Practice Profile

If you think understanding individuals is difficult, try working with couples — especially those who are fighting or have other serious communication problems.

But for Andrew Christensen, PhD, relationships hold a compelling interest. The veteran University of California, Los Angeles, psychologist has spent the last 35 years treating, studying and developing protocols for some of the most intractable partnerships, as well as for less troubled couples.

"With individual therapy, people tell you about their problems," the soft-spoken psychology professor says. "With couples therapy, they bring their problems to the session and enact them in front of you. For me this is exciting. I like the challenge of bringing calm to chaos, of finding the tender, human pain behind the angry, hostile face."

His efforts were vindicated last year, when the largest, longest study of its kind showed that a therapy he developed with the late Neil Jacobson, PhD, helps more troubled couples heal their relationships — through two years post-treatment — than the most widely studied treatment to date, traditional behavioral couple therapy. Christensen is now working to get the treatment — known as integrative behavioral couples therapy, or IBCT — up on the Internet for widespread use, and is training therapists at the Department of Veterans Affairs to use IBCT with military couples.

"Andy has never rested on his laurels," comments couples researcher Donald H. Baucom, PhD, Richard Lee Simpson Distinguished Professor of Psychology at the University of North Carolina at Chapel Hill. "He continues to develop new ideas, expand his research program and seek ways to make his treatment strategies available to increasing portions of the population."

‘A universal struggle’

Christensen developed his interest in couples work while attending graduate school at the University of Oregon in the early 1970s. He was considering specializing in anxiety, but when he conducted his first study — on social anxiety among college students — he found himself even more drawn to the relationships fueling the anxiety, especially the dynamics between people.

"Getting emotionally and physically intimate with someone, while keeping your independence and identity and managing the inevitable conflicts that arise; I find it absolutely fascinating how people do that," he says.

Not only does he see these issues among his clients, but also in his own relationships. "It’s kind of a universal struggle," he says.

Since discovering that calling, Christensen has become one of the world’s premier couples therapy researchers. Starting in the 1980s, he identified, then confirmed through studies, a "demand-withdraw" pattern of couple interaction that has been widely adopted by clinicians worldwide and remains a major focus of couples interventions today. In this pattern, one partner perceives a given problem and badgers the other partner about it, while the other partner withdraws or avoids the topic.

In the 1990s, he and Jacobson developed IBCT, which builds on behavioral couples therapy by helping partners identify, address and try to change problematic patterns — the keystone of behavioral therapy — and to accept and gain greater emotional understanding of one another.

"Certainly, change can be helpful for couples," says Christensen. "But Neil and I experienced that sometimes couples are unwilling or unable to change, and that sometimes the changes they make are fairly short-lived. Or they may not pack the punch the partner wants them to have — they don’t make the partner feel that much better." In other words, upon one partner’s complaint, the other partner may agree to do more dishes or stop flirting with others, but the initial partner may still not feel satisfied emotionally.

To this end, IBCT seeks to foster emotional acceptance and understanding of one’s partner, and to help couples change patterns they are both bothered by. The treatment also helps couples get a big-picture view of their problems by examining larger relationship patterns and exploring how past issues may inform the present. A woman might be particularly sensitive to her partner’s criticism because she had highly critical parents, for instance. Or a man might have trouble accepting his partner’s emotionality because emotions weren’t expressed in his family.

"It really helps couples to [see that] each of us has a history, and that history has shaped us," Christensen explains.

A five-year test

IBCT was put to the test in a five-year study reported in the April Journal of Consulting and Clinical Psychology (Vol. 78, No. 2). There, Christensen and colleagues at UCLA and the University of Washington compared relationship outcomes in 134 chronically and seriously distressed married couples who were randomly assigned to 26 sessions of either IBCT or traditional behavioral couples therapy.

Right after treatment, both groups showed about the same high rate of marital satisfaction, measured by a scale that examines factors including consensus between partners, mutual satisfaction, level of affection and relationship cohesion. But two years after treatment ended, a follow-up study found a statistically significant larger rate of improvement among IBCT couples than among those who received traditional behavioral sessions.

At five years, though, those differences evaporated. About half the couples in each group still showed clinically significant improvement, about a quarter were doing about as poorly as they had been before treatment, and a quarter had separated and divorced.

Christensen attributes this decline in IBCT’s impact to a lack of booster sessions, which would be given in the real world when couples report a crisis or find themselves slipping back into old ways. The researchers deliberately did not build in such sessions, he says, because adding them would have overly complicated the research design.

Other experts in couples therapy laud IBCT as a treatment, as well as the study, which they say combines the most current statistical methods, highly trained and experienced practitioners and supervisors and long-term follow-up.

"Dr. Christensen’s study is widely recognized as the gold standard for randomized clinical trials of couple-based interventions in terms of its methodological rigor," says marital outcome researcher Douglas K. Snyder, PhD, professor and director of clinical psychology at Texas A&M University. "And the improvement rate at two-year follow up — around 70 percent — is phenomenal, relative to the vast majority of previous randomized controlled trials of other treatments for couple distress."

