ChapterPDF Available
TOP 1%
Selection of our books indexed in the
Book Citation Index in We b of Science ™
Co re Collection (BKCI)
Chapter fr om the boo k
Cog nitive Be havioral Ther apy and Clinical Applications
Downloade d fro m: ks /co gnitive-behavioral-therapy-
World's largest Science,
Technology & Medicine
Open Access book publisher
Interested in publishing with IntechOpen?
Contact us at book.dep artment@intechope
Chapter 7
Cognitive-Behavioral Psychotherapy for Couples: An
Insight into the Treatment of Couple Hardships and
Caroline Dugal, Gaëlle Bakhos, Claude Bélanger and
Natacha Godbout
Additional information is available at the end of the chapter
Provisional chapter
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is properly cited.
DOI: 10.5772/intechopen.72104
Cognitive-Behavioral Psychotherapy for Couples: An
Insight into the Treatment of Couple Hardships and
CarolineDugal, GaëlleBakhos, ClaudeBélanger and
Additional information is available at the end of the chapter
In this chapter, a comprehensive literature review of the theoretical underpinnings and
clinical practices of cognitive-behavioral couple therapy (CBCT) will be presented. First, a
description of the theory underlying CBCT and the role of the therapist will be reviewed.
Dierent mandates and motives for couples to consult in CBCT will then be described,
with aention given to specicities for diverse populations. The assessment process and
main intervention techniques used by CBCT therapists will be presented, including com-
munication training, problem and conict resolution, cognitive restructuring, identica-
tion and expression of emotions, expression of aection and sexual problems as well as
acceptance and tolerance of dierences. The chapter will conclude with a critical analysis
of CBCT and suggestions for future clinical developments.
Keywords: cognitive-behavioral couple therapy, assessment, intervention, couple
distress, couple adjustment
1. Introduction
Intimate relationships are of great signicance for most adults and highly impact overall well-
being and health [1, 2]. Indeed, satisfying intimate relationships can provide happiness, social
support as well as buer the repercussions of numerous stressors [2–4]. However, when these
relationships are characterized by signicant distress, destructive conicts or general dissat-
isfaction with the relationship, they can also lead to deleterious consequences to physical and
psychological health [1] as well as great suering [2].
© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Cognitive-behavioral couple therapy (CBCT) aims at assisting romantic partners who report
distress in their relationship. Over the years, CBCT has been extensively evaluated in treat-
ment outcome studies, which have repeatedly concluded in its eectiveness for decreasing
couple distress and dissatisfaction as well as for addressing communication or problem-solv-
ing diculties [5–7]. Studies have also found that such improvements seem to be maintained
for up to 2 years by most couples [8].
In this chapter, a comprehensive literature review of the theoretical underpinnings and
clinical practices of CBCT will be presented. First, a description of the theory underlying
CBCT and the role of CBCT therapists will be oered. Possible mandates and motives for
consulting in CBCT will then be described, with particular aention to the specicities in
CBCT for diverse populations. The assessment process used in CBCT will also be addressed,
allowing readers to understand the particularities of psychotherapeutic work with couples.
Subsequently, the main intervention techniques used in CBCT will be dened: communi-
cation training, problem and conict resolution, cognitive restructuring, identication and
expression of emotions, expression of aection and sexual problems as well as acceptance
and tolerance of dierences. The chapter will conclude with a critical analysis of CBCT and
suggestions for future clinical developments.
2. A brief history of the theoretical underpinnings and objectives of
The origins of CBCT stem mainly from Stuart’s [9] work on behavioral exchanges between
partners. He based his analysis of couple interactions on learning principles [10] and social
exchange theory [11], postulating that individuals’ evaluation of their relationships would
depend on the ratio of benets to costs, resulting from positive and negative exchanges with
others. Stuart [9] thus proposed a behavioral exchanges paradigm where successful relation-
ships could be dierentiated from dysfunctional ones by the frequency of positive and nega-
tive behavioral exchanges. Positive behaviors include constructive problem solving as well as
empathically expressing and listening to each other, whereas negative behaviors refer to the
expression of criticism, hostility, contempt or withdrawal from interactions with the partner.
Early behavioral couple therapies [12, 13] focused primarily on behavior changes and the
acquisition of skills aimed at increasing the frequency of positive behaviors and reducing
aversive behavioral interactions through the development of eective communication and
problem-solving strategies [14].
During the last decades, behavioral couple therapy expanded by including interventions that
also addressed emotions and cognitions contributing to conicts and dissatisfaction. This was
achieved by highlighting the importance of aributions, dysfunctional beliefs and distorted
cognitions in romantic partners’ evaluation of their relationship [15]. For instance, by selec-
tively aending to specic behaviors or characteristics in the partner or by approaching the
partner with expectations or standards about how he or she should be or act, individuals will
Cognitive Behavioral Therapy and Clinical Applications118
see variations in their appreciation of their partner and of their relationship. Cognitions also
depict the way partners process information originating from the others’ behaviors, which
guide their interpretation of events as well as expectations towards the other and the relation-
ship [15].
