Overview of CBT models of couple therapy

1. Lecture 5. CBT theories, models
and methods of couple
relationships
Couple Counselling Skills
Kevin Standish

2. Learning outcomes
1. Phases of Development in CBT couple therapy
2. How CBT for Couples Works Generally
3. Comparison of CBT Couples therapy with Integrative behavioural
couples therapy

3. Overview
1. Phases of Development in CBT couple therapy
2. How CBT for Couples Works

4. Phases of Development in CBT couple therapy
• Behavioral couple therapy (BCT), launched by the work of Stuart and Jacobson has itself passed
through quite distinct periods:
• The “Old BCT” phase emphasized skills training (e.g., communication and problem solving) and
change in overt behavior (e.g., behavioural exchanges), and the therapist’s role was highly
psychoeducational and directive.
• “New BCT” phase, marked by the development of “Integrative Behavioral Couple Therapy”
(Christensen, Jacobson, & Babcock, 1995) shifted to a more balanced position of changing self as
well, marked by new interventions to facilitate the development of greater mutual acceptance,
especially around repetitive patterns of interaction and persistent partner characteristics or what
Gottman (1999) called “perpetual issues.”
• The “Self-Regulation Phase,” focused on the very salient impact of partners’ affective self-
regulation capacity, as sometimes highlighted in clinical work with volatile, “difficult” couples, in
which, for example, one of the partners has with a demonstrably significant personality disorder,
often, but not always, borderline personality disorder. This self-regulation phase overlaps with the
very current phase of BCT’s evolution which has made significant contributions to the treatment
of a wide variety of psychological/psychiatric disorders in their intimate relational context (e.g.,
alcoholism and drug abuse, sexual dysfunction, depression, and bipolar disorder).

5. Cognitive Behavioral Couples Therapy (CBCT)
• has become one of the most well researched approaches for the
treatment of marital and couple distress, with growing empirical
support for it effectiveness. Theoretically grounded in both social
learning and social exchange theories, the premise of CBCT is that an
individual’s behavior both influences and is influenced by his/her
environment. When applied to a marriage or other long-term
relationship, this premise suggests that one partner’s behavior
influences and is influenced by the actions of the other. CBCT typically
focuses on two aspects of this process: (a) exchanges of positive and
negative behaviors; (b) communication skills that influence the
interaction process (Epstein, Baucom, & Daiuto, 1997).

6. Cognitive Behavioral Couple Therapy
• begins with education, from a scientific perspective, on the biological and
psychological processes that underlie marital interactions, how interactions
become ineffective over time and how to get them back on track. Next, the
therapist and couple work together to assess how these patterns play out in the
couple’s relationship. Subsequent sessions are then used as opportunities for the
couple to practice communicating about challenging topics with the therapist as
coach. The therapist listens and guides the couple in effective interaction. He
helps the couple identify and examine the behaviors that are destructive to the
marriage (e.g., the “four horsemen” ), and prompts them to try out alternative,
more effective ways of thinking and behaving. There is a strong focus on
monitoring for emotion “spikes” that hijack effective communication and trigger
destructive expressions, and promoting emotion regulation when these occur.
Finding ways to accept and manage core differences is also emphasized. Finally,
shared goals are encouraged, and used as opportunities to build positive
emotional experience together to sustain an effective friendship for the years to
come.

7. Based on Gottman
• Research by John Gottman a leading marital therapist,
shows that the success or failure of a relationship can be
predicted with 96% accuracy. This is based on the
presence or absence of four simple behaviours.
• Criticism: Attacking your partner’s personality or
character, usually with the intent of making someone
right and someone wrong.
• Contempt: Attacking your partner’s sense of self with
the intention to insult or psychologically abuse him/her.
• Defensiveness: Seeing one's self as the victim and
continuously warding off a perceived attack.
• Stonewalling: Withdrawing from the relationship as a
way to avoid conflict.

8. Cognitive-Behavioral Couples Therapy
• Based on a belief that people evaluate their relationship and partners
according to unreasonable standards.
• If people’s appraisals of events are altered then there will be positive
changes in behavior and emotion accordingly.
• Two different stresses: primary distress and secondary distress.

9. Cognitive-Behavioral Couples Therapy
• Primary distress comes from one partner’s unmet needs (affiliation,
intimacy, autonomy...).
• Secodary distress emerges when that partner uses wrong strategies to
address the conflict coming from unmet needs (ignoring, verbally or
physically attacking).

