The ongoing evolution of behavioral couples therapy

Clinical Psychology Review, Vol. 18, No. 6, pp. 613–633, 1998 Copyright  1998 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/98 $19.00 ⫹ .00

PII S0272-7358(98)00022-1

THE ONGOING EVOLUTION OF BEHAVIORAL COUPLES THERAPY: RETROSPECT AND PROSPECT W. Kim Halford Griffith University

ABSTRACT. Behavioral couples therapy (BCT) was first described thirty years ago, and the conceptual basis of the approach has been evolving ever since. Whilst BCT in its current form is a well established treatment for relationship problems, there are significant limitations to its efficacy, and there are a number of new developments intended to enhance the efficacy of the approach. Currently BCT primarily is a skills training therapy, targeting change in couple’s interactions to promote greater relationship satisfaction. Current developments focus on broadening this traditional emphasis on changing couple interactions to greater attention to reducing negative emotional responses to partner behaviors (increasing acceptance), and increasing selfdirected personal change efforts. Future developments of BCT are likely to pay greater attention to different types of couple interaction which are associated with sustained relationship satisfaction, the individual vulnerabilities partners bring to relationships, and the environmental stresses impinging upon the couple.  1998 Elsevier Science Ltd THE FIRST papers describing a behavioral approach to couples therapy for relationship problems were published in the late 1960s and early 1970s (Azrin, Naster, & Jones, 1973; Stuart, 1969; Weiss, Hops, & Patterson, 1973). Since that time behavioral couples therapy (BCT) has become the most widely researched approach to assisting couples with relationship problems, with over 30 published controlled trials demonstrating the efficacy of BCT (Halford, Markman, & Fraenkel, in press; Jacobson & Addis, 1993; Lebow & Gurman, 1995). Throughout its thirty year history the conceptual basis of BCT has been continually evolving. In this article I analyze the development of BCT, with a particular focus on more recent changes. My approach in the article is to outline a general, heuristic model of the nature of relationship problems, and relate the developments in BCT to this model. THE NATURE OF RELATIONSHIP PROBLEMS Bradbury (1995) adapted the widely used stress diathesis heuristic to summarize the findings from 110 published studies assessing the longitudinal course of couple relaCorrespondence should be addressed to W. Kim Halford, Griffith University, School of Applied Psychology, Faculty of Health and Behavioural Sciences, Nathan Q4111, Australia. 613

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tionship satisfaction and stability (Karney & Bradbury, 1995). In Bradbury’s model it is proposed that there are three broad classes of variables associated with relationship problems: adaptive processes within the couple system, enduring individual vulnerabilities of the partners, and stressful events impinging upon the couple system (Bradbury, 1995). Adaptive processes refer to the behavioral, cognitive, and affective processes that occur during couple interaction. There has been extensive research on the adaptive processes that characterize distressed couples (Halford & Markman, 1997). For example, problems in communication are the most frequently cited complaint by couples seeking therapy (Bornstein & Bornstein, 1986). There has been a very large volume of research assessing both the cognitions and behaviors of distressed couples when they talk (Weiss & Heyman, 1997), and relating communication deficits to the development of relationship problems (e.g., Markman & Hahlweg, 1993; Murphy & O’Leary, 1989; O’Leary et al., 1989). Enduring vulnerabilities refer to the relatively stable historical, personal, and experiential factors which each partner brings to a relationship (Bradbury, 1995). For example, family of origin experiences have been widely studied as historical factors which correlate with risk of relationship problems. The adult offspring of divorce are more likely than the rest of the population to divorce (Glenn & Kramer, 1987), and interparental aggression is associated with a somewhat increased risk for being in an aggressive relationship as an adult (Widom, 1989). As a second example of enduring vulnerabilities, high rates of relationship problems and divorce consistently have been reported in people who enter relationships with psychiatric disorder (Halford, 1995a), particularly sufferers of depression, alcohol abuse or some anxiety disorders (Emmelkamp, De Haan, & Hoogduin, 1990; Halford, Bouma, Kelly, & Young, in press; Reich & Thompson, 1985; Ruscher & Gotlib, 1988; Weissman, 1987). Stressful events refer to the developmental transitions, and acute and chronic circumstances, which impinge upon the couple or individual partners. Relationship problems are more likely to develop during periods of high rates of change and stressful events (Karney & Bradbury, 1995). For example, the transition to parenthood often is associated with decline in couple relationship satisfaction (Cowen & Cowen, 1992). Other common transitions associated with increased risk for relationship problems include emerging behavior problems in children (Sanders, Nicholson, & Floyd, 1997), negotiating parenting roles within step families (Lawton & Sanders, 1994), change in work demands (Thompson, 1997), or a partner developing a major health problem (Schmaling & Sher, 1997). Couples with less robust adaptive processes are believed to be particularly vulnerable to the negative effects of life transitions or stressful events (Markman, Halford, & Cordova, 1997). In particular, couples who lack communication skills, or who have inflexible or unrealistic expectations of relationships, find it hard negotiate the changes required to adapt to stress and change (Markman et al., 1997).

