The Intercultural Exeter Couples Model. Reenee Singh

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.

      But, as we have said, until recently neither an interculturally‐based site nor practice have existed within the EM. The EM as initially constructed, needing to be built entirely upon validated interventions (either by gold‐standard RCTs or by Expert Reference Group: two high, but different standards, of validation) left out attention to culture explicitly directed through any of its interventions. The fact, in itself, that neither the NICE survey nor the ERG one found a “best practice”—at the very least, intervention that focused upon intercultural issues—is a sad comment on our dominant culture's myopia.

      So, jettisoning the need to have a model that conforms to the absolute highest standards of research practice was an inevitable outcome for the next phase of development of the EM. Otherwise we could not keep the EM in line with either attention to the fact that we are a global community or with society’s current societal needs—in particular in geographical areas in which there is high intercultural marriage and cohabitation. We wished to move it to a higher ethical standard of practice which would accord with those needs. Indeed, the authors believe that it is current “best practice” to include the multicultural dimension. What has been yielded is The IEM.

THE INTERCULTURAL EXETER MODEL

      The IEM gives practitioners a systemic‐behavioral way to focus on the cultural context of a couple's life, and a method to bring in this necessary focus of so many couples today.

This version of the EM, as in the original one, does not assume pathology within the interactions, nor make an assumption of pathology about the inherent difficulties in uniting different cultures. Instead, it assumes these differences are often unwitting but that they can maintain problems. It highlights the cultural differences so that they can be brought into focus. This is so couples can name and recognize and empathize with