Work from Jacobson and Christensen [16] increased focus on acceptance strategies as a
way to help partners recognize that they are dierent and eventually learn to respond con-
structively to diculties or incompatibilities within the relationship. In 2002, Epstein and
Baucom further enhanced CBCT by including work on partners’ needs for intimacy and
increased aention to emotions, not only as a result of modications in the dysfunctional
behaviors but also as a primary target of therapy. According to these authors, emotions
can signicantly impact relationships through various means: in their expression, through
their impact on the interpretations (cognitions) made as well as by aecting behaviors
expressed towards the other. Epstein and Baucom [17] also emphasized the importance
of considering partners’ vulnerabilities and the impact of the couple’s environment as
part of the multiple factors that can alter partners’ cognitions, emotional responses and
A specicity of CBCT lies in its dynamic understanding that cognitions can inuence inti-
mate relationships through each partner’s interpretations or appraisals of stressors and of
their partner’s behaviors [3]. Moreover, the interpretations partners make about the behav-
iors of the other will determine the positive and negative emotions experienced towards the
other. As shown in Figure 1, these emotions are considered to inuence future cognitions and
behaviors [14]. As such, in CBCT, behaviors, cognitions and emotions are observed as inter-
related and equally important in relationship functioning [18].
In summary, the main objective of CBCT is to help couples understand their diculties in
order to enhance their relational well-being by identifying and challenging the processes at
play in partners’ interactions while taking into account the external factors that can aect
them. To do so, CBCT not only relies on behavioral interventions in the treatment of couple
diculties, but also emphasizes the importance of working on various cognitive, emotional
and environmental factors that aect a couple’s functioning [18]. CBCT interventions also
aim at helping couples identify, regulate and express intense or negative emotions when they
arise in and out of sessions. By doing so, CBCT therapists help couples develop their ability
to observe and change their automatic thoughts, assumptions and standards as well as iden-
tify the impact that their ways of behaving, thinking, interpreting and feeling have on their
relationship [3].
Figure 1. Interrelations of behaviors, cognitions and emotions in cognitive-behavioral couple therapy.
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
3. The role of CBCT therapists
CBCT therapists hold dierent roles that will vary depending on the stage of therapy and
the needs of clients [19]. For instance, during the rst sessions of CBCT, the therapist typi-
cally uses psychoeducation to inform clients about the approach and related intervention
and acts as a facilitator by creating a safe and supporting environment where emotions
or concerns may be expressed freely. He/she will also act as a collaborator to develop the
treatment goals. However, a more directive approach will also be used by CBCT thera-
pists to address dysfunctional interactions or the escalation of conicts in order to create
and preserve a safe environment for therapy and help partners understand what is going
on and learn new ways of dealing with their disagreements [20]. A directive approach
might also be needed to deal with crisis interventions (see Section 4.4). Throughout ses-
sions, CBCT therapists can also take a more didactic role, for instance, when they teach
communication and problem-solving skills for couples [12]. They will also act as guides
when they help partners identify the interrelations between their cognitions, emotions and
behaviors [17].
In CBCT, the therapist undertakes the responsibility of establishing and maintaining the
therapeutic alliance with both partners [19]. In order to lay the foundations for a healthy
therapeutic alliance, the therapist is thus expected to swiftly orchestrate sessions by fairly
allocating speaking time for each partner to express themselves [20], while demonstrat-
ing neutrality and empathy [21]. If situations occur in which therapists feel unable to
remain neutral towards a couple and if it significantly hampers their ability to help part-
ners, they should seek supervision. Special consideration must also be given to the man-
agement of secrets between one partner and the therapist, for instance, in cases when
an ongoing extradyadic affair is admitted by a partner during the individual session of
assessment (see Section 5.2 for the phases of the assessment interviews). In such situa-
tions, it is advised that the therapist takes a neutral position by explaining to partners
that he/she cannot engage in therapy while withholding information that would affect
the process of therapy or bring he/she in collusion with one of the partners against the
other [20].
4. Possible mandates and motives for consultation in CBCT
The rst step a CBCT therapist undertakes is to question partners’ objectives and expectations
with regards to therapy. Poitras-Wright and St-Père [22] have proposed three main thera-
peutic mandates in couple therapy: alleviation of distress, ambivalence resolution and sepa-
ration intervention. According to Tremblay and colleagues [23], therapeutic mandates can
also be reliably classied and revised during the course of treatment to take into account the
specic needs of couples which may change over time. The following sections describe how
these dierent mandates are conducted in CBCT, with an additional section allocated to crisis
Cognitive Behavioral Therapy and Clinical Applications120
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
4.1.2. Indelity/extradyadic aairs
Indelity is a relational problem that many who consult in couple therapy might eventu-
ally face [39]. Indeed, studies have shown that from 20 to 40% of couples will experience
indelity at least once [40] and 20–57% of men and 14–32% of women will report having
had an extradyadic aair at least once in their life [41–43]. According to therapists, indelity
represents one of the most prevalent and dicult problems to treat in couple therapy [44,
45]. This is mainly due to the feelings of betrayal and relationship distress that commonly
result from extradyadic aairs [46, 47]. This problem is also particularly dicult to address in
treatment because it frequently puts partners in a situation where they question their desire
to continue their relationship [48, 49]. This being said, many studies have concluded in the
eectiveness of CBCT in the treatment of extradyadic aairs in terms of decreased psycho-
logical symptoms of depression and relationship distress [40, 50, 51]. Since CBCT commonly
addresses indelity as a form of interpersonal trauma experienced within the intimate rela-
tionship [52], interventions for this problem generally aim at dealing with the crisis following
disclosure of the extradyadic aair and at the exploration of factors that might have con-
tributed to the aair. This will be accomplished by giving the extradyadic aair a meaning
[17, 52]. Since this type of couple diculty tends to take place when the needs of a partner are
not fullled in the current relationship [46–48], forgiveness-based interventions can also be
used to help partners beer understand the circumstances in which indelity has taken place
and repair the relationship. Partners will then learn how to “reconnect” after having been hurt
by the other, to “turn the page” and to move forward [52].
