Neil S. Jacobson: AFTA's Year 2000 Distinguished Contribution to Research Award Recipient

The legacy as Neil saw it.

Neil S. Jacobson took great pleasure in intellectual activity and made a life in which it was a vivid, three-dimensional, interpersonal activity. A week before he died, Neil told his graduate student, Sona Dimidjian, that there were two things for which he was most proud in his career. The first was that he had three separate and remarkable programs of research-in marital therapy, domestic violence and treatments of depression. (He also liked to mention that he had a fourth major area, methodology-in particular his work on clinical significance.) And the second was that he was gifted at selected the best possible graduate students. His legacy in these arenas doesn't require special devotion from me, his wife, or anyone else.

You can watch and listen carefully to the work his former students will continue to produce. And what is delightful about remembering Neil is paying close attention to his ideas and continuing to engage in them. His most recent book, Reconcilable Differences, by Andy Christensen (UCLA) and Neil, reached #52 on amazon.com the first day it was released in February of this year. People dig the ideas. His next book, Clinical Handbook of Couple Therapy, Third Edition, with Al Gurman, will be out in another year and with the shape Al and Neil have given the book it will be another classic. His last book, Depression in Context, by Christopher Martell, Michael Addis, and Neil, also coming out next year, will be too. At the AFTA meeting on Saturday, June 24th, you can see a 15-minute video of Neil discussing each of his areas of research and his epistemology to get a reminder-directly from Neil-of what it was he wanted you to hear from him.

Early years of bmt and scientific optimism

Neil received his Ph.D. from the University of North Carolina in 1977. While in graduate school, Jacobson became interested in the application of behavior therapy to couples having relationship problems. Since this was not an area of interest on the part of any clinical faculty members at UNC, Jacobson relied on the literature-specifically the pioneering work of Gerald R. Patterson; Richard B. Stuart; and Robert L. Weiss-in developing his couple treatment. For his master's thesis, he conducted the first randomized clinical trial on what was to become known as behavioral marital therapy (BMT). Throughout graduate school, Jacobson developed and refined this promising treatment.

Graduate school was also where Jacobson began his work as a methodologist. In collaboration with one of his classmates, Donald H. Baucom, Jacobson and Baucom wrote an influential paper on the design and analysis of placebo control groups in psychotherapy research, published in 1978. During Jacobson's internship year at Brown University, he and Gayla Margolin received a book contract from Brunner/Mazel to write what would now be called a treatment manual on the behavior therapy approach for couples tested in Jacobson's masters thesis and his dissertation. Since Gayla had been a student of Bob Weiss, her contribution reflected her training from Bob, as well as her own ideas about assessment and therapy. This book (Jacobson, N.S., & Margolin, G. (1979) Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel) became a widely-used treatment manual, and inspired replications and extensions of Jacobson's research in laboratories around the world (e.g., Germany; Australia; England; Holland). In the meantime, Jacobson spent 1975-76 year working in a psychiatric setting, finding BMT to be an efficacious adjunct treatment for psychiatric inpatients also experiencing marital problems. This work was also published in 1979. Jacobson's first academic job was as an Assistant Professor at the University of Iowa. During his two years there (1977-1979), he concentrated on analogue couple therapy research, basic research on relationships, and, for the first time, began to study depression. This interest in depression was a direct outgrowth of Jacobson's interest in couples, as both research and clinical experience were suggesting a strong association between marital problems and depression, especially in women. The depression work focused on interpersonal consequences of depression for others, and the results of this work were published in 1982. Because this work received a fair amount of attention, Jacobson was invited to participate in an NIMH sponsored conference at Western Psychiatric Institute-chaired by Lynn Rehm-on behavior therapy for depression. A chapter on methodology and assessment came out of that conference, and the proceedings were published in 1982.

The basic research on marital distress was published between 1980-82, and the most noteworthy finding extended Gottman's bank account model of marital distress by operationally defining trust in terms of reactivity, the tendency of couples to respond to immediate as opposed to delayed contingencies. It turned out that the more unhappy a couple was, the more likely they were to be reinforced or punished by immediate as opposed to long-term events in the relationship. The primary graduate student collaborators on this research were Erling Anderson and Danny Moore. Jacobson also worked closely with Holly Waldron, now an Associate Professor of Psychology at the University of Mexico (at the time Holly was an undergraduate).

