The Intercultural Exeter Couples Model E-Book

Janet Reibstein

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 208

Veröffentlichungsjahr: 2020

Beschreibung

Increase the efficacy of your treatment interventions in intercultural couples therapy The Intercultural Exeter Couples Model: Making Connections for a Divided World Through Systemic-Behavioral Therapy provides practitioners with a thorough guide to effectively treating intercultural couples. The book consists of a systematic effort to translate systemic ideas that take into account a cultural perspective into a highly useable and practical form. The Intercultural Exeter Couples Model also attempts to marry two, often distinct, forms of practice: the systemic and the behavioral. Both approaches have much to contribute to effective couples' counselling but they are often theoretically siloed. This book demonstrates the value of using both approaches simultaneously. This book provides concrete and practical strategies for implementing systemic and behavioral approaches to intercultural couples' therapy in a manner consistent with clinical best practice. Rather than ignoring the significant and complex impacts that differing cultures can have on a relationship, The Intercultural Exeter Couple Model puts those differences front and center, encouraging the therapist to engage with the cultural mismatch that can be at the core of many couples' ongoing friction. The book's chapters tackle both the model itself and a variety of interventions, covering topics including: * Teaching couples how to break patterns and prepare them to establish new ones * Training couples to communicate effectively * Establishing new modes of behavior in couples * An explanation of empathic bridging maneuvers * A description of the use of life-space explorations Perfect for clinicians, students, and professors interested in or practicing in the field of couples' therapy, The Intercultural Exeter Couples Model provides readers with an in-depth exploration of an increasingly important model of couples therapy and describes, in painstaking detail, the interventions necessary to achieve positive patient outcomes.

Leseprobe

Table of Contents

Cover

Title Page

Copyright Page

PART 1: The Model and Its Development

CHAPTER 1: Introduction

THE ORIGINAL EM

THE INTERCULTURAL EXETER MODEL

THE INTERVENTIONS OF THE INTERCULTURAL EXETER MODEL

THE CULTURAL GENOGRAM: A KEY INTERVENTION

THE CULTUREGRAM: A SECOND INTERCULTURAL METHOD OF INTERVENTION

WHO CAN USE THE INTERCULTURAL EXETER MODEL?

THE FORMAT OF THE BOOK

NOTE

CHAPTER 2: The Wider Context of the Intercultural Exeter Model

CHAPTER 3: The Fulcrum of the Method

THE INTERCULTURAL EXETER MODEL CIRCULARITY: A CBT/SYSTEMIC INTERVENTION

CHAPTER 4: Clinical Practice with Intercultural Couples

OVERVIEW

SIGNIFICANT THEMES AND PROCESSES

PART 2: The Interventions

PART 2A: The Systemic‐Behavioral Interventions

CHAPTER 5: Circularities

THE IEM CIRCULARITY INTERVENTION; INTERRUPTING CIRCULARITIES; FINDING POSITIVES

NOTE

CHAPTER 6: Communication Training

ACTIVE LISTENING

CLEAR AND DIRECT SIMPLE STATEMENTS

ENCOURAGING POSITIVES

“I” STATEMENTS

PROVIDING CONTEXT FOR SAFE COMMUNICATION

STRUCTURING

PROBLEM‐SOLVING—HELPING COUPLES FIND A SOLUTION TO IDENTIFIED SPECIFIC PROBLEMS

NEGOTIATION

EMOTIONAL REGULATION IN PROBLEM‐SOLVING

CHAPTER 7 Behavioral Action Interventions

ENACTMENTS

HOMEWORK TASKS/PRACTICING NEW FORMS OF COMMUNICATION

CULTUREGRAM

PART 2B: Systemic‐Empathic Interventions

CHAPTER 8: Empathic Bridging Maneuvers

EMPATHIC QUESTIONING

VALIDATION: USING INTERVENTIONS TO MAKE SOMEONE KNOW THEIR EXPERIENCES ARE UNDERSTANDABLE

ELICITING VULNERABILITIES

MAKING LINKS BETWEEN VULNERABILITIES

CREATING SAFE SPACE

NORMALIZING

TRANSLATING MEANING

CIRCULAR QUESTIONING

BLAME REDUCTION

CHAPTER 9: Life‐Space Explorations

SCRIPTS

GENOGRAM

CULTURAL GENOGRAM

INTERVIEWING INTERNALIZED OTHER

ATTACHMENT NARRATIVES

DEVELOPING SHARED FORMULATIONS OF CENTRAL RELATIONSHIP THEMES

RECONCEPTUALIZING THE POSITIVES

CREATING SHARED POSITIVES

CHAPTER 10: A Final Word

References

Author Index

Subject Index

End User License Agreement

Guide

Cover

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The Intercultural Exeter Couples Model

Making Connections for a Divided World Through Systemic‐Behavioral Therapy

Janet ReibsteinReenee Singh

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PART 1The Model and Its Development

CHAPTER 1Introduction

The public debut of the Intercultural Exeter Model (IEM) at the annual conference of the UK's Association for Family Therapy in 2017 was in the year that Prince Harry and Meghan Markle announced their engagement, and, with that, came a worldwide, populist interest, an interest not ever before so publicly recorded in the area of intercultural couples. This striking public attention put the focus on something we, the authors, along with others working in this field for years already knew: there is a dearth of either research on, or reports of, best clinical practice about working with couples of this sort. How do you do it and do it well?