10. Cognitive-Behavioral Couples Therapy
• Delivered within 8-25 sessions.
• First 2-3 sessions are for the assessment and followed by a feedback
session. The couple and the therapist define the treatment goals
together.
• Socratic questioning and guided discovery techniques may be used.

11. Cognitive-Behavioral Couples Therapy
• Socratic questioning involves asking the client a series of questions to
reevaluate the logic behind his/her certain beliefs.
• Guided discovery involves creating experiences (role playing, pros and
cons of the relationship) to have different perspectives.

12. Integrative Behavioral Couples Therapy
• Adds “emotional acceptance” to BCT to increase positive feelings.
• Jacobson and Christensen (1996) say that in the early stages, partners
tolerate the differences in personality and see it them as the source
of attraction.
• In time, these differences become sources of discontent and concern,
and result in polarization, vilification.

13. Integrative Behavioral Couples Therapy
• This therapy is interested in the agent of behavior and the
receiver together.
• According to this therapy increased acceptance reduces
conflict and is a catalyst for change.
• Acceptance techniques’ aim is to soften the adversarial
attitudes partners take toward each other.

14. Integrative Behavioral Couples Therapy
• Gottman says that some problems cannot be solved. Instead of
aiming to solve them the sources of conflict can be turned into
sources of intimacy.
• IBCT therapists determine a central theme which summarizes the
central issue.
• They believe that as partners try to change each other, polarization
occurs. This is called the mutual trap.

15. Integrative Behavioral Couples Therapy
• The effort to change eachother creates a defense,
therefore the partner who want to change the other
experiences a frustration and hopelessness.
• The theme+polarization+mutual trap= the
formulation.
• Interested in the history of the relationship, the
individual’s family, and individual’s previous
relationships.

16. How CBT for Couples Works
• Cognitive Behavioural Therapy is used to identify these behaviours , understand the
triggers, expectations, beliefs and attitudes that keep them going and identify and
practise healthy a realistic alternatives.
• There are five steps in the CBT for couples process:
1. Identifying and acknowledging individual expectations and perceptions.
2. Exploring counter-productive triggers, beliefs and behaviours.
3. Agreeing differences and acceptable tolerance ranges.
4. Identifying and practising new behaviours based on shared values, mutual respect,
empathy, trust and tolerance.
5. Agreeing a new "emotional contract". This expresses the changes that each partner
commits to and forms the basis of the future relationship.
Couples are encouraged to adopt a positive emotional tone by actively building a shared
vision for the future. Relationship resilience is developed by shifting the focus and over-
riding conflict with a willingness to respect and tolerate each other's differences.

17. Integrative Behavioral Couple Therapy
• Integrative Behavioral Couple Therapy is "integrative" in at least two
senses:
• First, it integrates the twin goals of acceptance and change as positive
outcomes for couples in therapy. Couples who succeed in therapy
usually make some concrete changes to accommodate the needs of
the other but they also show greater emotional acceptance of the
other.
• Second, IBCT integrates a variety of treatment strategies under a
consistent behavioral theoretical framework.

18. Integrative Behavioral Couple Therapy
• Both the integrative and traditional behavioral couples therapy
models have origins primarily in behaviorism.
• While traditional behavioral couples therapy has more roots in social
learning principles and the later model in Skinnerian behaviorism.
• The Integrative model draws heavily on the use of functional analysis
(psychology) and the Skinnerian distinction between contingency
shaped and rule governed behavior to balance acceptance and
change in the relationship

19. Comparative Framework.
• 1. Background of the Approach
• 2. The Healthy/Well-Functioning versus Pathological/Dysfunctional
Couple/Marriage
• 3. The Role of the Therapist
• 4. Assessment and Treatment Planning
• 5. Goal Setting
• 6. Process and Technical Aspects of Couple Therapy
• 7. Curative Factors/Mechanisms of Change
• 8. Treatment Applicability and Empirical Support

20. 1. Background of the Approach
Cognitive-Behavioral Couple Therapy
(CBCT)
• developed from the confluence of three
major influences:
• (1) behavioral couple therapy
• (2) cognitive therapy (CT)
• (3) information processing in the field of
cognitive psychology regarding attributions
that individuals make about determinants of
positive and negative events in their
relationships and relatively stable schemas
that individuals develop on the basis of past
relationship experiences and subsequently
apply in understanding current relationship
events.
Integrative behavioral couples therapy
(IBCT) third-wave behavioral therapies
• IBCT grew principally from traditional
behavioural couple therapy (TBCT): skills-
• based, change-oriented treatment that relies
on two primary intervention components: (1)
behavior exchange, and (2) communication
and problem-solving training.
• problems that represented basic and
irreconcilable differences between partners
appeared to be less amenable to traditional
change strategies.
• the key to a better result was to promote
emotional acceptance of the other and not
emphasize change so much. Jacobson and
Christensen (1998) see acceptance as the
“missing link” in couple intervention.