4.1.3. Infertility
According to Sullivan et al. [53], the number of couples who encounter fertility problems is grow-
ing, with an average of 10–15% of couples experienced fertility issues. Importantly, for many
couples, infertility constitutes a major crisis, and even a signicant traumatic event that has
important repercussions on partners’ individual and relational well-being [54]. Indeed, infertility
as well as the many consequences related to its treatment, such as its cost, its time requirements
and the uncertainty of its results [53, 54], can lead to psychological consequences, especially high
levels of stress [55], depression, low self-esteem, marital and life dissatisfaction [56, 57], sadness
and denial [54] as well as feelings of guilt [54]. Some interventions using CBCT techniques have
been developed to treat this problem [53, 58] and aim at facilitating disclosure and communica-
tion between partners, exploring the meaning and nature of grief (e.g., when partners learn they
cannot have children), enhancing the couple’s ability to understand and support each other and
developing useful strategies for stress reduction and problem solving related to infertility.
4.1.4. Individual problems
In general, studies have demonstrated that couple-based therapies are eective across a wide
range of individual problems and disorders that not only address an individual’s psychologi-
cal functioning but also his or her partner’s relationship satisfaction. Consequently, CBCT has
also been customized to treat a plethora of individual diculties [19]. This approach argues
Cognitive Behavioral Therapy and Clinical Applications122
that by including the partner in the treatment of an individual’s diculties, the laer will ben-
et from support from his or her partner, which in turn will enhance the couple’s functioning
and alleviate personal diculties [18, 59]. Alcohol use disorder is an example of an individual
problem that is widely recognized as exerting a devastating eect on couple functioning and
satisfaction [60, 61]. Indeed, adults with an alcohol use disorder are four times more at risk
of separation and divorce than those who do not present such problems [62]. The perceived
quality of the romantic relationship is also known to modulate the eect of substance use
on couple functioning, so that satised couples experience less distress caused by substance
abuse than dissatised couples [63]. Interestingly, support was found for the use of CBCT to
reduce alcohol and drug use disorders as well as increase relationship satisfaction [64, 65]. For
instance, CBCT for alcohol use disorder, which draws upon cognitive-behavioral methods
for the treatment of alcohol use disorders [66] and behavioral couple therapy [67], simultane-
ously aims at decreasing alcohol use and increasing relationship stability and satisfaction [62].
The underlying assumption of this therapy is that drinking behaviors might be intertwined
with the ability to cope with negative couple interactions. As such, by learning new ways to
interact with the partner and by staying abstinent, partners are beer able to cope with rela-
tionship distress [62].
Mood disorders, particularly depression, are also known to have a bidirectional associa-
tion with couple functioning [68], with lower relationship quality leading to higher depres-
sive symptoms and higher depressive symptoms generating lower relationship quality [69].
As such, when depressive symptoms act as risk factors or follow relationship diculties,
couple therapy for depression has been shown to be eective in reducing depressive symp-
toms and relationship problems [70]. This therapy aims at enhancing positive interactions
between partners and diminishing negative interactions as well as improving communication
and problem-solving abilities [71]. Couple-based interventions have also shown encourag-
ing results for the co-occurring treatment of couple distress and bipolar disorder [72], emo-
tion dysregulation [73], post-traumatic stress disorder [74, 75], obsessive-compulsive disorder
[76], anxiety disorders [77] as well as anorexia nervosa [78].
4.2. Ambivalence resolution mandate
Sometimes, couples consult in therapy because one or both partners are unsure whether to
end the relationship [79]. Drawing from their empirical results, Boisvert and colleagues [25]
highlighted that one out of four couples consulting in therapy tend to report such ambiva-
lence. In these situations, CBCT therapists usually suggest an ambivalence resolution man-
date in order to help couples take a decision on the future of their relationship [80]. Yet, this
mandate is not much addressed in the CBCT literature. Among the few authors oering
clinical guidelines on this topic, Wright and colleagues [14] propose to include the explora-
tion of emotions, beliefs and expectations of each partner regarding the continuation of the
relationship, while puing any harsh decisions or behaviors about the relationship on hold
until a nal decision is reached by both partners. The therapist then helps partners dene a
new therapeutic mandate based on their decision, whether it is relationship improvement or
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
4.3. Separation mandate
Whether it results from a decision taken within the course of treatment or whether it is for-
mulated as a primary therapeutic objective, a separation mandate can be put forward to help
partners accept and deal with separation [81]. Indeed, albeit dicult, separation can generate
alleviation of distress in certain couples [79]. According to Lebow [82], the CBCT techniques
used in therapy with a separation mandate usually include psychoeducation on how to deal
with the consequences of the separation as well as feelings towards one another after the sepa-
ration. Problem-solving techniques and communication training are also often conducted in
session to alleviate the possible consequences of the separation for couples with a separation
mandate in CBCT.