Seattle and skepticism

In the fall of 1979, Jacobson moved to Seattle, and became an Assistant Professor at the University of Washington, Department of Psychology. While awaiting the results of a Federal Grant application, Jacobson began a program of research on the role of attributional processes in marital distress, much to the chagrin of his radical behavioral graduate research assistant Bill Follette. Although Jacobson eventually returned to his radical behavioral roots, these years produced a productive program of research on how particular kinds of thinking are related to gender differences, and differences in marital distress.

Perhaps the most important study to come out of this work was Amy Holtzworth-Munroe's master's thesis. In this study that was eventually published in JPSP in 1985, Holtzworth-Munroe (a graduate student from Brown then; a Professor of Psychology at Indiana University now) established a method for assessing without eliciting causal attributions, and found interesting interactions between gender and level of distress. Moreover, Jacobson received a major federal grant in the Spring of 1980, to conduct a study attempting to uncover the mechanisms of change in behavioral marital therapy. The results of this study, while shedding light on how BMT worked, were also instrumental in creating disillusionment on Jacobson's part regarding the absolute efficacy of BMT that lead inexorably to the development of Integrative Couple Therapy (also known as "acceptance therapy"). Finally, Jacobson's long-standing interest in gender politics combined with ethical and moral concerns about the rates of depression for married women led to a side interest in the politics of couple therapy. A chapter on this topic was published in the proceedings from the Germany conference (Hahlweg & Jacobson, 1984), and continued as an interest throughout his work (see Jacobson, 1989, The Politics of Intimacy, and Jacobson and Gottman, 1998, When Men Batter Women).

The results of the dismantling study went a long way toward explaining the mechanisms of change for BMT. These studies were gradually published between 1984-1987. By now, Jacobson's lab had conducted five clinical trials in four distinct locales contributing to knowledge regarding: when BMT was effective; what techniques were responsible for particular effects; how often the approach was successful; and which process variables contributed to its effects. Ever since 1976, but particularly since 1979, Jacobson began to disseminate BMT through clinical workshops delivered throughout the world. His extramural training lectures (including a separate one on Domestic Violence) comprised a major part of his travel time until the day he died, when he was scheduled to lecture on domestic violence to a group of advocates in Las Vegas.

There were a number of graduate students who made major contributions to this work: Amy Holtzworth-Munroe; Karen Schmaling (now in the Psychiatry Department at UW); Mark Whisman (now a professor at University of Colorado at Boulder); Bill Follette (now a professor at University of Nevada-Reno) and Victoria Follette (now a professor and a Dean at the University of Nevada at Reno); Lisa Wood (now at the University of Puget Sound); and Debbie MacDonald, Robert A. Berley, Carolyn Phelps, Nicole Gilbert, and Kathy Melman (now in private practice). BMT had become the gold standard for marital treatments, and to this day remains the only treatment for marital problems that has been designated "empirically validated" by APA's Division 12 Task Force. It was largely for this work, and the clinical contributions from the Jacobson and Margolin book, that Jacobson received an award in 1983 from the American Family Therapy Academy for his "Distinguished Contribution to Family Therapy Research." By 1981, based on a citation search published in the Journal of Marriage and Family Therapy, Jacobson was the most widely-cited couple therapist or couple therapy researcher in the world. This continues to be the status.

Clinical significance

Here was the dilemma that Neil couldn't get past: Their statistical comparisons between groups were disguising the overall disappointing results of BMT. The fact is, a substantial number of couples were not benefiting, and less than half seemed to be joining the ranks of the happily married and remaining in those ranks permanently. Jacobson and his colleagues were frustrated by the limitations of inferential statistics for highlighting these limitations, and took a detour from the "content" of couple therapy research to tackle the question of clinical significance. The question was: how could we depict results in ways that would highlight their clinical significance? At the time Dirk Revenstorf was on sabbatical with Jacobson, visiting from the University of Tubingen in Germany. He was an expert statistician. In collaboration with Revenstorf and Bill Follette, Jacobson published, in 1984, a statistical approach to assessing the clinical significance of psychotherapy effects, that could be used not just for couple therapy but for all forms of psychotherapy. These statistics for assessing the clinical significance of treatment effects are now used throughout the world, and even those who are critical of Jacobson, Follette, and Revenstorf (1984) have proposed, and include in their own research, alternatives for assessing clinical significance. In 1999, Neil's student Joseph McGlinchey completed an empirical test of the two most prominent alternatives to Neil's clinical significance statistic. The newer, far more baroque statistics were no more effective at assessing clinically significant change than Jacobson, Follette and Revenstorf's original, more economical statistic.