EVOLUTION OF BEHAVIORAL COUPLES THERAPY: RETROSPECT

Content of Behavioral Couples Therapy Behavioral couples therapy began, and largely has remained, as conjoint therapy targeting change in couple’s adaptive processes. Based upon the premise that a relationship is defined by the exchange of behaviors between partners, behavioral couples therapy (BCT) began as the application of behavioral contracting to the treatment of

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relationship problems. Couples were trained to monitor their partners’ behavior and, based on such assessments, contingency contracts were developed to reduce displeasing, and increase pleasing behaviors within the relationship (e.g., Azrin et al., 1973; Stuart, 1969; Weiss et al., 1973). Behavioral contracting initially stressed tightly structured ‘‘quid pro quo’’ agreements, in which spouses were taught systematically and immediately to reward desired behavior from the partner (Azrin et al., 1973; Stuart, 1969). This was later replaced by unilateral ‘‘good faith’’ contracts in which partners were asked to undertake positive change for the good of the relationship (e.g., Weiss, Birchler, & Vincent, 1974). Subsequently emphasis has been placed on each partner actively seeking out information in order to self-select and implement self-change goals to enhance the relationship (Halford, Sanders, & Behrens, 1994; Weiss & Halford, 1996). Although the details of the procedures have been refined, an emphasis on changing relationship behaviors remains an important element of BCT. In the early 1970s a second element was added to BCT: communication and problem solving skills training. Based on early observational studies that distressed couples showed very negative communication (Gottman, Markman, & Notarius, 1977; Wills, Weiss, & Patterson, 1974), couples were trained to use new communication behaviors. These process skills were conceptualized as providing couples with the means to enhance intimate communication, and resolve their current and future sources of conflict ( Jacobson & Margolin, 1979). In most applications of BCT the communication skills targeted in training were identified by the therapist, based upon contrasting the couple’s current communication with a model of adaptive marital communication. The models of adaptive marital communication were derived, in large part, from research contrasting the communication behaviors of maritally distressed and nondistressed couples in problem solving interactions within research laboratories (for reviews of this literature, see Weiss & Heyman, 1990, 1997). Often BCT would teach couples a relatively fixed curriculum of skills (e.g., paraphrasing, asking open ended questions, behavioral pin pointing), based on the assumption that each of these skills were adaptive as communication skills. Over time the communication skills targeted in BCT have changed so that less emphasis is placed on training specific micro-skills, and more emphasis is placed on identifying and changing maladaptive general patterns of communication (Notarius & Markman, 1995). For example, in the mid to late 1980s many distressed couples were found to exhibit a pattern of one partner approaching the other to seek change in the relationship, and the second partner withdrawing, during problem solving discussions in the laboratory (Gottman & Krokoff, 1989). Many distressed couples reported the approach-withdrawal pattern also occurs during discussions at home (Christensen & Heavey, 1990; Heavey, Layne, & Christensen, 1993). The extent of withdrawal was found prospectively to predict deterioration in relationship satisfaction, particularly when the male partner was withdrawing (Gottman & Krokoff, 1989; Heavey et al., 1993). Communication training changed to involve greater emphasis on reducing the pattern of approach-withdrawal, and less emphasis on training specific communication skills (e.g., Jacobson & Holtzworth-Munroe, 1986). When the development of BCT got to the point where it included behavior exchange and communication training, it was focused almost exclusively on the observable adaptive processes in the couple’s interactions. However, as some of the earliest research on couples showed, observable behavior accounted for only a modest proportion of the variance in relationship satisfaction (Wills et al., 1974). Although BCT included recognition of the importance of internal mediators of external experience

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from its earliest writings (Weiss, 1984), research in the 1980s lead to greater emphasis on measuring and changing cognitive processes in couples. Epstein and Eidelson (1981) were among the first directly to assess cognitions in couples with their Relationship Beliefs Inventory. They found that distressed couples were more likely to endorse beliefs such as : ‘‘all disagreement is destructive’’ or ‘‘change in my relationship is not possible’’ than satisfied couples (Eidelson & Epstein, 1982). Attributions made by partners about the causes of their spouse’s behavior also became a major focus of research into couple relationships (Bradbury & Fincham, 1990). Distressed couples were found often to attribute relationship difficulties largely to stable, global aspects of their partner’s personality whereas satisfied couples were more likely to attribute similar negative behaviors to transient, situational factors (Bradbury & Fincham, 1990, 1992). The third element of BCT, which developed in the 1980s, was a focus on altering cognitions of individual partners. Many of the strategies incorporated in BCT were standard cognitive therapy procedures applied to relationship problems. For example, self-instructional strategies were used to modify negative attributions (Baucom & Lester, 1986) or control anger (Schindler & Vollmer, 1984), and guided discovery, Socratic dialogue and behavioral experiments are used to challenge irrational relationship beliefs (Baucom & Epstein, 1990). BCT in its current form, at least as represented in the more recent books and articles describing BCT, consists of the three components of behavior exchange, communication training, and cognitive restructuring. In addition, clinical descriptions of BCT since the late 1970s have emphasised the importance of therapeutic process variables in successful work with couples (e.g., Baucom & Epstein, 1990; Jacobson & Margolin, 1979).

Therapeutic Process in Behavioral Couples Therapy A key characteristics of couples therapy is that you have two clients presenting simultaneously, and each of those clients is likely to see the nature and causes of the presenting problems differently. As most beginning couples therapists will attest, it often can be difficult to get distressed partners to agree on how to proceed in therapy. Procedures like behavioral contracting or communication skills training often fail if the partners argue angrily in sessions, or do not carry out agreed on tasks between sessions. Numerous writers have asserted the importance of developing therapeutic alliances with each partner, of developing a shared understanding between the partners and therapist of the relationship problems, and negotiating mutually acceptable goals which promote adaptive change in therapy (e.g., Beach, Sandeen, & O’Leary, 1990; Baucom & Epstein, 1990; Jacobson & Margolin, 1979; Stuart, 1980; Weiss & Halford, 1996). Developing a collaborative set with distressed couples is not a straightforward process. Clients do not have a ‘‘tabula rasa’’ ready to accept the therapist’s expert relationship wisdom. As noted previously, BCT therapists have conceptualized relationship problems largely in terms of the couple’s adaptive processes, adaptive processes including the behaviors and communication processes occurring between partners, and the cognitive appraisals of each partner. In contrast, many distressed people attribute their relationship problems to stable, global, negative characteristics of their spouses (Bradbury & Fincham, 1990), and believe relationship improvement is difficult or even impossible to attain (Vanzetti, Notarius, & NeeSmith, 1992). A clear challenge in BCT is how the disparate views of therapist and distressed partners can be shaped into common assumptions and goals.