4.4. Crisis intervention
Although crisis intervention is not a therapeutic mandate per se, it can be required prior to
CBCT, for instance, when a partner expresses severe personal diculties (e.g. manifests a
suicidal or homicidal risk), discovers the other has been unfaithful or when severe violence
occurs within a relationship. It is thus necessary for therapists to be able to identify, assess and
deal with such situations in order to help the couple regain stability and security before con-
ducting any other intervention. To do so, Wright and colleagues [14] have developed guide-
lines for couple therapists. The rst action to be performed is to ensure the safety of each
partner, and by extension of their children, if applicable. When a suicidal and/or homicidal
risk is present, the same guidelines used in individual psychotherapy are applicable in CBCT
with a particular aention given to the safety of both partners. The therapist must then assess
whether couple therapy should be continued or if individual therapy with a dierent thera-
pist would be beer suited to address these diculties before starting or resuming CBCT [68,
77]. If ongoing severe violence occurs within a relationship and especially when it is perpe-
trated by one partner towards the other, rather than minor and bidirectional (see the Section
4.1.1 on conicts and violence), couple therapy is usually contraindicated and specic proce-
dures must be undertaken to control aggressive behaviors and protect the victim. Guidelines
for such situations have been suggested by Lussier and colleagues [32, 36] and by Bélanger
and colleagues [33]. After safety has been ensured and the crisis has started to resolve, the
therapist can help couples make sense of this experience and feel validated in their distress,
which can potentially strengthen the therapeutic alliance. Only then does the therapist and
partners discuss new therapeutic goals if partners decide to remain in therapy.
4.5. Specicities in CBCT for diverse populations
As of now, there are clinical and research drawbacks regarding how CBCT can be eectively
oered to couples who present specicities that can aect how they experience intimate rela-
tionships, such as same-sex or intercultural couples [18, 83]. For instance, in the past decade,
the number of intercultural couples has increased in North America [84, 85] but these couples
remain understudied [85]. In addition, even if couples from dierent cultural backgrounds
usually experience the same kind of issues than other couples [86, 87], they may also face
unique challenges that require specic aention in CBCT. Indeed, studies have reported that
Cognitive Behavioral Therapy and Clinical Applications124
intercultural couples will experience greater diculties with communication, marital satisfac-
tion and divorce [88, 89]. As such, intercultural couples might need more negotiation skills
than others to deal with couple issues (e.g., discussing the language(s) spoken at home, reli-
gion and rituals that will be practiced by the children, etc.). Furthermore, parenting and dis-
ciplinary styles often involve debates in intercultural couples [85]. Exploring and negotiating
the couples’ cultural dierences could thus potentially foster intimacy between partners and
promote a sense of mutual understanding [90].
Due to widespread heterosexist standards, many lesbian, gay and bisexual couples experience
prejudice, rejection, discrimination and lack of social support, which can signicantly impede
couple satisfaction and functioning [83, 91]. However, research has shown that, in general,
same-sex and bisexual couples show more similarities than dissimilarities when compared to
heterosexual couples [92] and tend to seek couple therapy for similar reasons [93, 94]. Indeed,
most CBCT interventions, such as cognitive restructuring, role playing, assertiveness train-
ing, psychoeducation, decision making and negotiation, are used similarly with same-sex,
bisexual or heterosexual couples [23]. Communication and problem-solving training can also
be of signicant importance for certain same-sex or bisexual couples who struggle with inter-
nalized homophobia (i.e., refers to negative stereotypes, hate, stigma and prejudice about
homosexuality or bisexuality that a person with same-sex araction turns inward on him/her-
self), issues regarding disclosure of sexual orientation, conicts related to relationships or the
division of household work and parenting diculties (for a review, see [83]). Yet, many thera-
pists report diculties comprehending the unique situations in which same-sex or bisexual
partners live [95] or report a lack of condence about how to intervene with same-sex and
bisexual couples. In addition, many therapists have few opportunities to develop their psy-
chotherapeutic expertise with patients from sexual minorities given that the majority of their
clients are heterosexual [96]. Therapists must therefore possess a good understanding of the
challenges faced by these couples as well as the ability to have a non-discriminatory aitude
in order to help their patients overcome prejudice in and out of their relationship [23]. To do
so, couple therapists who decide to work with same-sex and bisexual couples should aim at
receiving specic training or supervision to further understand and help these populations.