When BMT outcome data were scrutinized under the microscope of clinical significance, Jacobson's results simply confirmed the clinical suspicion, i.e., that in absolute terms BMT was lacking: with the help of colleagues Baucom, Hahlweg, and Margolin, Jacobson, Follette, and Revenstorf published these disappointing findings in 1984. The disappointing outcomes do not seem unique to BMT: only 50% of couples benefit from all currently existing approaches to couple therapy, as Jacobson recently concluded in a review published with graduate student Michael Addis (now at Clark University) in JCCP. It was clearly a time for soul-searching, resilience, recovery, and hopefully, renewed creativity.

In the meantime, Jacobson and his colleagues moved to examining the application of couple therapy to the treatment of depression. The "mechanism" grant from NIMH was renewed, with a comparison between BMT and individual CBT, plus the combination as the comparison groups in a clinical trial. This work, which included major contributions from therapists Sandra Coffman and Joyce Victor, was done in collaboration with Dr. Keith Dobson, professor of Psychology at the University of Calgary, who is a co-Principal Investigator also on Neil's current depression study. Graduate students involved in this project were Mark Whisman, Alan Fruzzetti (now at University of Nevada-Reno), Post-doc's Kirk Strosahl and Sheppard Salusky. He identified a sub-group of married depressed women for whom couple therapy appears to be the treatment of choice, and found that BMT was just as effective as CBT at preventing relapse. Most of the work resulting from this project was published in 1991-93, but Jacobson's interest in the relationship between marriage and depression, especially for women, continued. His graduate student Stacy Prince, who just completed her dissertation on depression, straight and same-sex couples, and gender, was been involved in this work, and Prince and Jacobson's (1995) review of the marriage/depression literature is a widely-cited examination of what we know about the topic. Another recent graduate and former graduate student, Kelly Koerner, also played a major role in examining the basis for the expectation that couple therapy would be an effective treatment for depression in women.

The mid-eighties was a busy time for Jacobson and his laboratory. Jacobson became the Director of the Clinical Psychology Program at the University of Washington in 1989, and added that job to his research, teaching, and clinical responsibilities, until stepping down in 1989. In anticipation of stepping, down, Jacobson applied for a Research Career Development Award from NIMH to pay his salary so he could devote himself full-time to research. This award came through, and started in August, 1989-just as he passed the Clinical Director torch on to Ana Marie Cauce. Jacobson's funding foundation was becoming more secure. Now, he had at least 5 years of salary guaranteed for 12 months, and a large grant on marital problems and depression.

Treating Depression: When less is better or at least just as good and more efficient and respectful of the client

At this point Jacobson expanded to study individual psychotherapy and for the next 12 years methodically disturb the status quo in the treatment of depression. Up until now, all of Jacobson's work had been focused on either couples or research methodology. He had never done individual psychotherapy research, except when CBT was used as a control group in the recent depression study. But Jacobson was struck by how effective CBT seemed to be in expediting recovery from acute depressive episodes. Furthermore, he noticed that much of the improvement was occurring quickly, prior to the "cognitive" interventions. He began to wonder whether or not Beck's CBT for depression might work for other reasons than those suggested by the cognitive theory, and designed a study similar to his prior BMT "mechanism" study to dismantle CBT, and test competing hypotheses about the basis for its efficacy.

