Lecture 5.

CBT theories, models

and methods of couple
relationships
Couple Counselling Skills
Kevin Standish
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
Overview
1. Phases of Development in CBT couple therapy
2. How CBT for Couples Works
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).
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).
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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
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
1. Background of the Approach

Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy

(CBCT) (IBCT) third-wave behavioral therapies
• developed from the confluence of three • IBCT grew principally from traditional
major influences: behavioural couple therapy (TBCT): skills-
• (1) behavioral couple therapy • based, change-oriented treatment that relies
on two primary intervention components: (1)
• (2) cognitive therapy (CT) behavior exchange, and (2) communication
• (3) information processing in the field of and problem-solving training.
cognitive psychology regarding attributions • problems that represented basic and
that individuals make about determinants of irreconcilable differences between partners
positive and negative events in their appeared to be less amenable to traditional
relationships and relatively stable schemas change strategies.
that individuals develop on the basis of past
relationship experiences and subsequently • the key to a better result was to promote
apply in understanding current relationship emotional acceptance of the other and not
events. emphasize change so much. Jacobson and
Christensen (1998) see acceptance as the
“missing link” in couple intervention.
2. The Healthy/Well-Functioning versus
Pathological/Dysfunctional Couple/Marriage
Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy
(CBCT) (IBCT)
• CBCT employs a broader contextual • Distress is caused by the destructive ways
perspective in defining a healthy that some couples respond to areas of
relationship, difference and disagreement, which are
• A “healthy relationship” is defined as one assumed to be both normal and
in that contributes to the growth and inevitable.
well-being of both partners, in which the • Differences between partners are likely to
partners function well together as a team create difficulties when these differences
and relate to their physical and social spring from vulnerabilities within each
environment in an adaptive fashion partner rather than mere differences in
• A healthy couple relationship is one preference.
thatcontributes to the growth, • Three destructive patterns frequently
development, wellbeing, and needs characterize distressed couples’ conflicts
fulfillment of each partner. over their differences: 1.mutual coercion,
2.vilification, and 3.polarization.
2. The Healthy/Well-Functioning versus
Pathological/Dysfunctional Couple/Marriage
Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy
(CBCT) (IBCT)
• partners in distressed relationships are more
likely to track negative behavior selectively in
• distressed couples experience an
the other, to make negative attributions for erosion in their willingness to
such behavior and to reciprocate negative accept, tolerate, and compromise
behavior with negative behaviour. As partners around one another’s differences,
continue to engage in negative reciprocity they no longer look upon each
and perceive the other in a negative way, they
may develop “sentiment override,” or global other’s styles as sources of
negative emotions, toward each other. This attraction; they begin to exert
sentiment override increases the likelihood of efforts to change their partners
subsequent negative behavior and the
development of partners’ negative • Happy couples are able to confront
expectancies or predictions that the other their differences with greater
person will engage in negative acts. A cycle of
self-maintaining process of relationship acceptance and tolerance.
discord that often typifies distressed couple.
3. The Role of the Therapist

Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy

(CBCT) (IBCT)
• during the assessment and the early stages of therapy, the
therapist assumes a didactic role, striking a balance between • IBCT therapist is frequently very active
directiveness and collaboration with the couple in setting and directive in sessions, the
goals and applying cognitive-behavioural strategies toward
achieving them. particular form of the therapist’s
• Once treatment begins, the therapist at times assumes a interventions will vary
didactic role and provides rationales for treatment
recommendations and the assignment of homework; • therapist requires comfort with a high
• reviews assignments and events that occurred in the degree of flexibility and change
relationship during the past week;
• models skills and coaches the partners in practicing them in
• the highest priority for the IBCT
and outside of sessions; and continually fosters partners’ therapist is maintaining a focus on the
motivation. case formulation of the couple
• 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
• therapist is to attend to and highlight
preference for structure in therapy the function of behaviors.
3. The Role of the Therapist
Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy
(CBCT) (IBCT)
• the CBCT therapist also sets the pace of sessions, so that the
goals of treatment are addressed in a timely and reasonable • Using this historical context, the
fashion. therapist suggests that these
• In collaboration with the couple, the therapist typically
initiates setting the agenda for each session, contributing
histories have occasioned the
particular agenda items such as review of homework and current behaviors and associated
practice of a particular skill, always soliciting the couple’s
preferences for the agenda. feelings
• The therapist then monitors the use of time during the
session and ensures that the agenda is followed to the • Multiple roles of educator, teacher;
degree appropriate Coach; skills provider; facilitator;
• The therapist also adopts the role of facilitator, creating a
safe and supportive environment in which the couple can • The IBCT therapist uses language as
address difficult issues.
an important intervention tool,
• it is important the therapist’s direction and imposition of because impactful language is one
structure gradually diminish over time, as the partners
assume increasing responsibility for managing their
concerns.
important way to alter a couple’s
relationship context
4. Assessment and Treatment Planning

Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy

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

Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy

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

Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy

(CBCT) (IBCT)
• The therapist also describes behavioral, • The major treatment goals in IBCT are
cognitive, and affective response patterns to help couples better understand and
that the assessment has indicated are accept one another as individuals and
contributors to the couple’s relationship to develop a collaborative set
difficulties. whereby each partner is willing to
• The therapist asks the partners for make necessary changes to improve
feedback about this case the quality of the relationship.
conceptualization,checking to see
whether it matches their views of their • Specific goals for treatment are
difficulties. determined collaboratively by the
therapist and couple, and are
• The therapist then collaborates with the explicitly discussed during the
couple in translating descriptions of feedback session.
relationship problems into statements of
positive goals.
5. Goal Setting
Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy
(CBCT) (IBCT)
• The therapist relates these goals to • The formulation is so important that it
specific intervention techniques designed forms an overarching goal to get
to substitute desired patterns for the couples to see their relationship
existing ones. through the lens of the formulation,
• Explicit goal setting is important as it relates to their daily struggles and
• It is important that the therapist joys, the therapist helps the couple
process their interactions throughout
• caution the partners that it is not unusual the treatment
for additional concerns to present
themselves as therapy progresses, • Implicit in the goals of understanding,
particularly if a pressing problem has acceptance, and collaboration is the
distracted them from noticing other acknowledgment that staying
issues. together is not always the right
• Goals for therapy often evolve over time. outcome for all couples
6. Process and Technical Aspects of Couple
Therapy
Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy
(CBCT) (IBCT)
• it is important to recognize that • Interventions fall into three
behavior, cognitions, and categories: 1. acceptance
emotions are integrally related. strategies, 2. tolerance
strategies, 3. change strategies.
• Changes in one domain typically
• 1. acceptance strategies:
produce changes in the other empathic joining; unified
domains detachment; these strategies
aim to help couples turn their
problems into vehicles for
greater intimacy.
6. Process and Technical Aspects of Couple
Therapy
Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy
(CBCT) (IBCT)
• Interventions for Modifying • 2. tolerance strategies: allow partners
Behavior: Guided Behavior to let go of their efforts to change one
Change; Skills-Based Interventions; another. Techniques such as pointing
out the positive features of negative
• Interventions That Address behavior, practicing negative behavior
Cognitions: Socratic Questioning; in the therapy session, faking negative
Guided Discovery; behavior between sessions, and self-
• Interventions Focused on care
Emotions: Restricted or Minimized • 3. change strategies: behavior
Emotions; Containing the exchange techniques and
Experience/Expression communication/problem-solving
training
• of Emotions; • Acceptance through Empathic Joining
7. Curative Factors
/Mechanisms of Change
Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy
(CBCT) (IBCT)
• different couples might need • all the strategies in IBCT come
different types of intervention, from a behavioural theoretical
and mechanisms of change vary perspective
accordingly • it integrates strategies for
change with strategies for
• relationship schematic acceptance.
processing (RSP) refers to the
degree to which an individual • IBCT focuses as much on the
recipient of behavior as on the
processes information in terms agent of behavior.
of circular relationship processes
7. Curative Factors/Mechanisms of Change

Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy

(CBCT) (IBCT)
• three major reasons for the shift in emphasis in IBCT from the
• Therapists who are able to agent to the recipientof behavior:
• 1. there are in every relationship some “unsolvable”
process information quickly and problems that the agent is unwilling or unable to change to
the level the recipient desires. Improvement in these cases
respond in the moment are will be mediated by increased acceptance and tolerance.
• 2. Paradoxically, increased acceptance in one partner may at
most effective with this times also mediate increased change. The pressure for
change from one partner that contributes to the
approach. 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”
8. Treatment Applicability and Empirical Support

Cognitive-Behavioral Couple Therapy Integrative behavioral couples therapy

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