effective Collaboration in Identifying Critical respective professional pursuits in working with
Questions Related to Integrative Couple Treat- couples in a more theoretically integrative and
mentsDesigning and Conducting Relevant Re- clinically effective manner.
integrative approaches to couple therapy 23

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