CHAPTER 1
Introduction

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...