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In BCT, assessment has been seen as crucial in the achievement of process outcomes in couples therapy (Baucom & Epstein, 1990; Jacobson & Margolin, 1979). In essence, the therapist seeks through assessment both to establish an empathic understanding of each partner’s experience of the relationship, and to promote a shared conceptualization of problems in terms of relationship adaptive processes. The shared conceptualization is the basis for the participants to negotiate the goals of therapy, and to determine how those goals are to be achieved.

Efficacy of Behavioral Couples Therapy The overwhelming majority of empirical studies of BCT have incorporated behaviour exchange strategies (BE), communication and problem solving training (CPST; Hahlweg & Markman, 1988), with a smaller number of more recent studies including BE, CPST and cognitive interventions (Epstein, Baucom, & Daiuto, 1997). BCT incorporating BE and CPST consistently has been shown to be superior to no treatment or therapist contact control conditions in reducing relationship distress (Hahlweg & Markman, 1988; Markman & Hahlweg, 1993). More specifically, BCT improves couples’ communication skills, reduces destructive conflict, enhances positivity of day to day interactions, increases the positivity of couples’ cognitions about their partners and their relationships, and increases relationship satisfaction (Hahlweg & Markman, 1988; Halford, Sanders, & Behrens, 1993; Lebow & Gurman, 1995). In meta-analyses of the outcome research literature, BCT produces a mean effect size of approximately 0.95, which corresponds to large effect size (Dunn & Schwebel, 1995; Hahlweg & Markman, 1988). Despite the impressive treatment effect size of BCT, there are significant limitations to the efficacy of BCT. Approximately 25–30% of distressed couples who present for therapy show no measurable improvement with BCT, and a further 25–30% improve somewhat but still remain significantly maritally distressed after treatment with BCT (Halford et al., 1993; Jacobson, 1989; Jacobson et al., 1984). Even amongst those couples who initially respond well to BCT, there is substantial relapse toward marital distress over the next few years ( Jacobson, Schmaling, & Holtzworth-Munroe, 1987; Snyder, Wills, & Grady-Fletcher, 1991a). Recognition of the limitations of BCT led to efforts to enhance its efficacy. Cognitive interventions alone modify maladaptive relationship cognitions, and improve relationship satisfaction (e.g., Emmelkamp, van Linden van den Heuvell, Ruphan, Sanderman, Scholing, & Stroink, 1988). However, the addition of cognitive interventions to BE and CPST does not significantly increase marital satisfaction gains from BCT (Baucom & Lester, 1986; Baucom, Sayers, & Sher, 1990; Halford et al., 1993). Demonstrating greater efficacy of one active intervention over another is notoriously difficult, as very large sample sizes are required to provide adequate statistical power to detect the differential effect (Kazdin & Bass, 1989). Given that BCT is efficacious for many couples, the failure to demonstrate additive effects of cognitive interventions to BCT may be due to a lack of statistical power in the designs of studies. Moreover, even if cognitive interventions do not add to average efficacy of BCT across distressed couples, cognitive interventions may be useful to a particular subset of distressed couples. However, it has to be conceded that, despite the enormous research effort into cognitions within BCT since the early to mid 1980s, there is no evidence that we have improved upon the efficacy obtained 20 years ago in BCT. The focus of BCT on BE, CPST and cognitive interventions includes an implicit assumption that changes in these aspects of couple adaptive processes mediate im-

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provements in relationship satisfaction resulting from BCT. However, there is inconsistency in the findings on the association of changes in communication and relationship satisfaction, with two studies finding little association between these variables (Halford et al., 1993; Iversen & Baucom, 1990), and one study finding a modest association between improvements in communication and relationship satisfaction across the course of BCT (Sayers, Baucom, Sher, Weiss, & Heyman, 1991). Changes in cognitions consistently have not been found to covary with changes in relationship satisfaction across the course of BCT (Emmelkamp, van Linden van den Heuvell, Sanderman, & Scholing, 1988; Halford et al., 1993). In summary, there is little evidence that BCT produces therapeutic improvement by the means assumed in the traditional models of BCT. EVOLUTION OF BEHAVIORAL COUPLES THERAPY: CURRENT A gradual shift has been occurring in BCT since cognitive interventions became an increasing focus of couples therapy, a shift towards more directly targeting changes in the partners’ experience of their relationship, rather than just targeting change in the relationship interactions. This shift has been developed by Christensen, Jacobson, and Babcock (1995) in their integrative couples therapy (ICT), and by colleagues and myself in the self-regulation model of couples therapy (SRCT; Halford et al., 1994). In Table 1 there is a summary of these two approaches and how they differ from traditional BCT.

Integrative Couples Therapy (ICT) Christensen and Jacobson propose that, in addition to behavior change, BCT needs to promote greater emotional acceptance of the partner (Christensen et al., 1995; Jacobson & Christensen, 1996). They define emotional acceptance as: a situation in which behavior change does not occur, or does not occur as much as the spouse requesting [change] would like . . . [but] the requesting spouse experiences the problematic behavior . . . in a new way. Whereas before, the behavior was experienced as offensive, unacceptable, and blameworthy, now it is experienced at one extreme as understandable and tolerable, if not necessarily desirable, or at the other extreme as something valuable, to be appreciated. (Christensen et al., 1995, p. 39)

A detailed ICT treatment manual recently was published by Jacobson and Christensen (1996). This manual includes most of the procedures of traditional BCT, such as systematic assessment and feedback, BE and CPST, and also adds a number of interventions to promote acceptance. Four broad acceptance strategies are described: empathic joining around the problem, detachment from the problem, tolerance building, and self-care. Empathic joining assists the couple to develop mutually respectful, and nonaccusatory understanding of their key problems as arising from differences between the partners. Strategies to achieve empathic joining include reviewing and discussing the common themes and patterns of couple conflict, and therapist modeling interpretations of couple conflict in nonaccusatory, empathic terms. A particular focus in this strategy is encouraging emotional expression of partner reactions to their spouse, particularly emotions of vulnerability and hurt. Like empathic joining around the problem, problem detachment is aimed at reducing negative emotional responses to spouse behavior, and also involves discussion of