5. Assessment in CBCT
Before conducting CBCT, the couple therapist must inquire on the partners’ expectations
about therapy, evaluate the level of functioning or distress of the couple as well as the part-
ners’ motivation for staying together and in engaging in a therapeutic process [22]. By doing
so, the therapist can determine the form of assistance that can be oered and tailor a treatment
that will be most benecial for both partners [2]. The main objective of assessment is to for-
mulate a case conceptualization of the couple. This is accomplished by dening the concerns
for which partners have sought assistance, identifying the individual, dyadic and environ-
mental factors at play in the diculties reported as well as by discerning the couple’s existing
strengths that might potentially facilitate the therapeutic process [97]. Therapists also aim at
understanding both partners’ respective goals in therapy and perspectives with regards to the
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
concerns they report in order to assess their level of commitment in their relationship and in
therapy. By doing so, the therapist will be able to determine the appropriateness of CBCT for
the clients or propose an alternate course of action. For instance, the therapist might recom-
mend that one or both partners should rst follow an individual therapy [17, 19]. Assessment
can also continue throughout sessions: as partners become more comfortable or familiar with
the therapist, they may reveal more about themselves as individuals and as partners, which
allows the therapist to get a more precise understanding of the couple’s relational dynamics
and, if applicable, to rene the therapeutic objectives and strategies [97].
5.1. Assessment methods
In the assessment phase of CBCT, the therapist gathers information from dierent sources
in order to understand a couple’s functioning. This multi-method approach is highly recom-
mended as it allows the therapist to draw a beer portrait of a couple’s functioning and concerns.
5.1.1. Clinical interviews
Throughout evaluation sessions with a couple, the therapist collects information on both
partners by means of semi-structured clinical interviews. Clinical interviewing includes
therapists’ inquiry of the couple’s history and environment, as well as of the partners’ indi-
vidual functioning and backgrounds [19], which will be further explained in Section 5.2 on
the phases of assessment interviews. Clinical interviews also allow CBCT therapists to ques-
tion partners’ reactions, emotions and cognitions as they occur in session or when couples are
asked to describe their concerns [98].
5.1.2. Self-report measures
The use of self-report questionnaires is highly valuable in CBCT as an adjunct to clinical inter-
view. It can help therapists have access to information that may otherwise remain unknown.
The use of self-report measures constitutes a fast and aordable way to assess numerous
constructs [99], and it can also grant access to information that might not be disclosed dur-
ing sessions [100, 101]. Depending on the problems reported by the consulting couple,
self-report questionnaires that may be used in the assessment phase of CBCT can evalu-
ate couple satisfaction and adjustment (e.g., Dyadic Adjustment Scale: [102]), partners’ cog-
nitions (e.g., Inventory of Specic Relationship Standards: [103]), communication paerns
(e.g., Communication Paerns Questionnaire: [104–106]), sexual satisfaction (e.g., the Global
Measure of Sexual Satisfaction Scale: [107]), dyadic coping (e.g., Dyadic Coping Inventory:
[108]) and support (e.g., Romantic Support Questionnaire: [109]), as well as psychological
symptoms (e.g., Psychiatric Symptom Index: [110]) and levels of violence exhibited by each
partner towards the other (e.g., Revised Conict Tactics Scales: [111]; Coercive Control Scale:
[112]). The measurement of aachment (e.g., Experiences in Close Relationships: [113]) can
also signicantly help therapists understand the internal representations of self and other
their patients hold in romantic relationships. Finally, considering the high prevalence of
childhood trauma in the clinical population, especially consulting for sexual or relational
problems (up to 95% [114]), the lack of spontaneous self-report, and given the direct and
Cognitive Behavioral Therapy and Clinical Applications126
indirect inuence of such trauma on couple functioning [114–116], it is also central to sys-
tematically assess adverse childhood experiences (e.g., Childhood Cumulative Trauma
Questionnaire [117]) as part of the standard assessment of couples.
5.1.3. Direct behavioral observation
In CBCT, special aention is also given to the couple’s interactions, as they take place during
sessions. As such, therapists observe how partners behave towards one another in a problem-
solving task. They can take note of the positive and negative behaviors that partners initiate,
for instance, with criticism or support when the other speaks [17]. Baucom and colleagues [19]
also emphasize the importance of creating tasks or exercises during the assessment phase that
will encourage partners to interact in order to allow therapists to beer assess the couples’
interactions. Couples can thus be asked to discuss a specic concern or problem they report
currently having, to share their thoughts on a specic maer as well as try to engage in a
decision-making discussion.
5.2. Phases of the assessment interviews
The assessment phase of CBCT is typically formed of three parts: one or two couple sessions
in which both partners are present and one individual session with each partner followed by
a feedback session for the couple. During the rst couple session, the therapist presents his
or her qualications, theoretical orientation as well as the objectives and structure of CBCT
[17]. During this session, the therapist also informs partners that all information gathered
during individual sessions aims to help design a well-tailored couple intervention so may be
discussed during the following couple sessions. The therapist informs the patients that this is
a couple therapy process where he/she would not be forced to keep a secret from one partner
during treatment [118]. The therapist then collects information on the couple’s concerns for
which they seek therapy. Assessing each partner’s goals is primordial in clinical interview-
ing since they can be quite dissimilar, for instance, when one partner wants to improve the
relationship and the other rather wishes a separation [19]. The therapist then inquires on the
couple’s relationship history in order to beer understand how the relationship has evolved
over time. He/she will ask questions on the beginning of the relationship, for instance, by
inquiring on the duration of the relationship, on how partners met and what aracted them
to one another [118]. The therapist also typically asks partners to describe past hardships or
signicant events that they have experienced and that might have aected them as a couple
and to relate the ways they adapted or the resources they used to overcome them [98]. Finally,
assessment of the couple’s physical and social environments that are likely to contribute to
the couple’s problems [19] and evaluation of the couple’s sexual functioning [119] are also
conducted during the rst evaluation session.
