approaches fuse various behavioral techniques with those that develop empathy. The emphasis on both of these things—empathy and behavior—were reflected in the interventions, which were roughly categorized as “systemic‐behavioral” or “systemic‐empathic.” Indeed, the EM, while explicitly utilizing behavioral interventions, was also in other ways resonant with other systemic couples therapy models, one prominent one being Emotionally Focused Couples Therapy (Johnson et al., 2005), which, of course, emphasizes the need to strengthen the empathic connection within the couple. Interestingly, a number of years before the publication of the work coming from Johnson's lab around this the research team of Jacobson and Christensen, coming from a behavioral tradition, had also emphasized the need for therapists to work on this area. Their research showed that, without such an emphasis, any initial progress made would deteriorate over time (Jacobson & Christenson, 1998).
The NICE statement was based on the “best available” evidence, which equates to “gold standard” researched treatments: that is, RCTs. Only a handful of these past research endeavors approached the “gold standard.” These were all on behavioral couples therapy, yielding specifically behavioral interventions that formed the specifically approved interventions. However, there is, of course, a problem using only these to reflect best practice on the ground. That is largely because of the difficulty of funding, the problem of establishing quantifiable variables, and the length of time incurred in carrying out and publishing RCT research. This issue is enlarged upon in Chapter 2. In consequence, a less‐than gold standard methodology to establish “best current practice” was carried out within a government‐sponsored effort through the use of an Expert Reference Group. In this, nominated seasoned and research‐savvy practitioners in couples therapy agreed on current best practice interventions (see University College London (UCL) Core Competences, Couple Therapy for Depression webpage1).
Because there has been more research on the effectiveness of couples therapy for depression than for other mental or physical health conditions there have been a number of different couples therapy modalities for treating depression. These have included the original purely behavioral, Behavioral Couples Therapy (cf. Gottman, Notarius, Gonso, & Markman, 1976; Jacobson & Margolin, 1979). Such models taught direct, clear communication skills; conflict management skills; utilized behavioral exchange and problem‐solving skills; and were programmatic and time‐limited.
While these behavioral interventions demonstrated effectiveness, Integrative Behavioral Couples Therapy (Jacobson & Christenson, 1998) was developed to address the fact that effectiveness tended to fade after about a year. This newer model added in “Acceptance/Tolerance” work. Indeed, adding in interventions that increased “acceptance” and “tolerance” (i.e., gaining understanding, apprehending respective limitations) yielded longer lasting effects. Acceptance and tolerance work was about increasing the ability to understand each other, empathically, and to being able, through this, to make adaptations to each other. This meant embracing the other's limits and limitations, yielding a more generous tolerance as well as better emotional understanding. In the EM the interventions that increased such understanding—that is, the ones nominated by the Expert Reference Group that did so—were added to those validated in the behavioral couples work. So the EM encompasses specific behavioral and specific empathic interventions, as will be delineated below.
Other couples therapy modalities have included a previous attempt to integrate behavioral and systemic, using a less comprehensive and at that point not as clearly validated set of behavioral techniques and systemic ones: that is, Behavioral‐Systemic Couples Therapy (Crowe & Ridley, 1990), and also Systemic Couples Therapy (e.g., Jones & Asen, 2000), which did not specify specific interventions.
The EM took as its starting point the systemic proposition underlying the NICE guidelines statement. It then created a rubric of best practice interventions that could be subsumed within that systemic proposition. These could be divided into “systemic behavioral” (which were from the “gold standard” research papers and endorsed within the Expert Reference Group (ERG) description) and “systemic empathic” (which were from the ERG description). The EM idea was to make systemic behavioral and behavioral systemic. It extends behavioral techniques that have been shown to be effective treating depression, but—crucially—framing them within a systemic lens.
The original EM, after formulating this fusion of behavioral and systemic ideas into its investigation of the circularities of behaviors, thoughts, and feelings that become reinforced within a couple, leading to the often unwitting reinforcement of depression, uses the following interventions, each of which were either cited as “gold standard” ones for depression (and so are “behavioral”) by NICE, or as agreed upon “best practice” ones by the ERG (and, in the main, are “empathic” interventions):
| Systemic Empathic | Systemic Behavioral |
| Reframing | Circularities |
| Genograms | Enactments |
| Interviewing internalized other | |
| Circular questioning | Communication training |
| Translating meaningCreating safe space for exploration | Problem solving |
| Empathic bridging maneuvers | Homework tasks |
| Investigating family scripts | Behavioral exchange |
| Investigating attachment narratives | Communication skills training |
The model combines both these approaches (behavioral and systemic). But it sets as its rationale that stated in the NICE statement: the maintenance cycle of the couple system is the fulcrum of treatment. Change comes about through effective disruption of the maintenance cycle. This disruption comes about through the skillful deployment of the validated interventions, but within a context that sees things systemically.
The key invention of the EM however is its concatenation of the idea of a couple’s maintenance cycle—that is, that they reinforce each other through their responses to each other—with the CBT one of the thoughts–feelings–behavior feedback loop maintenance cycle. This is a fusion of CBT and systemic. It will be enlarged upon in Chapter 3 and illustrated in Part 2 of the book. It teaches the therapists how to describe a couple's maintenance cycle. It asks each member of the couple about the behaviors they are reacting to in relation to each other, but asks them also to reveal—and subsequently, together interrogate—the reactive sequence of hidden, unspoken thoughts and feelings that accompany the seen or spoken behaviors. The unspoken parts of the maintenance cycle become the vehicles for revelations to the other member of the couple, who characteristically might have been making inaccurate assumptions and attributions about the observable behaviors and reacting to them inaccurately. Investigating why and how they have the reactions, through the use of the (validated) interventions within the EM, in their thoughts and feelings, becomes revelatory for the couple and, in narrative terms, frees them to create a different story, as other possible ones can emerge.
The couple's maintenance cycle has as its focus how the interactive cycle of responses to each other maintains whatever the presenting problem may be. (In the case of its use in the training clinic, this was depression). Its assumption is that this cycle maintains the problem, most often unwittingly. Indeed, often couples who come in for treatment of a problem have a caring, loving relationship, yet are unwittingly doing behaviors and/or making distorting assumptions