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Couples interaction and individual partner cognitions

Behavior exchange, communication and problem-solving training, cognitive restructuring

Well-established treatment of moderate efficacy

Key change strategies

Empirical status

Traditional Behavioral Couples Therapy (TBCT)

Targets of therapeutic change

Domain

As for TBCT plus acceptance building through empathic joining around the problem, detachment from the problem, tolerance building, and self-care Preliminary pilot data suggest greater efficacy than TBCT

As for TBCT plus acceptance

Integrative Couples Therapy

Brief (3 sessions), similar to 15 sessions of TBCT

Self-directed changes to individual and couple affect, cognition, and behavior A self-regulated process targeting personal change; this can include seeking to change own behavior to influence interaction processes

Self-Regulatory Couples Therapy

TABLE 1. Summary of the Behavioral, Integrative, and Self-Regulation Couples Therapy Approaches

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themes and recurrent patterns of couple conflict. In the case of problem detachment, the emphasis is on intellectual analysis of these themes, rather than the focus on emotions in empathic joining around the problem. Tolerance building involves systematically exposing the partners to negative behaviors of the partner under conditions which reduce negative responses to problem behavior. A fundamental assumption underlying this strategy is that the efforts to prevent, avoid, or escape the partner’s negative behaviors may serve to maintain the strength of negative emotional response to those behaviors. Tolerance building includes strategies such as the therapist asking one partner to engage in certain negative behaviors over the next week, or role playing negative interactions in the session, or the therapist highlighting the positive as well as negative features of a particular behavior. Self-care is an attempt to balance looking at partner change with self-change. This may be achieved by meeting needs partners seek to fulfill through the relationship in other ways (e.g., by overcoming loneliness by seeking out new friends, and not just relying on the spouse to meet companionship needs). The therapist also assists partners to respond to negative spouse behaviors differently, either in actions or thoughts, in order to alter their emotional distress. There has been some debate in the literature about whether the concept of acceptance and the associated procedures in ICT are truly new, or are new labels for existing ideas (Markman, 1991). Certainly some of the acceptance procedures described by Christensen et al. (1995) and Jacobson and Christensen (1996) seem similar to traditional BCT procedures. For example, empathic joining around the problem has some similarities to the development of the collaborative set described by Jacobson and Margolin (1979), Baucom and Epstein (1990), and Beach et al. (1990). Both empathic joining around the problem and developing a collaborative set involve the use of structured discussion, reframing, and feedback to encourage the partners to discuss interactive relationship processes without partner blame or destructive anger. Joining around the problem adds a focus on drawing out the expression of emotions of vulnerability and hurt, though a similar process is part of emotional expressiveness training used by Baucom et al. (1990) in their approach to BCT. As a second example, some of the self-care acceptance strategies also seem similar to existing BCT procedures. The use of assertion to express dissatisfaction with the partner’s negative behaviors, or the assessment and change of cognitions which mediate excessive upset, have been fairly standard BCT procedures for the last ten years or so (Baucom & Epstein, 1990). Some acceptance interventions clearly do go beyond traditional BCT. For example, in tolerance building Jacobson and Christensen (1996) describe instructing couples to engage in the problem behavior. Whilst similar procedures have been used by systemic couples therapists for many years (Fraenkel, 1997), there are distinctions between systemic and ICT use of this procedure. In systemic therapy instructing couples to engage in the problematic behaviors is seen as a paradoxical intervention intended to reduce the chance of the behavior occurring, and therapists usually see it as important not to give a rationale to clients for the instruction (Fraenkel, 1997). In contrast, in ICT the instruction to engage in the behavior is seen as part of tolerance building, and is not aimed at reducing the frequency of the targeted behavior, but rather altering the response to that behavior. Explanation of the purpose of the procedure in ICT is seen not only as acceptable, but as highly desirable. There are no published data on the process or outcome of ICT. However, the published descriptions of ICT suggest that ICT is at least a substantial shift in emphasis in therapy content from traditional BCT. In ICT much less therapy time is devoted to CPST and BE procedures than in BCT, and much more time is focused on acceptance

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building ( Jacobson & Christensen, 1996). Recently preliminary data was presented at a conference of the behavioral coding of therapy sessions of ICT and BCT . This coding showed that BCT and ICT were reliably different ( Jacobson, Cordova, Prince, & Christensen, 1996), and that within sessions ICT was associated with greater emotional expressiveness and less blaming (more accepting) descriptions of relationship problems (Cordova, 1996). Furthermore, in a small pilot study ICT produced greater increases in relationship satisfaction than BCT ( Jacobson et al., 1996).

Self-Regulation Approach to Couples Therapy Like Jacobson and Christensen (1996), my colleagues and I have become concerned about the heavy influence on changing couple interactions in BCT (Halford et al., 1994; Weiss & Halford, 1996). As noted earlier, distressed couples tend to attribute relationship problems to stable personality characteristics of their partner (Bradbury & Fincham, 1990), and to feel powerless to change aspects of the relationship with which they were dissatisfied (Vanzetti et al., 1992). In essence, many clients felt powerless in their relationship to identify or carry out actions that would change the focus of their dissatisfaction. In our clinical experience the focus in BCT on therapist directed procedures to change couple interactions did not empower individual action. In fact, BCT often maintained the focus on getting the partner to change. For example, CPST sometimes became a struggle for each partner to persuade the other to be different. We reasoned that clients have most direct influence over their own behavior, so perhaps that should be the focus of couples therapy (Halford et al., 1994). Based on selfregulation theory (Karoly, 1993) we proposed a reformulation of the process of BCT such that the emphasis in therapy was on individual, self-directed change by the partners. Karoly (1993, p. 25) defined self-regulation as follows. Self-regulation refers to those processes, internal and or transactional, that enable an individual to guide his/her goal directed activities over time and across changing circumstances (contexts). Regulation implies modulation of thought, affect, behavior, or attention via deliberate or automated use of specific mechanisms and supportive metaskills. The processes of self-regulation are initiated when routinized activity is impeded or when goal directedness is otherwise made salient (e.g., the appearance of a challenge, the failure of habitual patterns; etc.).