The therapist will then meet with each partner separately in order to gather information
on their personal history as well as their current psychological and social functioning. The
therapist will therefore inquire on each partners’ developmental or family history, anterior
romantic relationships, medical or psychological health, substance use, possible stressful or
traumatic events, academic or professional functioning and how all these factors aect, or not,
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
their current relationship and perception of their partner [20]. During these individual ses-
sions, specic aention will be given to potential subjects that might not have been explored
during couple sessions, such as sexual diculties, extradyadic aairs or the presence of part-
ner violence [17, 19]. Indeed, potential partner violence, its severity and frequency must be
explicitly inquired with both partners, as well as the level of safety victimized partners feel
while living with the other [36].
After both partners’ individual sessions, the couple and the therapist meet for another session
during which the therapist will oer feedback using a cognitive-behavioral formulation of
the couple’s functioning and the factors that aect it, namely how each partner’s cognitions,
emotions and behaviors inuence one another and aect couple interactions [118, 120]. The
therapist also uses the feedback session to present his or her interpretation of the causes of
the couple’s concerns and to highlight the positive aspects that partners have expressed about
their relationship [20]. The therapist then sets the treatment mandates and goals in collabora-
tion with the couple and proposes a treatment plan [19].
6. Intervention techniques commonly used in CBCT
The following section describes the most common intervention techniques used in CBCT. These
strategies include the development of communication, problem-solving and conict resolu-
tion skills, cognitive restructuring, the improvement of the identication and expression of
emotions, the improvement of the expression of aection and sensuality between partners as
well as enhancement of sexual functioning and the development of acceptation and tolerance
of dierences and incompatibilities.
6.1. Communication training
Communication training is a central feature of CBCT and aims to enhance the way in which
partners learn to express and listen, without criticism or aack. Interestingly, this type of inter-
vention has demonstrated observable short-term changes, even in highly distressed couples
[14, 17]. In order to lead communication training in CBCT, therapists must learn to recognize
and identify dysfunctional behaviors expressed by either partner during sessions, as well as
identify the emotions and beliefs that underlie such interactions in order to help couples develop
more appropriate and functional dialogs [120]. In order to do so, the therapist rst helps the
couple identify a topic of conversation that is problematic, but does not involve overwhelm-
ing emotions [14]. Then, partners are successively assigned the roles of speaker and listener.
The speaker is guided in expressing his or her subjective experiences and feelings within the
relationship. The listener is directed in demonstrating openness, non-judgment and to respond
with empathy and respect through the use of non-verbal demonstrations, reections and sum-
maries in order to help the speaker further describe his or her feelings and thoughts and feel
listened to while doing so [121]. During this exercise, the therapist’s role consists of reinforcing
partners eorts, providing partners with constructive comments or suggestions and model-
ing certain speaker or listener behaviors in order to help partners’ perfect communication and
Cognitive Behavioral Therapy and Clinical Applications128
listening techniques [98, 121]. However, in cases where partners bicker during the session, the
therapist must quickly take control of the situation and ask them about what did they feel and
perceive that triggered the dysfunctional interaction [14]. Following is an example of how a
communication training exercise can take place in CBCT.
Melanie and Ethan are new parents and have decided to consult in CBCT in order to deal with feelings
of dissatisfaction resulting from diculties they experience in adapting to their new life as parents.
During a session, Melanie and Ethan mention a situation they have experienced which disappointed
them both.
Therapist: I think this situation is a good example we could use to practice the communication skills
you have learned last session, don’t you think? Remember, when you are the speaker, you must express
your subjective experience, by using “I”, and focus on your feelings and perceptions. When you are
the listener, you must demonstrate openness and respond with reections and summaries about your
partner’s experience. (Both partner express they do remember). Who would like to begin?
Melanie: I’ll start.
Therapist: Ok, I would like you to take the role of the speaker for now and Ethan, that you take the role
of the listener. We will then exchange roles ok?
Melanie: Ethan, I was hurt last Sunday when you came home late from your hockey game without
telling me beforehand because I felt you did not care about us.
Ethan: You are saying that you were hurt because I came home late without telling you and you felt as
if I did not care about you and Lily.
Melanie: Yes, exactly. I wish you would also tell me when you plan on being late, so that I would not
feel hurt like last Sunday.
Therapist: Melanie, could you rephrase it so it will not be a request; at this point try to focus on what
you felt or thought during this event.
Melanie: Ok. When you do not tell me when you are going to be late, I feel that Lily and I are not your
priorities, and that I am not important to you. This is how I felt last Sunday.
Ethan: So you are saying you don’t want me to play hockey on Sundays because you feel hurt, correct?
Therapist: Ethan, try to stay focused on what Melanie said; Melanie, is it what you said?
Melanie: No, not exactly. I am not saying I don’t want Ethan to play hockey.
Therapist: Tell Ethan….