21. 2. The Healthy/Well-Functioning versus
Pathological/Dysfunctional Couple/Marriage
Cognitive-Behavioral Couple Therapy
(CBCT)
• CBCT employs a broader contextual
perspective in defining a healthy
relationship,
• A “healthy relationship” is defined as one
in that contributes to the growth and
well-being of both partners, in which the
partners function well together as a team
and relate to their physical and social
environment in an adaptive fashion
• A healthy couple relationship is one
thatcontributes to the growth,
development, wellbeing, and needs
fulfillment of each partner.
Integrative behavioral couples therapy
(IBCT)
• Distress is caused by the destructive ways
that some couples respond to areas of
difference and disagreement, which are
assumed to be both normal and
inevitable.
• Differences between partners are likely to
create difficulties when these differences
spring from vulnerabilities within each
partner rather than mere differences in
preference.
• Three destructive patterns frequently
characterize distressed couples’ conflicts
over their differences: 1.mutual coercion,
2.vilification, and 3.polarization.

22. 2. The Healthy/Well-Functioning versus
Pathological/Dysfunctional Couple/Marriage
Cognitive-Behavioral Couple Therapy
(CBCT)
• partners in distressed relationships are more
likely to track negative behavior selectively in
the other, to make negative attributions for
such behavior and to reciprocate negative
behavior with negative behaviour. As partners
continue to engage in negative reciprocity
and perceive the other in a negative way, they
may develop “sentiment override,” or global
negative emotions, toward each other. This
sentiment override increases the likelihood of
subsequent negative behavior and the
development of partners’ negative
expectancies or predictions that the other
person will engage in negative acts. A cycle of
self-maintaining process of relationship
discord that often typifies distressed couple.
Integrative behavioral couples therapy
(IBCT)
• distressed couples experience an
erosion in their willingness to
accept, tolerate, and compromise
around one another’s differences,
they no longer look upon each
other’s styles as sources of
attraction; they begin to exert
efforts to change their partners
• Happy couples are able to confront
their differences with greater
acceptance and tolerance.

23. 3. The Role of the Therapist
Cognitive-Behavioral Couple Therapy
(CBCT)
• during the assessment and the early stages of therapy, the
therapist assumes a didactic role, striking a balance between
directiveness and collaboration with the couple in setting
goals and applying cognitive-behavioural strategies toward
achieving them.
• Once treatment begins, the therapist at times assumes a
didactic role and provides rationales for treatment
recommendations and the assignment of homework;
• reviews assignments and events that occurred in the
relationship during the past week;
• models skills and coaches the partners in practicing them in
and outside of sessions; and continually fosters partners’
motivation.
• The therapist’s level of directiveness varies according to the
partners’ presenting concerns ; their ability to self-monitor
their behaviors, emotions, and cognitions; and their
preference for structure in therapy
Integrative behavioral couples therapy
(IBCT)
• IBCT therapist is frequently very active
and directive in sessions, the
particular form of the therapist’s
interventions will vary
• therapist requires comfort with a high
degree of flexibility and change
• the highest priority for the IBCT
therapist is maintaining a focus on the
case formulation of the couple
• therapist is to attend to and highlight
the function of behaviors.