This definition emphasises that self-regulatory processes are embedded in a social context that not only provides opportunities and limitations for individual self-directedness, but implies a dynamic reciprocal interchange between the internal and external determinants of human motivation. From a therapeutic perspective, self-regulation is a process whereby individuals learn to change themselves. In the context of relationship problems, self-regulation involves focusing on each partner’s attempts to change their own behavior, cognitions, and affect to enhance their personal satisfaction with the relationship. The process of traditional BCT focused largely on moving people from a partnerblaming to a collaborative set with a dyadic focus ( Jacobson & Margolin, 1979). From a self-regulation perspective we suggest a third step in the therapeutic process is critical, to help each partner to identify specific actions they can take to address the problems identified in the relationship (Weiss & Halford, 1996). Without this final step, clients are not empowered to produce change in their own relationships. The disap-

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pointing long term maintenance of benefits from BCT may be attributable to this failure individually to empower our clients. Applying the self-regulation ideas to addressing the subjective dissatisfaction which defines relationship problems, it is possible to define at least five possible responses to distress about the relationship. First, one can retain the traditional focus on behavior change by the spouse, but translate this to self-regulation by focusing on changing the complainant’s attempts to persuade their spouse to change. In other words, the current methods of attempting to influence the spouse have not worked, as the areas of concern remain problems, so the individual seeks new ways to more effectively communicate their concerns. Second, the person could alter their response to the partner’s behavior, so that it is less stressful for them. This can be achieved in several different ways such as identifying and changing cognitions which mediate distress, or using exposure to reduce affective distress. Third, it is possible to attempt to meet the needs currently not being met in new ways. For example, the person who craves more closeness or support from their spouse may meet more of their needs through friendships. Fourth, the person may decide that the behavior is unacceptable, intolerable, and unchangeable, and resolve to leave the relationship. Finally, clients can do nothing, maintain the status quo and hope that their spouses eventually will change. In our experience few clients have explored all of these options which are open to them. A fundamental difference between SRCT and BCT is the emphasis in the former on helping the individual partners to self-select goals for personal change. It has been our experience that, once this is achieved, many partners are able to implement their desired changes without extensive therapist input. For example, in considering deficits in communication we assist each partner to self-assess their individual strengths and weaknesses in communication, and to set goals for personal change (for details, see Halford, in press; Weiss & Halford, 1996). Often clients seem able to implement such goals (e.g., listening better to their partner, not withdrawing from conflict) without intensive skills training. Some early research found that the negative communication shown by distressed couples was only evident when they talked with their spouses, and not when communicating with partners of other people (Birchler, Weiss, & Vincent, 1975). This may mean that, for at least some couples we are assisting them to apply skills they possess rather than teaching them new skills. SRCT sessions differ significantly from traditional BCT in that much more time is spent on helping partners to identify the goals they wish to implement for self-change, and much less time is spent on BE and CPST. For example, if a couple report consistent problems with heated conflict, in traditional BCT emphasis is placed on CPST to overcome the skills deficits assumed to underlie the repeated conflict. This often involves asking the couple temporarily to ignore recent or current topics of conflict, as those topics which generate most intense emotion are seen as the most difficult contexts in which to learn new skills. In contrast, in SRCT the focus is on exploring each partner’s experience of the most difficult couple interactions (see Weiss & Halford, 1996). The goal is to assist each partner to identify the nature of the problem interactions, and to formulate individual goals to address the problem area. There have been three preliminary evaluations of SRCT. In one study three sessions of SRCT was compared with 15 sessions of BCT within a quasi-experimental design. Despite the substantial difference in mean number of sessions across conditions, the two therapies produced similar improvements in relationship satisfaction (Halford, Osgarby, & Kelly, 1996). This study must be interpreted with caution as maintenance of outcome was not assessed, and couples were not randomly assigned to conditions. However, the results suggest that SRCT holds promise as a cost-effective intervention for couples. In the second study a self-regulation based relationship education pro-

