Prevention & Treatment, Volume 3, Article 17, posted June 2, 2000
Copyright 2000 by the American Psychological Association

IN MEMORY OF NEIL S. JACOBSON

The Clinical Significance of Neil's Couple Therapy Research

Andrew Christensen
University of California, Los Angeles

Correspondence concerning this article should be addressed to Andrew Christensen, Department of Psychology, University of California, Los Angeles, Los Angeles, California 90095.
E-mail: Christensen@psych.ucla.edu

One cannot seriously discuss the scientific study of couple therapy without mentioning Neil Jacobson. He wrote the first authoritative review of behavioral couple therapy (Jacobson & Martin, 1976). He conducted one of the first clinical trials of the approach (Jacobson, 1977). His book with Gayla Margolin (Jacobson & Margolin, 1979) became the definitive treatment manual for behavioral couple therapy. He edited, with Alan Gurman, the first and most influential handbook of couple therapy (Jacobson & Gurman, 1995; he was preparing the 3^rd edition of the handbook when he died). He produced more clinical trials of couple therapy, a total of 8, than any other researcher (Jacobson, 1977, 1978, 1979, 1984; Jacobson & Anderson, 1980; Jacobson, Christensen, Prince, Cordova, & Eldridge, 2000; Jacobson, Dobson, Fruzzetti, Schmaling, & Salusky, 1991; Jacobson et al., 1989). This body of research was a major part of the empirical foundation on which the scientific community judged behavioral couple therapy (or behavioral marital therapy) as the most widely researched treatment for couples and as the only couple treatment reaching the highest level of empirical support—an "efficacious and specific" treatment (Baucom, Shoham, Meuser, Daiuto, & Stickle, 1998).

These accomplishments would be plenty reason for most to rest on their laurels (which in Neil's case were many) and enjoy the accolades of the community. However, he just could not leave well enough alone. From his own experience supervising the cases in his clinical trials, he knew that many couples were not getting that much better, the .05 significance levels notwithstanding. He wanted a more rigorous criteria of clinically significant change at the level of the individual couple rather than the simple criteria of statistically significant change at the level of a group of couples.

Although Neil did not invent the concept of clinically significant change (see, for example, Kazdin & Wilson, 1978), he was the first to operationally define it in statistical terms. He, Follette, and Revenstorf (1984) came up with an ingenious way of defining "normal functioning" statistically. On the basis of normative data on an appropriate measure of outcome, one could calculate a criterion point at which functional and dysfunctional populations overlapped. A score on one side of the criterion point would put the client in the normal range; a score on the other side would put the client in the dysfunctional range. To achieve clinically significant improvement in therapy, a client would need to (a) make a reliable change from pre- to post-treatment, such that his or her score might improve more than would be expected by chance and (b) achieve a post-treatment score on the functional rather than the dysfunctional side of the criterion.

Neil would not develop a concept without trying it out. In the article that we chose for this section (Jacobson, Follette, Revenstorf, Baucom, et al., 1984), Neil got data from several colleagues who had conducted clinical trials of behavioral marital therapy. Including a study of his own, there were four sets of outcome data. The results were very disappointing. Slightly more than half of the couples improved; slightly more than a third ended up in the nondistressed range. It was little consolation that his own research had produced the highest client gains.

Rather than frustrating him into inaction, these disappointing data encouraged Neil to experiment with variations in behavioral couple therapy that might be more effective. He investigated the value of a clinically flexible version of behavioral couple therapy (Jacobson et al., 1989). Eventually, he and I teamed up and focused on acceptance as a key concept in couple therapy. Strategies for promoting acceptance, we thought, would enhance behavioral couple therapy (Christensen & Jacobson, 2000; Jacobson & Christensen, 1996). An article based on our pilot study of this treatment is Neil's last empirical contribution to couple therapy (Jacobson et al., 2000).

Beyond its immediate impact on couple therapy, the metric that Neil and his colleagues developed has gained widespread acceptance in the broader area of outcome research. Today one would be seriously remiss to report outcome only based on statistical significance. A measure of clinical significance is all but mandatory. When there is not an obvious social indicator of clinical significance, such as a return to work, then Neil's metric is used.

Neil's lasting contribution is not just the development of a metric for assessing clinical significance, but also the emphasis he put on clinical significance. He was not satisfied with what we were doing for our clients, and he would not let us be satisfied either. His was a repeated and clarion call that we should develop treatments that would generate clinically significant effects in the lives of our clients.

It is tempting to evaluate Neil's professional work with the standard of clinical significance that he so successfully promulgated. Neil's work not only caught the attention of the scientific community, it changed it in important ways. His work changed how we do therapy and how we evaluate therapy. Without a doubt, his work was clinically significant.

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