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Andrew Christensen's "Unified protocol for couple therapy" - overview

Couple therapy was a major theme in last month's British Association for Behavioural & Cognitive Psychotherapies conference and I wrote three blog posts about this.  One of several initiatives I followed up after the conference was to get a copy of the book "Enhancing couples: The shape of couple therapy to come".  It's good, and I've particularly enjoyed a chapter by the expert Andrew Christensen of "Integrative couple therapy" fame on "A unified protocol for couple therapy".  This links very explicitly to David Barlow's work and the series of posts I wrote back in the Spring on his "Unified protocol for the treatment of emotional disorders".

The abstract for Christensen's book chapter reads: "Drawing from the 'unified protocol for emotional disorders' ... and drawing from several evidence-based treatments for couple problems, this chapter proposes a unified protocol for couple therapy.  The protocol is based on five central principles: (1) provide a contextualized, dyadic, objective conceptualization of problems, (2) modify emotion-driven dysfunctional and destructive interactional behavior, (3) elicit avoided emotion-based private behavior, (4) foster productive communication, and (5) emphasize strengths and encourage positive behavior.    The clinical and research implications of this unified protocol for couple therapy are discussed."

A bit "jargony", but interesting stuff.  Can Christensen's unified protocol help improve the outcomes of couple therapy (or make it more easily teachable)?  Shadish & Baldwin's 2003 paper "Meta-analysis of MFT interventions" commented "This article briefly reviews 20 meta-analyses of marital and family interventions.  These meta-analyses support the efficacy of both MFT for distressed couples, and marital and family enrichment.  Those effects are slightly reduced at follow-up, but still significant.  Differences among kinds of marital and family interventions tend to be small.  MFT produce clinically significant results in 40-50% of those treated, but the effects of MFT in clinically representative settings have not been much studied."  So these authors found only small differences between the results achieved by a variety of well-structured kinds of couple therapy.  It may be that (as is probably the case with Barlow's unified protocol for individual therapy) Christensen's model is more about helping to organize a disparate field and make couple therapy more easily teachable, than about getting better therapeutic results.  In contrast, it's worth noting that incorporating session-by-session client feedback (whatever the specific kind of couple therapy being used) can significantly improve results - see "Using client feedback to improve couple therapy outcomes: a randomized clinical trial in a naturalistic setting" and "Effect of client feedback on couple psychotherapy outcomes".  In fact the improvements achieved through incorporating routine client feedback look better than the improvements achieved through switching from one kind of couple therapy to another. 

But one needs to use some kind of approach!  The Christensen ideas are relatively independent of a particular couple therapy school, although his commendation of "functional analysis" is a bit of a give-away.  He states that his proposed five principles " ... are implemented based on a functional analysis of behavior".  The great majority of couple therapists (whatever their therapeutic orientation & language) are going to put together a picture of the triggers for, expression of, and consequences of problem behaviours through discussion with (and observation in session of) the couple seeking help.  Happily this provides plenty of opportunity for the couple to highlight what problematic interactions/behaviours they themselves most want to change.  It provides opportunities as well to explore the couple's own current understanding of why the problems occur, what makes them worse, and also what - at times - seems to make them better.  This gives the therapist and couple plenty of opportunity to co-construct key therapy goals and to reach initial agreement over what methods have a good chance of helping ease the situation.  

See tomorrow's post for a fuller exploration of Christensen's "Five principles".

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