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gram for nondistressed couples was compared with a minimal intervention within a randomised controlled trial. The self-regulation approach was found to produce significant and sustained improvements in couple communication (Halford, Sanders, & Behrens, 1996). Together those studies show that the extensive skills training traditionally used in BCT is not always necessary to achieve change in couple’s adaptive processes. A third study illustrates a key advantage of the self-regulation approach. Halford, Price, Kelly, Bouma, and Young (1997) compared a minimal intervention, individual therapy, and couples therapy in assisting women who reported personal distress and relationship problems associated with heavy drinking by their husbands. Both the individual and couples therapy were based on the self-regulation model, and targeted helping the women to decide whether they wished to remain in the relationship, and if so how they could reduce the burden of the husband’s drinking on them, and influence the husband to reduce his drinking. The sample was characterized by particularly heavy drinking men (mean daily intake of 11.4 standard drinks), and severe relationship distress for the women. Very few of the husbands agreed to participate in therapy, and so the couples therapy was not really appropriate for this population. The individual therapy for the women included enhancing the women’s range of enjoyable activities and social contacts, challenging maladaptive cognitions about the men’s drinking, such as that the women were to blame for the drinking, and enhancing their ability to self-regulate negative feelings induced by the drinking. This therapy was effective in significantly reducing the women’s distress and sense of burden, but there was no effect on relationship satisfaction or husbands’ drinking (Halford, Price, et al., 1997). The behavior of the heavy drinking husbands seemed not to be responsive to change attempts by the women, yet despite the lack of change in couple adaptive processes the self-regulation approach assisted the women to reduce their sense of distress and burden. SRCT and ICT developed independently, but share some important commonalities. First, relative to traditional BCT both approaches place increased emphasis on the dissatisfaction expressed by partners about their relationship interaction, rather than the interactions per se. The dissatisfaction might be addressed by changing the interactions, as in traditional BCT, or the dissatisfaction might be changed in other ways (e.g., increasing acceptance or self-directed personal change). Second, both SRCT and ICT add a number of interventions to what has been included in BCT previously, such as exposure to negative partner behaviors, change in self-care behaviors, and a direct focus on exploring highly negative interchanges (see Christensen et al., 1995; Halford, in press). Whilst the theoretical rationale for inclusion of these procedures differs somewhat between ICT and SRCT, the procedural descriptions of the actual techniques used are remarkably similar. There is one important difference between SRCT and ICT: SRCT includes the proposition that the meta-competency of self-regulation is important in mediating change in couples therapy, whilst ICT includes the proposition that acceptance mediates therapeutic change. To date there is only preliminary work done on developing measures of self-regulation (Halford et al., 1996), and acceptance (Christensen, 1996). The testing of the hypotheses that either self-regulation or acceptance mediate the effects of couples therapy is yet to be undertaken.

Nonbehavioral Approaches to Couples Therapy Some approaches to couples therapy other than BCT, notably emotion-focused and insight-oriented couples therapy, have been demonstrated in controlled trials to im-

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prove the relationship satisfaction of couples who present for therapy (Greenberg & Johnson, 1985, 1988; Shadish et al., 1993; Snyder & Wills, 1989; Snyder et al., 1991a). Emotion-focused and insight-oriented therapy share the BCT focus on conjoint therapy to change couples’ adaptive processes, but do not place the same emphasis as BCT on behavioral or cognitive change. In insight-oriented and emotion-focused couples therapy emphasis is placed on changing partners’ subjective experience of relationship interactions through corrective emotional experiences, or insights gained into the individual significance of particular relationship events (Greenberg & Johnson, 1988; Snyder, Wills, & Grady-Fletcher, 1991b; Wills, Faitler, & Snyder, 1987). There is very limited research on the relative efficacy of BCT and other approaches to couples therapy, though the effect sizes obtained from the BCT and other approaches across all published studies seems similar (Lebow & Gurman, 1995; Shadish et al., 1993). In one study emotion-focused therapy and a form of BCT including only CPST were compared ( Johnson & Greenberg, 1985). The emotion-focused therapy produced a very large treatment effect size of 2.19, which was significantly larger than the BCT effect size of 1.12. However, as this study excluded the BE component of BCT, and worked with only mildly distressed couples, further research is needed to determine the relative efficacy of emotion-focused therapy and BCT. Another study compared BCT, including BE and CPST, with insight-oriented couples therapy, and the latter was found to have greater long term efficacy than BCT (Snyder et al., 1991a). The interpretation of the study as supporting greater efficacy of insight-oriented therapy was challenged on the grounds that the treatment in the BCT condition allegedly was not state of the art BCT, and that the insight-oriented therapy included much of what should be included in BCT ( Jacobson, 1991). Snyder et al. (1991b) rebutted these criticisms, and showed that their versions of insight-oriented and BCT treatments were distinctive, and included the elements they intended (Wills et al., 1987). Given there is only one study comparing BCT with emotion- focused therapy, and one comparing BCT with insight-oriented therapy, it cannot be determined if either treatment truly is more effective then BCT. However, there certainly is no evidence that BCT is superior to either emotion-focused or insight-oriented couples therapy. In the clinical descriptions of both SRCT and ICT it was acknowledged that some therapeutic procedures new to BCT are similar to procedures included in emotionfocused and insight-oriented couples therapy (Halford, in press; Jacobson & Christensen, 1996). In particular, the increased emphasis in both SRCT and ICT on affect expression and interpretation of patterns of interaction, overlap with similar procedures in insight-oriented and emotion-focused therapy. Conversely, insight-oriented therapy includes use of many procedures that are similar to BE and CPST ( Jacobson, 1991). Emotion-focused therapists also openly acknowledge using procedures like CPST (Greenberg & Johnson, 1988). Across different approaches to couples therapy, both within the BCT tradition and within other theoretical approaches, there is some convergence toward changing strong negative emotional reactions during couple interaction by methods other than skills training. The use of exposure based paradigms in ICT and SRCT represents a significant addition to what is included in BCT.

EVOLUTION OF BEHAVIORAL COUPLES THERAPY: PROSPECT

Refining Our Understanding of Adaptive Couple Processes The content of traditional BCT evolved in large part from research assessing the behavioral differences between distressed and nondistressed couples, and then using these