Here was the first time that Jacobson had set about studying depression without an interpersonal or couple focus. He was particularly interested in the component of CBT focused on behavioral activation: a behavioral treatment that was quick, easy to administer, and parsimonious. What if this treatment worked as well, or formed the basis for the effectiveness of CBT? In other words, what if there was no need for the cognitive in cognitive therapy? Would that not have important theoretical and practical implications? As an aside, both Jacobson and his colleague from UCLA, Andrew Christensen, had been interested in how to provide psychotherapy less expensively, and had written a controversial and widely-cited think piece about the absence of a relationship between professional training or experience and outcome in psychotherapy research (Christensen & Jacobson, 1993). This research fit nicely with the goals outlined in the article. Thus, Jacobson and Dobson renewed their marital therapy/depression grant, but shifted their focus to individuals. Jacobson received a MERIT award for this grant proposal, which was funded in the late 1980's, and has led to controversial but fascinating results, published from 1996-98, mostly in JCCP. Basically, Jacobson and colleagues found no support for Beck's theory, and plenty of evidence that behavioral activation (BA) was just as effective. During the early phases of this work, Paula Truax (now a Psychologist in the military) was Project Coordinator, Addis was the Data Analyst, and Koerner was in charge of monitoring adherence to treatment protocols. Other contributors included Prince, and newer graduate students Eric Gortner and Jackie Gollan. Gortner and Gollan continued to collaborate with Jacobson and Dobson as the others graduated and moved on. The original "component analysis" study of cognitive therapy versus behavioral activation alone ended up being the preliminary to the next study. In 1998, Jacobson launched a new study with collaborators Dave Dunner from Psychiatry at the University of Washington, Steve Hollon from Vanderbilt University, and Keith Dobson. This study is the largest single-site clinical trial ever done in the area of depression, and it featured what Jacobson called "the dream team" of cognitive therapists: Steve Hollon as co-principal investigator, Philadelphia-trained Sandra Coffman and Steve Scholl as research therapists. The behavioral activation research therapists, including Depression in Context co-author Christopher Martell, Ruth Herman, and Tom Linde assured highly consistent treatment in the more straight-forward behavioral activation condition. Behavioral activation, however, had a theoretical and ethical basis to it. Theoretically behavioral activation as Neil has developed it is contextual: it is more reasonable to examine factors outside the individual in the environment rather than inside the individual in order to understand and treat their depression. As Neil has said in other domains, factors outside the individual may include family factors, but are not limited to family factors. From an ethical standpoint, approaches that seek to address intrapersonal "causes" of depression tend to be blame the depressed person and tend to ignore a host of practical conditions that are available and practical to address.

The team of graduate students who worked closely with Neil on this study included Jackie Gollan, who completed her dissertation on depression a month before Neil died, Eric Gortner, whose dissertation completed the year before was also on depression, Lisa Roberts, Sona Dimidjian. Neil referred to this group as "the big unit." Gollan is currently a post-doc at Brown University; Gortner is completing law school at Harvard; Lisa is completing her dissertation on psychopathology (she's already published a book on the topic); Sona Dimidjian, who was trained as a family therapist before pursuing a clinical research career and Ph.D. at the U.W., has provided the key continuity and leadership to the study in the wake of Neil's death and continues as the project coordinator as she develops her dissertation. Graduate students Joe McGlinchey and Mandy Steiman continue to work on the study as well. The study will be completed in 2002.

Domestic violence and a scandal in couple therapy

In the meantime, back in the mid to late 1980's, Amy Holtzworth-Munroe wanted to expand her research paradigm to domestic violence. Jacobson had always planned to study domestic violence some day. It was a natural integration for someone interested in couples and gender, and it fit one of Jacobson's main criteria for meaningful clinical research: that it have political and social as well as clinical implications. Serendipity struck when the Psychology Department hired John Gottman as a Developmental Psychologist. John was a renowned family researcher. Neil and Amy quickly talked John into collaborating with them on a domestic violence grant proposal, which was ultimately funded in 1990 (Amy was banished to Bloomington but still involved). Neil and John combined their clinical and methodological skills to paint a dark and intimate portrait of batterers, and to reveal the resourcefulness, courage, and heroism of battered women. As they began to publish this work (1993-1999), their careful look at batterers and battered women led to a great deal of media coverage, and eventually a contract to write a book for the public: When men batter women: New insights into ending abusive relationships (1998). New York: Simon and Schuster.