In fact, IBCT is considered so effective that the Department of Veterans Affairs chose it as the one couples intervention it is disseminating nationally, part of a major VA-wide training effort to disseminate evidence-based psychotherapies, says Shirley M. Glynn, PhD, a clinical research psychologist at VA who develops policy and organizes trainings for family and couples services throughout the system.

"IBCT’s benefits have been well-supported with empirical findings, and it builds on a skill set in cognitive-behavioral techniques consistent with many other evidence-based treatments being disseminated by VA," says Glynn. "With minor tailoring, it can also be used across a host of mental health problems, which makes it appealing in a diverse service-delivery system like the VA."

Demand-withdraw patterns

Complementing his work on therapy models, Christensen also has been observing common relationship patterns that he and others have coded, measured and incorporated into their treatment with couples.

"Demand-withdraw" is a major one. In a series of rigorous studies, Christensen and colleagues have found that women are more likely to be demanders, and men more likely to be withdrawers. The researchers have also found that the more often couples engage in these behaviors, the lower their relationship satisfaction.

Similar patterns appear in gay and lesbian couples, says Christensen. A study in the June Journal of Family Psychology (Vol. 24, No. 5) found that both gay and straight couples showed about the same rates of the demand-withdraw pattern, as well as a tendency to be more demanding when discussing an issue that they want their partner to change, than when discussing an issue their partner wants them to change. While that may seem obvious, communication can get convoluted in these scenarios: Just because couples agree to talk about a topic, they don’t always stick to it. A "withdrawer," for instance, may change the topic and focus on some other perceived inadequacy of the "demander" as a way of avoiding the central topic, Christensen explains.

Gender patterns held up as well. When asked to discuss topics chosen first by one partner and then the other, overall, both straight and lesbian women were more demanding, and straight and gay men more withdrawing.

A partial explanation, says Christensen, may be that in both same-sex and opposite-sex relationships, women tend to be more interconnected and more affected by the quality of their relationships than men. That said, his research and others’ show that men and women are more alike than different in the types of topics they bring up and how they engage in them. While men are stereotypically more interested in sex than women, for instance, "there are lots of women who wish their partner showed more sexual interest in them," he says. Christensen and colleagues have identified and studied other unhealthy patterns as well, including one in which both partners withdraw.

Spreading the word

Working with Brian Doss, PhD, of the University of Miami, Christensen is seeking to disseminate his relationship findings as broadly as possible. The two have a five-year, $426,269 grant from the National Institute of Child Health and Human Development to adapt IBCT for self-administered Internet delivery and then examine its effectiveness through a clinical trial. The intervention would allow couples to access a free online program that trains them in IBCT strategies using videotaped illustrations of couples communicating, interactive technology and other tools.

"We’ll always need in-person couples therapy, but if we can reach more couples sooner with a less expensive, less intrusive intervention, that would be ideal," Christensen says. (Couples can sign up to receive the program at www.ourrelationship.com, and will be contacted when the training program is up and running, he notes.)

In a separate project, he is creating a unified protocol for couples therapy that captures the most effective elements of empirically supported couples therapies — much like the unified protocol on emotional disorders developed by Boston University psychologist David H. Barlow, PhD. In Christensen’s first published work on the subject, a chapter in "Enhancing Couples: The Shape of Couple Therapy to Come" (Hogrefe, 2010), he outlines the protocol, suggests ways to test its principles and advocates such a protocol as a model for future practice. The protocol captures overarching principles that can be applied in a variety of treatment situations, so that instead of having to learn and use a new treatment manual for each new treatment, clinicians can instead apply these broad principles more flexibly in their therapy practices.

Christensen probably wouldn’t have been able to make these contributions without having worked on and nurtured his own relationships, comments colleague Baucom.

"Andy lives his own theory and work about how relationships flourish and how you optimize them," Baucom says. Christensen enjoys a close relationship with his wife of 27 years, University of Southern California psychologist Louise Macbeth, PhD, as well as with their two adult children, Lisa, 27, and Sean, 20. He’s also mentored countless students, and collaborates and travels regularly with a cadre of international couples researchers who are also good friends.

What’s next for Christensen? He says he’d like to take a closer look at successful couples’ relationships, to see what they might contribute to struggling ones.

"I’ve noticed that in marriages you often have opposites — one person is more emotional, the other more Buddha-like, for example. I haven’t tested this, but in a difficult marriage, I’d surmise people would become more polarized, while in a good marriage, they might move a little more toward each other."

In his own marriage, he says, his wife has become less emotionally reactive over time, while he’s gotten more emotionally tuned. "We’ve been fortunate to move toward each other."


Tori DeAngelis is a writer in Syracuse, N.Y.