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Guildford BABCP conference: last morning and the NICE guideline recommendation on the provision of couple therapy (seventh post)

The last morning of the conference was pretty abbreviated for me as I needed to catch a train to London at around 11.00am.  I went along to the first three talks of the symposium on "Behavioural couples therapy (BCT) in the South-West: New developments."   Interesting times.  Working in Scotland and outside the National Health Service, I hadn't realized just what a strong driver the NICE guidelines are for NHS service development in England & Wales.  Mostly this sounds like a pretty good thing, but it also leads to some surprising situations - in this case people seemed to be trying to push their preferred therapy (here it was Systemic Couples Therapy) into a shape that will allow it to pass as the "NICE recommended" form of therapy (in this instance Behavioural Couples Therapy).  It's a bit like watching someone work to squeeze into a dress that wasn't entirely designed for them.  Sometimes of course this could have pretty happy results!

As background, it's interesting to note what the NICE Guideline (Issued October 2009) "Depression: the treatment and management of depression in adults (update)" actually says: 

  • For people with persistent subthreshold depressive symptoms or mild to moderate depression who have not benefited from a low-intensity psychosocial intervention, discuss the relative merits of different interventions with the person and provide:
  • an antidepressant (normally a selective serotonin reuptake inhibitor [SSRI]) or
  • a high-intensity psychological intervention, normally one of the following options:
    • - CBT
    • - interpersonal therapy (IPT)
    • - behavioural activation (but note that the evidence is less robust than for CBT or IPT)
    • - behavioural couples therapy for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit
  • For people with moderate or severe depression, provide a combination of antidepressant medication and a high-intensity psychological intervention (CBT or IPT).
  • For all high-intensity psychological interventions, the duration of treatment should normally be within the limits indicated in this guideline. As the aim of treatment is to obtain significant improvement or remission the duration of treatment may be:
    • reduced if remission has been achieved
    • increased if progress is being made, and there is agreement between the practitioner and the person with depression that further sessions would be beneficial (for example, if there is a comorbid personality disorder or significant psychosocial factors that impact on the person's ability to benefit from treatment).
  • Behavioural couples therapy for depression should normally be based on behavioural principles, and an adequate course of therapy should be 15 to 20 sessions over 5 to 6 months.

Mm ...  The talks this morning were all from the Exeter Systemic-Behavioural Couples Therapy programme.  The first introduced the model.  The abstract included the comments "A model of couples treatment which aims to build on the evidence base for behavioural treatment for depression (cf NICE guidelines, 2009) within a couples modality, while also acknowledging the evidence for systemic interventions (Asen and Jones, 2000; Leff, 2000) is beginning to be developed within a new training clinic (opened July 2010) within the University of Exeter Mood Disorders Centre.  The developing model also draws on the work of Jacobson and Christensen, (Jacobson, et al, 2000; Christensen, et al, 2004) on the importance of what they have termed developing "acceptance and tolerance" within the relationship for sustaining the effectiveness of behavioural interventions."  The second talk gave an illustrated overview of some of the techniqes, while the third described a case study.

It was good to be reminded of Jacobson & Christensen's work trying to increase the effectiveness of behavioural couples therapy.  Their augmented model of "Integrative behavioural couple therapy (IBCT)" was a very promising initiative.  It contrasted "acceptance" and "change" interventions showing that "IBCT couples significantly increased their nonblaming description of problems and significantly decreased their expressions of hard emotions and their problematic communication over time" (in contrast to more Traditional Behavioural Couple Therapy (TCBT) with its greater emphasis on change methods).  Pilot research was very encouraging, see the 2000 paper "Integrative behavioral couple therapy: an acceptance-based, promising new treatment for couple discord."  The major comparison trial followed - "Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples" - and showed "Both treatments produced similar levels of clinically significant improvement by the end of treatment (71% of IBCT couples and 59% of TBCT couples were reliably improved or recovered on the Dyadic Adjustment Scale; G. B. Spanier, 1976)."  Not as great a difference as the pilot study had lead one to hope for, but still IBCT looks a little better value than TBCT.  Interestingly this trend for IBCT to do a bit better than TBCT held up both at two year and five year follow-up - see "Couple and individual adjustment for 2 years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy" and "Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy."  The emphasis on both change and acceptance procedures links interestingly to the rapidly accumulating research on mindfulness which has spread to the couples arena too - see, for example, the articles on couples & mindfulness in the October 2007 edition of the Journal of Marital and Family Therapy.  I think it's time to dust off my copies of Jacobson & Christensen's "Integrative couple therapy: promoting acceptance and change" (for therapists) and "Reconcilable differences" (for clients too). 

Challenging to evolve better approaches to couple therapy.  As 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."  In the 2010 multi-authored book "The shape of couple therapy to come: enhancing couples", both Andrew Christensen and Douglas Snyder & Molly Gasbarrini write thought-provoking chapters on potential unified/integrated approaches to couple therapy.  And important to note the very impressive gains achievable in couple therapy (as well as individual therapy) through adding session-by-session feedback - 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 the last of this series of eight posts on the BABCP annual conference, tomorrow I describe "The four main areas I want to use clinically after this conference".

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