During the early phases of this research, Jennifer Waltz and Regina Rushe were co-Project Coordinators. Jennifer is now at the University of Montana, and Regina is now a post-doc at the Palo Alto V.A. Most recently, Eric Gortner and Sara Berns have played major roles in the longitudinal phase of the research, exploring questions such as "When do battered women leave abusive relationships?" "When does the violence stop?" Our current research is on the process of trauma, resilience, recovery, and heroism, in battered women: an attempt to understand the natural processes by which battered women recover from abusive relationships, and how those natural processes can inform advocacy. Graduate students Sona Dimidjian and Sara Berns are continuing this work with a survey study begun under Neil's supervision on the success or failure of couple therapy training to provide family therapists with minimum competence for screening for domestic violence in the couples they see. The results, still in being collected, will confirm or refute the apprehension that Neil and others who work in the domestic violence field have suspected, that couple therapists do a spotty job, at best, of screening couples individually for domestic violence.

Jacobson continued to be recognized, mostly for his couple therapy research, but also for his methodological contributions to psychotherapy research methodology. In 1988, Jacobson was President of APA's Society for a Scientific Clinical Psychology. In 1991, Jacobson was President of the Association for the Advancement of Behavior Therapy. He has been invited to give hundreds of keynote and invited addresses, plenary speeches, and clinical workshops. In 1993, he received an award from the American Association for Marriage and Family Therapy for his Lifetime Contributions to Family Therapy Research. In 1994, his Research Career Development Award was renewed for five additional years; this award was repeated in 1999 prior to his death.

Integrative couple therapy: the basis of Reconcilable Differences

Lurking in the background of these expansions into depression and domestic violence was the growing dissatisfaction with BMT. In 1991, Christensen began to collaborate with Jacobson in a program of research which was to culminate in a new radical behavioral treatment, Integrative Couple Therapy, which has shown great promise in a pilot study funded by NIMH in 1993. Norton published a manual on this treatment approach, which integrates traditional behavior change strategies with those designed to foster acceptance, in 1996. A book for the public is on the way. The pilot study showed 89% success for ICT, the highest success rates the group has ever seen. Starting in September, 1997, a two-site study has been funded by NIMH, with Jacobson overseeing the UW site and Christensen overseeing the UCLA site: a randomized clinical trial will definitively compare ICT with BMT. Sara Berns coordinates the UW project; and Kathy Eldridge coordinated the UCLA project until 1998. Graduate students David Atkins, who has written papers with Neil and infidelity, the topic of his dissertation, and Jennifer Wheeler are also part of the couple therapy project, which runs for five years.

Finally, Jacobson remained active in his writings on methodology. With Waltz, Addis, and Koerner, Jacobson published a paper in JCCP on methods for assessing treatment integrity and quality of treatment delivery. In a recent American Psychologist article, Jacobson and Christensen debated Seligman and others regarding the merits of the Consumer Reports Study. In a 1995 article in the Family Therapy Networker, Jacobson questioned the state of the evidence that psychotherapy works. While those articles help to illustrate the kind of consummate skepticism necessary for an empiricism which is not mechanistic, perhaps his article "Contextualism is Dead, Long Live Contextualism" (Family Process, 1994) does justice to Neil's overriding epistemology, that of radical behaviorism or "contextualism."

In short, the center of Neil's research activity, the Center for Clinical Research at the University of Washington has been in existence since 1979., and has its roots in Jacobson's graduate work, beginning in 1973. Remarkably, the wave of excitement and enthusiasm for scientific discovery was still growing-and at the time of Neil's death he was the number one grant recipient at the entire University of Washington system. There was no rest for Neil, his students, and colleague collaborators at the Center for Clinical Research. He was conducting the largest ever couple therapy study, the largest ever single-site depression study, results that by the study designs assured integrity and early results of which inspire those of us who are enthusiasts. To be a true fan of Neil's work is to understand that while there may not be such a thing as truth, there are most definitely truths that are more useful, and Neil was on to those truths. And you have to believe that while science is only one way of knowing, that it is a powerful knowledge system that can be used well, poorly, or brilliantly. And Neil used this knowledge system brilliantly and there by produced-and will continue to produce in his lab-discoveries that are more reliable because of the quality of this science. Now, as to the eloquence of the work, the humanity, idealism, ethics, and insight. Go ahead, there's lots to read and see for yourself.

By Virginia Rutter, based on Neil's biography for the Center for Clinical Research website which Neil wrote in 1997.