Melanie: (Looking at Ethan) In fact Ethan I know that it is important for you. But if you would tell
me when you plan on coming home late after the game, I would not feel hurt or not important like I
did Sunday.
Ethan: So if I hear you well, you would like me to call you when I plan on staying longer for a lunch
after the game, so that you won’t feel as if I do not care about you and Lily.
Melanie: Yes, that’s it.
Therapist: Perfect, now Ethan, would you like to continue as the speaker and Melanie, as the listener?
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
6.2. Problem and conict resolution
In CBCT, ve strategies are commonly used to help couples develop problem-solving skills
[17, 98, 121]. First, partners must dene and identify one problem on which they want to
work. Second, the therapist helps partners understand the meaning this problem holds for
them by dening each partners’ underlying needs. Third, partners are asked to suggest as
many solutions they can think of, using brainstorming, which is known to increase feelings
of interest, appreciation and consideration in the relationship as well as being particularly
useful in case of serious conict or strict paerns of interactions. Fourth, partners are asked to
select a solution together that will allow to fulll both partners’ wishes, although it is possible
they will not be equally satised. The fth and last step involves a trial period that will take
place between sessions. A feedback discussion is then held during the following session and,
if partners feel unhappy during with the chosen solution, a new solution may be chosen with
the therapist.
Similar steps as those used in problem-solving can also be used in CBCT to help couples
learn how to resolve conicts [28]. Yet, as conicts can sometimes involve strong negative
emotions, particular aention must be given to the expression of emotions and needs and the
exploration of the meaning of the conict by partners during these exercises [14]. In addition
to guiding couples in acquiring these techniques, the therapist also holds the responsibility
of observing conictual interactions that arise in session, for instance, if partners aack or
withdraw from an interaction, in order to provide feedback as to the impacts each partners’
behavior exert on the other. This will allow the therapist to highlight and challenge the cogni-
tions and emotions that underlie or contribute to these dysfunctional interactions with the
intention of decreasing their recurrence [17]. The following case describes how these strate-
gies can be used.
Thomas and Sandra have sought couple therapy due to constant bickering and frustration resulting
from problems they have diculty resolving together. Sandra blames Thomas for the amount of time he
spends at work, especially since he has been working on weekends. Thomas gets home late, is often too
tired to engage with his partner and goes to bed shortly thereafter. Thomas admits to being exhausted
and criticizes Sandra for constant complaints about nancial maers.
Therapist: Sandra, why do you want Thomas to spend less time at work?
Sandra: Because we would be able to spend more time together, which would help me feel important
and like more connected to him.
Therapist: And you, Thomas, what are you looking for in spending extra time at work?
Thomas: When I’m at work, I don’t hear complaints about our financial situation. It would be so
great to hear some appreciation of all my efforts to improve our finances and how wearing is my
Therapist: Thomas, I understand that you would like more appreciation for your hard work. Sandra,
you’ve expressed that spending more time with Thomas would help you feel more valued and connected.
Now that you’ve both addressed your needs, I invite you to name of as many possible solutions you can
think of that could help resolve the problem expressed by Sandra.
Cognitive Behavioral Therapy and Clinical Applications130
Sandra: Thomas, maybe you could start by taking the weekends o?
Thomas: I understand where you are coming from Sandra, but my job makes it dicult for me not to
work for the whole weekend. What if I try to come home earlier on weeknights?
Sandra: Hum… Why don’t you take Sunday mornings o so that we can brunch together just like we
used to?
This brainstorming continues until the most suitable solution is provided and agreed upon by both
partners. The therapist encourages partners to be open for a trial period until the next session where
the solution will be revaluated based on their feedbacks of the trial period. Since in the rst exercise, the
couple has addressed a problem that was initially reported by Sandra, the next problem-solving exercise
will focus on a problem reported by Thomas, such as his complaints regarding Sandra’s lack of acknowl-
edgment of Thomas’ eorts concerning nancial maers.
6.3. Cognitive restructuring
CBCT therapists are interested in identifying and confronting the distorted ways in which
partners process information and how these cognitive distortions, namely selective aen-
tion, unrealistic or inappropriate aributions, expectations, assumptions and standards, are
related to negative emotions and behaviors experienced within the relationship [31, 122].
Cognitive interventions used in CBCT thus aim at helping couples learn to detect and evalu-
ate the appropriateness of their cognitions. They also aim at helping partners to challenge
the cognitions they hold that negatively inuence their emotional and behavioral responses
towards their partner. These interventions thus allow couples to broaden their perspective on
the relationship by gaining a mutual understanding of how the other thinks and interprets
events. Partners will also begin to anticipate the impact of those interpretations on their inter-
actions [17]. To do so, CBCT therapists often give information to couples on their cognitive
distortions and the impact it can have on their interactions. They then solicit feedback from
partners to promote integration of these concepts and encourage partner’s ability to detect
and question further cognitive distortions [123].