24. 3. The Role of the Therapist
Cognitive-Behavioral Couple Therapy
(CBCT)
• the CBCT therapist also sets the pace of sessions, so that the
goals of treatment are addressed in a timely and reasonable
fashion.
• In collaboration with the couple, the therapist typically
initiates setting the agenda for each session, contributing
particular agenda items such as review of homework and
practice of a particular skill, always soliciting the couple’s
preferences for the agenda.
• The therapist then monitors the use of time during the
session and ensures that the agenda is followed to the
degree appropriate
• The therapist also adopts the role of facilitator, creating a
safe and supportive environment in which the couple can
address difficult issues.
• it is important the therapist’s direction and imposition of
structure gradually diminish over time, as the partners
assume increasing responsibility for managing their
concerns.
Integrative behavioral couples therapy
(IBCT)
• Using this historical context, the
therapist suggests that these
histories have occasioned the
current behaviors and associated
feelings
• Multiple roles of educator, teacher;
Coach; skills provider; facilitator;
• The IBCT therapist uses language as
an important intervention tool,
because impactful language is one
important way to alter a couple’s
relationship context

25. 4. Assessment and Treatment Planning
Cognitive-Behavioral Couple Therapy
(CBCT)
• The primary goals of a clinical assessment are:
• (1) to identify the concerns and potential areas of
enrichment/ growth for which a couple has sought
assistance;
• (2) to clarify the cognitive, behavioral, and affective factors
associated with the two individuals, the couple as a dyad,
and the couple’s environment, that contribute to their
presenting concerns;
• (3) to determine the appropriateness of couple therapy in
addressing these concerns.
• The therapist clarifies partners’ goals for treatment and their
respective positions and perspectives regarding the areas of
concern.
• the therapist determines each partner’s emotional
investment and motivation for continuing with the
relationship.
Integrative behavioral couples therapy
(IBCT)
• A comprehensive and structured assessment
process provides the foundation
• The foundation of any truly behavioral
assessment process is the functional analysis
• With that information,the clinician can then
alter the controlling stimuli and change the
problematic behaviour
• the therapist seeks to understand the
variables that control dissatisfaction, which
are more often broad response classes of
behaviour to see the common thread in
diverse complaints and problems

26. 4. Assessment and Treatment Planning
Cognitive-Behavioral Couple Therapy
(CBCT)
• the focus is on strengths, as well as
problems, the questions posed by the
therapist often draw partners’
attention to the positive aspects of
their relationship.
• Distressed couples entering therapy
often selectively track negative
behaviors and events, so refocusing
on the positive can increase
• common methods are used in self-
report, interview, and observational
approaches to assessment.
Integrative behavioral couples therapy
(IBCT)
• A functional analysis in IBCT emphasizes
not only the broad class of behaviors by
the “agent” that is a source of
dissatisfaction for the recipient but also
the reactions of the recipient partner.
• The primary goal of the functional
analysis is the development of a case
formulation and a resultant treatment
plan.
• the “formulation” comprises three
primary components: the theme, the
polarization process, and the mutual trap.

27. 5. Goal Setting
Cognitive-Behavioral Couple Therapy
(CBCT)
• The therapist also describes behavioral,
cognitive, and affective response patterns
that the assessment has indicated are
contributors to the couple’s relationship
difficulties.
• The therapist asks the partners for
feedback about this case
conceptualization,checking to see
whether it matches their views of their
difficulties.
• The therapist then collaborates with the
couple in translating descriptions of
relationship problems into statements of
positive goals.
Integrative behavioral couples therapy
(IBCT)
• The major treatment goals in IBCT are
to help couples better understand and
accept one another as individuals and
to develop a collaborative set
whereby each partner is willing to
make necessary changes to improve
the quality of the relationship.
• Specific goals for treatment are
determined collaboratively by the
therapist and couple, and are
explicitly discussed during the
feedback session.

28. 5. Goal Setting
Cognitive-Behavioral Couple Therapy
(CBCT)
• The therapist relates these goals to
specific intervention techniques designed
to substitute desired patterns for the
existing ones.
• Explicit goal setting is important
• It is important that the therapist
• caution the partners that it is not unusual
for additional concerns to present
themselves as therapy progresses,
particularly if a pressing problem has
distracted them from noticing other
issues.
• Goals for therapy often evolve over time.
Integrative behavioral couples therapy
(IBCT)
• The formulation is so important that it
forms an overarching goal to get
couples to see their relationship
through the lens of the formulation,
as it relates to their daily struggles and
joys, the therapist helps the couple
process their interactions throughout
the treatment
• Implicit in the goals of understanding,
acceptance, and collaboration is the
acknowledgment that staying
together is not always the right
outcome for all couples

29. 6. Process and Technical Aspects of Couple
Therapy
Cognitive-Behavioral Couple Therapy
(CBCT)
• it is important to recognize that
behavior, cognitions, and
emotions are integrally related.
• Changes in one domain typically
produce changes in the other
domains
Integrative behavioral couples therapy
(IBCT)
• Interventions fall into three
categories: 1. acceptance
strategies, 2. tolerance
strategies, 3. change strategies.
• 1. acceptance strategies:
empathic joining; unified
detachment; these strategies
aim to help couples turn their
problems into vehicles for
greater intimacy.

