Principle‐Based Integrative Therapy with Couples: Theory and a Case Example

• Author: Traci P. Maynigo,Shalonda Kelly,Kiara C. Wesley,Simone C. Humphrey,Steven M. Clark,Yasmine Omar
• Date: 01 September 2019
• Published date: 01 September 2019
• DOI: http://doi.org/10.1111/famp.12442

Principle-Based Integrative Therapy with Couples:

Theory and a Case Example

SHALONDA KELLY*

KIARA C. WESLEY

†

TRACI P. MAYNIGO

‡

YASMINE OMAR

§

STEVEN M. CLARK*

SIMONE C. HUMPHREY*

The Principle-Based Integrative Therapy (PBIT) framework harnesses the principles of

change underlying each theoretical model within integrative couple therapy treatments.

PBIT has commonalities with other integrative approaches, and additional advantages

stemming from its four tenets that guide therapists in combining strengths across models

and overcoming each of their deficiencies. Tenet 1 advises that each model adds a core

principle or mechanism of action that other models do not automatically address. Tenet 2

focuses on how techniques of one model may actualize the principles of other models. Ten et

3 ensures complementarity and a lack of conflict across principles. A case study and com-

mon case considerations are presented to illustrate how Tenets 1–3 can work in integrating

Cognitive-Behavioral, Multicultural, and Emotionally Focused Therapy models in work-

ing with a couple. Finally, Tenet 4 advocates for the use of models and empirically sup-

ported principles that also have received empirical support with diverse populations.

Prerequisites and training implications for PBIT, and future clinical and research direc-

tions to further the utility of PBIT are discussed.

Keywords: Integration; Couple Therapy; Psychotherapy Techniques; Psychotherapy

Process; Diversity; Multiculturalism

Fam Proc 58:532–549, 2019

THE NEED FOR PRINCIPLE-BASED INTEGRATIVE THERAPY

The field of couple therapy recognizes major deficiencies inherent in treatments that

rely on a single theoretical model (Fraenkel, 2016; Snyder & Balderrama-Durbin,

2012). First, each model lacks flexibility and adequate explanatory power across all

*Graduate School of Applied and Professional Psychology (GSAPP), Rutgers, The State University of New

Jersey, Piscataway, NJ.

†

VA San Diego Healthcare System, San Diego, CA.

‡

Montefiore Medical Center, New York, NY.

§

Baylor College of Medicine, Houston, TX.

Correspondence concerning this article should be addressed to Shalonda Kelly, Graduate School

of Applied and Professional Psychology (GSAPP), Rutgers, The State University of New Jersey, 152

Frelinghuysen Road, Piscataway, NJ 08854-8085. E-mail: skelly@gsapp.rutgers.edu.

We gratefully acknowledge Drs. Peter Economu, Daniel Fishman, and Stanley Messer for their helpful

feedback on a prior draft. We also thank our colleagues and students who have participated in our GSAPP

couple therapy clinic and Emotionally Focused Therapy supervision group, as well as Shalonda Kelly’s

behavioral couple therapy and diversity courses. The conversations in those venues stimulated the

development of our approach to integration.

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Family Process, Vol. 58, No. 3, 2019 ©2019 Family Process Institute

doi: 10.1111/famp.12442

couples and situations, by limiting its scope to a “one size fits all” set of categories and con-

structs for understanding clients. For example, across multiple evidence-based couple

therapies, a host of constructs are deemed essential to couple disharmony and success,

and the presumed mechanisms of change and therapeutic strategies vary for each treat-

ment (Gurman, 2013b; Harris, Kelley, & Shepard, 2015; Snyder & Balderrama-Durbin,

2012). Moreover, individual differences in the sources and functions of couple distress can

result in some couples doing better in treatments espousing one model and others doing

better in treatments espousing another model (Gurman, 2013b; Lebow, Chambers, Chris-

tensen, & Johnson, 2012; Snyder & Balderrama-Durbin, 2012). Second, most therapists

use more than one theoretical model in their work (Schottenbauer, Glass, & Arnkoff,

2007), yet practically there is a paucity of widely accepted methods and tenets to assist

with effective psychotherapy integration (Stricker & Gold, 2011). Third, the history of cou-

ple therapy involved adherence to single-models and studies seeking to show the superior-

ity of one model over another, with increasing recognition that single theories are

incomplete and irreconcilable (Fraenkel, 2016). Also, findings typically show tha t each

model works similarly well (e.g., Shadish & Baldwin, 2003).

PBIT Addresses Overlap of Models and the Individuality of Therapists

The long history of integration within couple therapy to overcome single-model deficien-

cies has revealed much overlap of models and their principles and strategies. Couple ther-

apists and researchers using different models commonly take a systems perspective in

understanding couple and family relationships (Fraenkel, 2009), and they acknowledge

and address many contexts that shape and constrain couples (e.g., Breunlin, Pinsof, Rus-

sell, & Lebow, 2011). Also, couple therapists and researchers using a variety of models

have documented a common reciprocal distressed couple pattern wherein one partner has

the role of the pursuer or demander in the relationship and the other has the role of a dis-

tancer or withdrawer (Christensen, Dimidjian, & Martell, 2015; Fogarty, 1979; Scheink-

man & Fishbane, 2004; Wile, 2013). Recognizing the overlap and usefulness of multiple

models, many prominent couple and family therapists have developed integrative treat-

ments (e.g., Breunlin et al., 2011; Fraenkel, 2009; Gurman, 2002; Jacobson & Chris-

tensen, 1996; Pinsof, 1995). Each integrative model has some conceptualization of how

thoughts, feelings, behavior, physiology, and other key factors relate to couple distress, as

well as which of these to use as a “change entry point” to improve the couple relationship

(Fraenkel, 2016; Lebow, 1987). Yet no model has the ownership of any of these foci, even

when they are core to that model. In addition, over time, newer models of couple therapy

began to incorporate aspects of different models and combine them in new ways (e.g.,

Jacobson & Christensen, 1996; Johnson, 2004). Thus couple therapy has long been inte-

grative, with ongoing efforts to integrate even these integrative approaches.

Compounding model overlap is each therapist’s unique view of couple therapy models,

and of what each model validly covers versus not. This fits the pluralistic perspective of

many integrationists, in which multiple interpretations are legitimate and desirable (e.g.,

Messer, 1992). When a therapist gets a couple to “fake” bad or negative interactions within

Integrative Behavioral Couple Therapy (IBCT) in order to join empathically with them

and develop their distress tolerance (Christensen et al., 2015), another therapist may view

it as an “enactment” within a structural family therapy model, to make the problem come

alive so as to address it (Nichols & Schwartz, 2005, p. 127). Similarly, Nichols and

Schwartz (2005) describe IBCT’s encouragement of partners to talk about their own expe-

rience, shifting from “She never shows me any affection!” to “I’m not always sure she cares

about me” (p. 272). Another therapist can consider that shift to be the start of honing in on

attachment issues from an Emotionally Focused Therapy (EFT) model for couples

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