Читать книгу The Intercultural Exeter Couples Model - Reenee Singh - Страница 7

The original EM arose in response to the NICE recommendation in 2009 for using behavioral couple treatment for depression. We italicize “behavioral” as that points specifically to the contribution of behavioral methods to the recommendation, while the statement itself, implies the importance of a systemic approach:

A time‐limited, psychological intervention derived from a model of the interactional processes in relationships where the intervention aims to help participants understand the effects of their interactions on each other as factors in the development and/or maintenance of symptoms and problems. The aim is to change the nature of the interactions so that they may develop more supportive and less conflictual relationships.

(National Institute of Clinical Excellence [NICE], 2009)

This statement is a systemic one: it underscores that the couple dynamic is an important part of the change mechanism, in this case for depression. Other research has found this to be so for other conditions (cf. Baucom, Whisman, & Paprocki, 2012). This is thought to be due, in part, to the effects of continuous, daily reinforcement of habit change within the intimate, real life of an ongoing domestic relationship. The evidence being amassed by CBT researchers on couples work in depression specifically has put couples therapy on that treatment map (Snyder & Halford, 2012). But systemic workers and thinkers have useful ideas and techniques to offer.

That this is so was pointed to in an early article by Hafner and his co‐authors that partners can aid therapy (Hafner, Badenoch, Fisher, & Swift, 1983) as well as in research discussed by Snyder and Halford (2012) who provide a comprehensive overview of research on the effectiveness of couples therapy not only for relationship distress, but also for a variety of individual physical and mental health problems. On the flip side, problems are also maintained through reinforcement of habits within couple and family relationships, and there is also established evidence that relationship distress is associated with the onset or maintenance, or both, of mental health problems (Parker, Johnson, & Ketring, 2012).

The EM was developed in an attempt to make systemic work more empirically sound: it resonates with past work that has been empirically verified. That is, its interventions are all ones that have been either validated as “gold standard” ones from (behavioral therapy) randomly controlled research trials (RCTs) or from the validation by a group of experts in current couples therapy practice. Therefore, the non‐behavioral, empathy‐based interventions it uses are ones validated by a convened Expert Reference Group to establish best practice for NHS commissioned work and for externally validated training courses (Pilling, Roth, & Stratton, 2010; Stratton, Reibstein, Lask, Singh, & Asen, 2011). The EM became a systemic‐behavioral training and practice and was developed by Janet Reibstein and Hannah Sherbersky at the University of Exeter. It was created within the School of Psychology, Clinical Education Development And Research (CEDAR) programme and its Accessing Evidence‐Based Psychological Therapies (AccEPT) clinical training clinic. It was subsequently rolled out and has been in practice since 2010 in numerous settings, both within that university clinic, various NHS services across the UK, and within private practices.

A manual was drawn up by Reibstein and Sherbersky (2010) for use for both research projects and for training within a pilot training clinic for both MSc in Systemic Practice and Doctorate in Clinical Psychology students within the University of Exeter. This clinic ran for 4 years, treating couples in which at least one member of the couple had a diagnosis of depression. They were referred to the clinic either through their NHS GP practices or the local depression treatment services. As a manualized model it could more easily go on to be able to be validated, as a whole therapy approach, in itself. The EM also was part of a general trend in third wave CBT which emphasizes the salience of empathy (e.g., Gilbert, 2010; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Linehan, 1993; Lynch, Trost, Salsman, & Linehan, 2007); these 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 about what the other wants, needs, thinks, and feels out of benign motives that in fact maintain the presenting problem. Examining the maintenance cycle asks what it is—perhaps unwittingly—in a couple's interactions that are maintaining the symptom. In this the model is purely systemic and differs from many other forms of the use of couples therapy, in which couple distress is assumed or meant to be the presenting feature to qualify for couple intervention. In the EM and IEM the couple may be very supportive of each other, unwittingly maintaining unhelpful things. Unlike many other forms of couples therapy, to use the model, therefore, couple dysfunction is not a prerequisite; in fact, just being in a couple is the only one.

Couples were seen in the University of Exeter clinic mainly for from 6 to 18 sessions for treatment of depression. Trainees in the EM from outside the university brought it into use to treat other issues. These were those that present within the NHS IAPT (Integrated Access to Psychological Therapy) services; private therapy treatment for couple dissatisfaction, sexual problems, and other couple issues; within a pilot treatment program for alcohol and substance abuse; in NHS CAMHS—Children and Adolescent Mental Health Services—(for the treatment of couple dysfunction within family therapy settings); and in outpatient services such as crisis intervention services and older adult services.

But, as we have said, until recently neither an interculturally‐based site nor practice have existed within the EM. The EM as initially constructed, needing to be built entirely upon validated interventions (either by gold‐standard RCTs or by Expert Reference Group: two high, but different standards, of validation) left out attention to culture explicitly directed through any of its interventions. The fact, in itself, that neither the NICE survey nor the ERG one found a “best practice”—at the very least, intervention that focused upon intercultural issues—is a sad comment on our dominant culture's myopia.

So, jettisoning the need to have a model that conforms to the absolute highest standards of research practice was an inevitable outcome for the next phase of development of the EM. Otherwise we could not keep the EM in line with either attention to the fact that we are a global community or with society’s current societal needs—in particular in geographical areas in which there is high intercultural marriage and cohabitation. We wished to move it to a higher ethical standard of practice which would accord with those needs. Indeed, the authors believe that it is current “best practice” to include the multicultural dimension. What has been yielded is The IEM.