Behavioral Versus Insight-Oriented Marital Therapy Labels Can Be Misleading Neil S. Jacobson University of Washington ABSTRACT Snyder, Wills, and Grady-Fletcher (1991) reported a 4-year follow-up comparing insight-oriented (IOMT) with behavioral marital therapy (BMT). The effects of IOMT were more durable than those of BMT. These comments question the adequacy with which the two treatments were represented. The BMT treatment manual adequately represents behavioral technology as it existed in 1980 but fails to include more recent clinical innovations. The IOMT treatment manual includes many clinical skills that are integral to BMT but not included in the BMT manual. Documentation is provided that therapists in the BMT condition were not using these important techniques. These and other questions regarding the adequacy of training and supervision may have compromised the integrity of BMT. Nevertheless, the findings do suggest that traditional BMT technology alone may be neither necessary nor sufficient for long-term change. Preparation of this article was supported by Grants #2R01 MH33838-10, #5R37 MH44063-02, and #5R01 MH43101-02 from the National Institute of Mental Health, awarded to Neil S. Jacobson. I wish to express special thanks to the following people who read an early draft of this article and provided valuable comments: Donald Baucom, Andrew Christensen, Rick Heyman, Amy Holtzworth-Munroe, Howard Markman, and Robert Weiss. Correspondence may be addressed to Neil S. Jacobson, Department of Psychology NI-25, University of Washington, Seattle, Washington, 98195. Received: August 2, 1990 Revised: August 31, 1990 Accepted: August 31, 1990 Snyder, Wills, and Grady-Fletcher (1991) have reported 4-year follow-up data from an outcome study comparing behavioral (BMT) with insight-oriented marital therapy (IOMT). This report, as well as others that have emerged from this clinical trial ( Snyder & Wills, 1989 ; Wills, Faitler, & Snyder, 1987 ), represents an impressive program of research. Among the notable features are the use of treatment manuals; careful documentation of treatment integrity; a comprehensive, multidimensional assessment battery; and the unprecedented 4-year follow-up. The findings that warrant comment are the significant differences in long-term outcome favoring the insight-oriented treatment over behavioral marital therapy. Whereas the two treatments did not differ in efficacy either immediately after treatment or at a 6-month follow-up, the treatment gains held up better in IOMT than they did in BMT. Given space limitations I will focus my comments on one concern about the study: the treatment manuals used to represent BMT ( Wills, 1982a ) and IOMT ( Wills, 1982b ). In my view, there are problems with both manuals. There is a great deal of state-of-the-art technology that is missing from the Journal of Consulting and Clinical Psychology © 1991 by the American Psychological Association February 1991 Vol. 59, No. 1, 142-145 For personal use only--not for distribution. Page 1 of 511/27/2000http://spider.apa.org/ftdocs/ccp/1991/february/ccp591142.htmlBMT manual: cognitive techniques, strategies aimed at destructive interactional themes, and innovations in the way behavior exchange interventions are conducted, just to name a few prominent examples. Moreover, the sections in the manual on inducing homework compliance and fostering collaboration between spouses are thin; this point is worth noting because compliance with homework and collaboration during sessions are strong predictors of outcome ( Holtzworth-Munroe, Jacobson, DeKlyen, Whisman, 1989 ). Snyder et al. (1991) have noted the absence of recent clinical innovations and have considered the possibility that the findings would have been different if the new developments had been incorporated. Unfortunately, in view of the fact that the study was begun before these new developments were in print, there is no way that they could have been included. There are several clinical skills and therapist attributes thought to be essential to effective BMT ( Jacobson & Holtzworth-Munroe, 1986 ) that are not discussed or that are mentioned only in passing in the Wills BMT manual. These more generic clinical skills are too numerous to list here, but they include creating therapeutic environments in the session, fostering collaboration between spouses at home, providing empathy and emotional nurturance, and fostering hope in distressed spouses. His BMT manual adequately depicts the traditional technology as it existed in 1980 but does not address the clinical skills required in the effective implementation of technology. These skills were by and large being taught to behavioral clinicians as far back as 1980, but some were not in the literature at that time. However, these same clinical skills are discussed at length–in the IOMT treatment manual! Despite the distinct theoretical framework at the beginning of the IOMT manual, almost all of the techniques listed are not only consistent with a behavioral approach but in my view are an integral part of BMT. In fact, in most instances it was hard to tell how these techniques were related to psychodynamic theories of marital satisfaction and distress. Wills acknowledged the heavy use of behavioral techniques in the IOMT manual and justified their use by quoting from Gurman (1981) and Jacobson and Margolin (1979) to the effect that behavioral techniques are common to all marital therapy protocols ( Wills, 1982b ). Of the 31 intervention strategies listed in the IOMT treatment manual, none are incompatible with BMT, and 26 would be considered integral to a behavioral approach. These intervention strategies are listed in Table 1 , which also lists (when appropriate) the labels used to describe these interventions when they are used by behavioral marital therapists. Citations from our treatment manuals are provided (when appropriate), showing where the techniques are described. In some cases, the techniques described in our BMT manuals are virtually identical to the techniques described in the IOMT manual written by the Snyder group. In other instances, the techniques listed in the IOMT manual constitute examples of a more general intervention strategy discussed in our BMT manuals. Few of the techniques listed in their IOMT manual map clearly onto the three basic IOMT interventions (probing, reflecting, affective reconstruction) delineated by Wills et al. (1987) .
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