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observed differences as the targets for change in therapy (Weiss & Heyman, 1997). Implicit in the use of marital satisfaction as the independent variable is the assumption that distressed and nondistressed couples are homogenous with respect to fundamental adaptive processes. This assumption is inconsistent with recent findings, and it is likely that BCT has to be modified to meet the needs of particular subgroups of distressed couples. Gottman (1994) developed a typology of couple interaction styles based on direct observation of couple communication found prospectively to predict relationship satisfaction and stability. Gottman (1994) defined three types of adaptive couple interaction: volatiles who were characterized by high rates of expression of negative emotions and very high rates of expression of positive emotions, validaters who expressed high rates of positive emotions and moderate to low rates of negative emotions, and avoiders who expressed low rates of positive and very low rates of negative emotions. He also defined two types of maladaptive couples interaction which predicted relationship distress and high risk of dissolution: hostile couples who express very high rates of negative emotion and low rates of positive emotions, and hostile-detached couples who expressed moderate to low rates of hostility and very low rates of positivity. A common element to each of the adaptive couple styles was a ratio of rates of positive to negative communication of greater than 5:1, whilst a common element to the maladaptive styles was a ratio of less than 1:1. Gottman speculated that a high ratio of positives to negative sustains a positive affective balance in couple relationships, which in turn sustains partners’ positive global perception of the relationship. There are significant limitations to our knowledge of the types proposed by Gottman (1994). We do not know if the types are generalizable across cultures, nor do we know how stable the types may be over time. Furthermore, all of Gottman’s work is correlational and we have no evidence that the types of interaction have a causal impact on relationship satisfaction. However, the work does raise the likelihood that there are multiple styles of adaptive couple interaction. Implicitly the practice of BCT, and most other approaches to couples therapy seem to teach the validater style of couple interaction (Gottman, 1994), For example, the emotional expressiveness training used by Baucom et al. (1990) teaches couples to be more expressive of emotions, with emphasis particularly on expression of positive emotions. However, it may be that the volatile or conflict minimizer styles are more appropriate for some couples. Jacobson (1992) made an argument closely related to the point of differences between couples in what may be adaptive. He argued that BCT needed to emphasize the applied behavior analysis tradition of assessing the functional impact of behaviors within a given context. In a similar vein, my colleagues and I advocated the self-regulation approach as a means by which clients can test hypotheses about what is functional in particular settings within their relationship (Halford et al., 1994; Weiss & Halford, 1996). It is unlikely that we can define universally adaptive couple processes; what is functional for couples varies in response to factors such the settings and the cultural context in which interaction occurs (Halford, Gravestock, Lowe, & Scheldt, 1992; Halford, Hahlweg, & Dunne, 1990). Given this, BCT practitioners need to assess rather than presume that particular interactional behaviors are adaptive for particular couples. Another important difference between couples who present with relationship problems is the impact of violence. Up to 70% of couples presenting for couples therapy report an episode of physical violence in the past 12 months (Cascardi, Langhinrichsen, & Vivian, 1992; O’Leary, Vivian, & Malone, 1992). In some of these couples the aggression is infrequent, is limited to less severe aggression, and is directed by the

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man to the woman and vice versa. This reciprocal, less severe violence might be seen as an example of maladaptive conflict management which could be changed by BCT. There are some data showing that BCT does reduce aggression in these couples in which there is less severe violence (Heyman & Neidig, 1997). However, in some couples the violence is severe, and is associated with the women being physically injured and/or feeling intimidated and fearful of their partners (Cascardi et al., 1992). There are some men who use physical violence and other coercive intimidation (e.g., sexual coercion, restriction of access to money) to attempt to control their partners (Holtzworth-Munroe, Smutzler, Bates, & Sandin, 1997). The use of BCT with couples in which the woman is coerced, threatened, intimidated or fearful seems highly questionable (Vivian & Heyman, 1996). Under these circumstances the woman may be unable safely to assert her needs and desires within the relationship, which would preclude effective use of BCT. More research is needed on how best to respond to severe relationship violence. In the mean time I advocate BCT practitioners routinely screen for violence, and suggest that BCT, at least in its current form, is not appropriate for couples in which there is severe violence.

Adaptations of Couples Therapy for Individual Vulnerabilities Until the mid 1980s the practice of BCT contained little explicit attention to individual vulnerabilities in partners. Implicitly it seemed to be assumed that any impact of individual vulnerabilities would be reflected in the couple’s adaptive processes, and if those processes were corrected then attention to the individual vulnerabilities was redundant. However, in the last 10 to 12 years there has been considerable research on the interaction of individual psychopathology and relationship problems (Halford et al., in press). For example, there is clear evidence that relationship problems are common in couples in which one partner suffers from a psychotic disorder (Halford, 1995a), the wife is depressed (Beach, Arias, & O’Leary, 1986; Beach & O’Leary, 1986), or the husband abuses alcohol (Halford & Osgarby, 1993; Reich & Thompson, 1985). There is substantial research assessing the relationship adaptive processes of couples in which one partner has a psychological disorder. As a broad generalization, this research shows that the dysfunctional adaptive processes evident in distressed couples in general also are evident in couples in which one partner does have a psychological disorder (Halford et al., in press). For example, couples in which the woman is depressed or the man abuses alcohol show many of the deficits in communication and conflict management seen in distressed couples where neither partner has a psychological disorder (Biglan et al., 1985; Hops et al., 1987; Hautzinger, Linden, & Hoffman, 1982; Jacob & Leonard, 1992; Jacob, Ritchey, Cvitkovic, & Blane, 1981; Nelson & Beach, 1990; Schmaling & Jacobson, 1990). There are additional problems in couples in which one partner has a significant psychological disorder. For example, alcohol abuse is associated with a range of relationship problems which seem directly related to the drinking, and these problems only reduce when the drinking is moderated (Halford, Price et al., 1997; Zweben, 1986). In the 1980s there was a substantial body of research evaluating the effects of BCT in treating couples in which one partner had significant psychopathology (for review, see Halford et al., in press). Analyzing this research is beyond the scope of this paper, but one clear point has emerged: when individual and relationship problems coexist, couples therapy needs to be modified significantly to allow for the individual vulnerabilities of the partner with the psychological disorder. For example, in treatment of