Indeed, most clinical models of couples work do not even nod to the contribution culture will make to any of the myriad presenting conditions people need help with. Those clinicians working systemically will know that an exception has been within systemic theorizing (e.g., Falicov, 2014; Gabb & Singh, 2015b). Broadly, systemic theory explicitly encourages practitioners to be aware of culture, both pointed to in a general way and a more specified one by referring to the ways in which gender, race, religion, age, sexuality, ethnicity, and class shape experience (Burnham, 2012); and more particularly as a background to specific events in the Coordinated Management of Meaning (CMM) model that also denotes ways in which culture, events, and cultural beliefs contribute to people's reality (Pearce, 2007). However, despite this admirable emphasis on cultural context and consequence, therapists need more. There has been no systematic effort to translate systemic ideas that take into account a cultural perspective into working with couples. None has existed to enable the clinician both to focus on and utilize data about cultural differences in a theorized way, or even in a way that incorporates other existing clinical tools to adapt them specifically to address cultural differences.

This is a significant and gaping hole in working with couples who come from different cultures. That is the raison d'être for this book: it describes a method that helps clinicians to do so.

There is another purpose to the book: to join up best practice, to make the systemic behavioral and the behavioral systemic. There has been work with couples in which both behavioral/cognitive behavioral therapy (CBT) approaches and systemic ones have had much to contribute to ameliorate distress in a variety of conditions (cf. Reibstein & Burbach, 2012, 2013). But till now there have not been attempts to marry up these two approaches. The systemic one has the potential impact of being in a couple on capacity to make changes when there is psychological distress in at least one member of the couple (cf. Reibstein & Burbach, 2013). Because of this it has much of value to contribute. Meanwhile, hardy research has shown the value of using particular behavioral interventions, both purely behavioral and CBT, in reducing distress (cf. Reibstein & Burbach, 2012, 2013).

Indeed, specifically in the treatment of depression the value of both approaches was enshrined by the UK's NICE (National Institute for Clinical Excellence) Guidelines in 2009. In Chapter 2 we detail how significant the UK government's approach, through its NICE, has been. It has been so in helping to validate, standardize, and make accountable clinical work, in general. But we point out also how this approach has both contributed to but also handicapped the development of innovative and effective new models of therapy. Despite the NICE 2009 validation given to the systemic approach to couples therapy, specifically around depression, and to particular interventions that stem from a behavioral approach, this NICE approach left a question: How do you join them in a comprehensive way? The original Exeter Model (EM), which we describe below (Reibstein & Sherbersky, 2012), was in fact developed to do this.

The impact of cultural differences began to emerge as the EM evolved both within its original clinic. But this was increasingly more pertinently visible outside, in settings across the UK where diversity and its impact began to emerge among the clients presenting at practitioners' offices. And as it did, it became clear that the question of the impact of culture—something we intuitively know to be the case—still remained unaddressed. In consequence we began adapting the EM to begin to fill that hole, yielding the IEM.

The IEM now addresses, front and center, using best couple practice techniques, how to work explicitly with the differing cultural aspects of people's lives. In our global world, in a world of multicultural families and couples, in which children of couples who partner across cultures increasingly are raised within a hybridity of cultures, this is imperative. To avoid doing this is tantamount to avoiding something as basic as age, gender, abilities, sexualities, or income, language or educational constraints or privileges: in other words, the very seeds of people's actual, lived, daily lives. For couples, most essentially, the meshing or clashing of the cultural can be the often unexamined heart of misunderstandings instead of becoming the source of great enrichment.

Our current rhetoric of love does not really allow the consciousness of difference to become part of our discourse around intimate relationships. These result in a denial of the actuality of romantic life: conflict is an inevitable fact of couples' reality. As John Gottman's research has so clearly shown (cf. Gottman, 1994), all couples need to learn how to manage conflict between themselves. Leaving out how to think about and work with the cultural difference within a couple in a couple training, therefore, is at the very least ignorant. At its worst, it's irresponsible. Hence the IEM, the evolution of the EM.

There are two urgent, major, and progressive themes calling ever more loudly and persistently through current developments in therapy theory, practice, and training—particularly within work with families and couples. Firstly, there is the need to work sensitively, wisely, and constructively and be attentive to differences in cultures within relationships that present in the therapy room. Secondly, there is the need to become able to work within evidence‐based practices that can cut across different schools of psychotherapy. That is, to be aware, or part of, a “third wave” of psychotherapy practice that unites themes and practices across formerly divided trainings. A currently well‐equipped clinician should be able to employ and understand techniques and ideas from a range of therapies, using these in a way that is coherent with their basic therapeutic training and stance. A currently well‐equipped clinician should be able to understand and be alert to nuances of cultural differences that will necessarily be playing out within couples and families that present for therapy, or that an individual brings in their individual narrative as it may unfold within the therapy room for individual therapy. Yet there has been no single coherent model of therapy theory, training, and practice, until now, that unites these two major themes. There is still no training that can thus prepare a therapist to practice in this way.

THE ORIGINAL EM

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.