30. 6. Process and Technical Aspects of Couple
Therapy
Cognitive-Behavioral Couple Therapy
(CBCT)
• Interventions for Modifying
Behavior: Guided Behavior
Change; Skills-Based Interventions;
• Interventions That Address
Cognitions: Socratic Questioning;
Guided Discovery;
• Interventions Focused on
Emotions: Restricted or Minimized
Emotions; Containing the
Experience/Expression
• of Emotions;
Integrative behavioral couples therapy
(IBCT)
• 2. tolerance strategies: allow partners
to let go of their efforts to change one
another. Techniques such as pointing
out the positive features of negative
behavior, practicing negative behavior
in the therapy session, faking negative
behavior between sessions, and self-
care
• 3. change strategies: behavior
exchange techniques and
communication/problem-solving
training
• Acceptance through Empathic Joining

31. 7. Curative Factors
/Mechanisms of Change
Cognitive-Behavioral Couple Therapy
(CBCT)
• different couples might need
different types of intervention,
and mechanisms of change vary
accordingly
• relationship schematic
processing (RSP) refers to the
degree to which an individual
processes information in terms
of circular relationship processes
Integrative behavioral couples therapy
(IBCT)
• all the strategies in IBCT come
from a behavioural theoretical
perspective
• it integrates strategies for
change with strategies for
acceptance.
• IBCT focuses as much on the
recipient of behavior as on the
agent of behavior.

32. 7. Curative Factors/Mechanisms of Change
Cognitive-Behavioral Couple Therapy
(CBCT)
• Therapists who are able to
process information quickly and
respond in the moment are
most effective with this
approach.
Integrative behavioral couples therapy
(IBCT)
• three major reasons for the shift in emphasis in IBCT from the
agent to the recipientof behavior:
• 1. there are in every relationship some “unsolvable”
problems that the agent is unwilling or unable to change to
the level the recipient desires. Improvement in these cases
will be mediated by increased acceptance and tolerance.
• 2. Paradoxically, increased acceptance in one partner may at
times also mediate increased change. The pressure for
change from one partner that contributes to the
maintenance of the undesirable partner behavior. Thus,
when the pressure to change is eliminated by increased
acceptance or tolerance, change may follow. As partners let
go of their efforts to change one another, they become less
emotionally reactive; as a result, change becomes more
likely.
• 3.the reaction to an offending behaviour is as much a
problem as the offending behaviour itself.: “crimes of the
heart are usually misdemeanors”

33. 8. Treatment Applicability and Empirical Support
Cognitive-Behavioral Couple Therapy
(CBCT)
• CBCT is the most widely evaluated
couple treatment
• findings suggest that between roughly
33 and 67% of couples are in the
nondistressed range of marital
satisfaction after receiving CBCT.
• Most couples appear to maintain
these gains for short time periods (6–
12 months); however, long range
follow-up results are not as
encouraging. 30% of couples who had
recovered during therapy
subsequently relapsed
Integrative behavioral couples therapy
(IBCT)
• Improvements in relationship
satisfaction and stability come about
through changes in behavior, and
changes in the emotional reactivity
(acceptance) of that behaviour
• IBCT improved or recovered (80%)
compared to couples treated with
TBCT (64%).
• 69% of IBCT couples demonstrated
clinically significant improvement at
the 2-year follow-up relative to their
initial status

34. Readings
• Core Readings:
• Gurman (2008) :
• Chapter 2. Cognitive- behavioral Couple Therapy by Donald H. Baucom , Norman B.
Epstein, Jaslean J. LaTaillade , and Jennifer S. Kirby.
• Chapter 3: . integrative behavioral Couple Therapy Sona Dimidjian, Christopher R.
Martell, and Andrew Christensen
• Patterson (2005) CBT couple therapy
• Advanced reading:
• Gurman (2008) Chapter 13: integrative Couple Therapy: a depth- behavioral approach
• Mairal & Cela (2015) Integrative Behavioural couple therapy
• Davila (2003) chapter 7 attachment processes in couple therapy: informing behavioural
models found in Johnson and Whiffen (2003).