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coexisting severe alcohol and relationship problems, the use of individual treatment to establish sobriety is a prerequisite for effective use of BCT (O’Farrell & Rotunda, 1997). Attention to individual vulnerabilities which do not meet criteria for psychological disorder has not yet become a systematic part of BCT. There is substantial evidence that individual vulnerabilities such as exposure to parental divorce, exposure to violence in the family of origin, and high neuroticism each are associated with the risk for development of relationship problems (Karney & Bradbury, 1995). Recent research also shows that such individual vulnerabilities are associated with dysfunctional couple adaptive processes. For example, couples in which there is a history of parental divorce or family of origin violence show significantly more negativity during problem solving discussions than other couples (Halford, Skuja, Sanders, & Behrens, 1997; Sanders, Halford, & Behrens, 1997). In insight-oriented therapy there is specific emphasis upon the way in which couple interaction is influenced by individual vulnerabilities (Snyder & Wills, 1989). For example, there often is exploration on the role of earlier relationships and family of origin experiences in shaping the individual partner’s expectations of, and affective responses to, couple interaction. Whilst it remains to be shown that such a focus underlies the effects of insight-oriented therapy, this possibility is consistent with the accumulating evidence for the importance of individual vulnerabilities in influencing relationship satisfaction. Greater attention to individual vulnerabilities in BCT, and possible integration of insight-oriented and traditional BCT procedures are worthy of further research.

Couples Therapy and Stressful Events Most of the writings on couples therapy, including BCT, do not include much attention to current stresses and transitions having impact upon the couple relationship. Implicitly it seem to have been assumed that, if couples have adequate adaptive processes, this will allow them to cope with a wide range of stresses. For example, Notarius and Markman (1995) advocated that the particular issues that distressed couples are attempting to manage is less important than the communication processes. However, there is evidence that different external stresses impacting upon the couple and relationship, such as parenting problems (Sanders et al., 1997), work stress (Thompson, 1997), and health problems (Schmaling & Sher, 1997), may require different therapeutic responses. For example, Dadds, Schwartz, and Sanders (1987) worked with couples who presented with a child with conduct disorder, and who also had relationship problems. They emphasized behavioral parent training in their therapy but also provided a brief (3 session) adaptation of BCT. Their adaptation of BCT focused on partners supporting each other in parenting roles. The partner support training did not include the extended skills training usually included in BCT, yet the therapy was effective in producing sustained improvements in the couples’ relationship satisfaction, and reduction in child behavior problems (Dadds et al., 1987). Another common stressful situation which requires modification of BCT is entering a step-family. Relationships in which there are dependent children from an earlier relationship break down at very high rates (Booth & Edwards, 1992; Martin & Bumpass, 1989). Furthermore, the pathways to relationship dissolution seem different in step-families compared to other relationships. Whilst first relationships typically break down following a sustained period of declining relationship satisfaction (Gottman,

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1990), in step-families couples often separate reporting high relationship satisfaction but difficulties in negotiating partner roles in parenting (Lawton & Sanders, 1994; Nicholson, Halford, & Sanders, 1996). BCT adapted to focus specifically on the crucial issue of negotiating parenting holds substantial promise for enhancing relationship satisfaction and stability in step-families (Kelly & Halford, 1993; Nicholson et al., 1996). A common element in the findings of Dadds et al. (1987) and the more recent work on step-families, is that attention to strained parent child interactions can improve the couple relationship, even with very limited direct targeting of couple interaction. Given the established relationship between work stresses and relationship functioning (Thompson, 1997), couple interaction and relationship satisfaction also may be enhanced in some couples by assisting partners to manage their work better. Parenting, work and other important life roles provide the broader context within which couple interaction occurs, and improving the partners’ coping with extra-relationship stresses alters the context and may thereby enhance couple functioning. There also can be stresses or crises within the relationships. For example, the discovery that one partner in a committed relationship had, or is having, an affair is a common stimulus to relationship breakdown (Glass & Wright, 1985; Sprenkle & Weiss, 1978). To the extent that the occurrence of an extra-marital relationship may reflect pre-existing relationship problems, the traditional components of BCT may be helpful. However, it is likely that specific interventions to reduce destructive anger and hurt, and to rebuild trust within the relationship, are likely to be needed before traditional couples therapies like BCT are helpful (Glass & Wright, 1997). There are extensive clinical descriptions of procedures which are focused on recovery of relationship from infidelity (e.g, Glass & Wright, 1997), but systematic evaluation of these procedures is lacking.

CONCLUSIONS BCT incorporating BE, CPST and cognitive interventions is a well established, and moderately efficacious means of treating relationship problems. However, the traditional focus of BCT on changing couple interaction as the means of promoting relationship satisfaction is too narrow. Recent developments of Integrative Couples Therapy, with its emphasis on promotion of acceptance as well as change, and SelfRegulatory Behavioral Couples Therapy, with its emphasis on self rather than partner change, reflect a broadening of the adaptive couple processes believed to underpin relationship satisfaction. Approaches other than BCT, notably emotion-focused and insight-oriented couples therapy, also are established means of enhancing relationship satisfaction. These different perspectives hold out further directions for the development of a broader conceptualization of the couple adaptive processes which relationship therapy can target. Individual vulnerabilities of partners, and the stressful events impinging upon couples are known to impact upon relationships, yet BCT has paid limited attention to these factors until now. Attention to individual vulnerabilities is a key characteristic of insight-oriented and emotion-focused couples therapies. Empirical evidence is accumulating that greater attention to individual vulnerabilities enhances couple therapy outcome. Furthermore, adaptation of couples therapy to attend to the specific stresses and developmental transitions facing couples also is likely to enhance couples therapy outcome.

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Acknowledgements—Preparation of this article was supported by an Australian Research Council Grant entitled ‘‘Prevention of Marital Problems’’ to W. Kim Halford, Matthew R. Sanders, and Brett C. Behrens. I thank Neil Jacobson and Andrew Christensen for giving me materials on their Integrative Couples Therapy, Doug Syder for providing materials on insight oriented therapy, and Rhoda Richardson and Ruth Bouma for help with manuscript preparation. I also am grateful to two anonymous reviewers for helpful comments on an earlier version of this article.

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