The Intercultural Exeter Couples Model. Reenee Singh

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