Since CBCT allows couples’ interactions to take place within sessions, therapists have the
opportunity to address cognitive distortions as they spontaneously arise between partners, to
help them question their way of thinking and to consider dierent alternative explanations or
perspectives on the partner and on the relationship [19]. CBCT therapists also guide partners
interacting in ways that will allow them to challenge their distortions by sharing their respec-
tive experiences on a particular issue [123]. Typically, cognitive interventions are also used to
help partners revaluate the logic or incoherence of their thinking and understand the underly-
ing issues and concerns. For instance, Socratic questioning entails asking questions to partners
that help them understand the logic in their inferences or beliefs as well as evidence for their
validity. Other cognitive techniques also used in CBCT involve inquiring about the evidence
that supports a cognition, weighing its advantages and disadvantages, as well as considering
the worst possible outcomes of negative predictions that partners make about their relationship
[98, 124]. Cognitive interventions also include helping partners gain a mutual understanding
of their diculties by considering each partner’s perspective on the concerns they report [99].
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
Nancy and Jacob began their relationship before Jacob left a former partner (Sarah). Jacob’s history of
indelity is the subject of several arguments with Nancy. Jacob repeatedly told Nancy of his regrets at
having been unfaithful with Sarah, and of his feeling that his relationship with Nancy is completely
dierent. However, in the past few months, Nancy has been geing angry and has expressed jealousy
when Jacob goes out with friends, convinced that indelity might be an issue.
Therapist: I understand you are angry when Jacob goes out with friends. What do you think will
Nancy: That Jacob will meet someone and cheat on me.
Therapist: What makes you think Jacob might cheat on you?
Nancy: Nothing that I can think of … except what happened with Sarah.
Therapist: Do you think that Jacob could be unfaithful to you, even though that has not happened?
Nancy: I don’t know…Jacob told me that the relationship with Sarah was not a happy one.
Therapist: Do you think Jacob is happy with you?
Nancy: …. seems happy….
Therapist: You are saying that the cheating with Sarah was because Jacob was unhappy in that rela-
tionship. You also believe Jacob is happy in the relationship with you. Explain to Jacob why do you think
he might be unfaithful to you?
Nancy: Actually, there are no concrete signs that indicate that you would cheat on me… I think I’m
just afraid of losing you.
Therapist: I understand you care a lot about Jacob and do not want to lose the relationship. Jacob, how
does it make you feel to hear that?
6.4. Identication and expression of emotions
In CBCT, emotions that are minimized, avoided, repressed or excessively expressed by
partners are known to negatively impact a couple’s relational functioning and satisfaction
[120]. Indeed, individuals who do not express their emotions are generally more distant and
less involved in their relationship, which ultimately leads to less intimacy and satisfaction
between partners [30]. As such, CBCT intervention techniques have been developed to iden-
tify, modify and enhance tolerance of negative emotions [19]. By enhancing partners’ identi-
cation, expression and tolerance of negative emotions, CBCT therapists can also help couples
identify the sources of their relational dissatisfaction and, eventually, foster higher levels of
intimacy between partners.
For Wright and colleagues [14], since certain negative or strong emotions that aect couple
interactions, such as anger or fear, are often avoided by partners, the therapist must help part-
ners clarify and regulate avoided emotions. To address this, strategies used in CBCT hold the
purpose of accessing and heightening partners’ emotional experiences as well as helping them
receive the emotions expressed by the partner. To do so, therapists generally address spontane-
ous emotions, as they arise in session or as they are expressed non-verbally by partners. They
Cognitive Behavioral Therapy and Clinical Applications132
will also encourage partners to express feelings and detect how they aect their way of think-
ing and behaving. When emotions have been identied and understood, partners are encour-
aged to express them by using the communication skills previously learned. Therapists can
also access repressed or minimized emotions by asking partners to describe in detail specic
experiences, by using reections or questions or by encouraging partners to use metaphors
and images to describe what they experience [19]. Techniques also include normalizing the
expression of both positive and negative emotions, encouraging partners to care and support
the other when he/she expresses emotions and guiding partners to stay focused on their emo-
tional experiences rather than concentrating solely on more cognitive or behavioral aspects of
an experience, for instance, during a conict with the partner [19].
Sometimes, therapists also meet couples that struggle with diculties in regulating nega-
tive emotions. These partners will express them in a more dysfunctional manner, potentially
leading to serious arguments and even partner violence. With these couples, scheduling
times to discuss subjects that trigger such interactions can be useful in order to contain the
expression of negative emotions to a specic time and place [125]. Skills specically address-
ing emotion regulation as proposed in dialectical behavior therapy [126] have also been
included in CBCT. Such interventions include the development of skills that enhance both
partners’ tolerance to strong or negative emotions and decrease their emotional reactivity in
order to provide couples with the ability to deal with emotional interactions they may face
together [73].
6.5. Expression of aection and sexual problems
Lack of emotional aection or sensuality and dissatisfaction in the quality or frequency of sex-
ual relations are frequently invoked when consulting in couple therapy. Many sexual prob-
lems can also be put forward by couples consulting in CBCT, some of which include various
sexual dysfunctions, such as erectile disorders, orgasmic disorders, genito-pelvic pain/pen-
etration disorder and sexual desire/arousal disorder [119]. Indeed, sexuality holds a decisive
place in a couple’s functioning and satisfaction [127], and thus, it is generally important to
address the sexual domain in CBCT. However, since the various biological, social and psycho-
logical factors that contribute to the development and the persistence of sexual dysfunctions
make their treatment complex [128], it is recommended that couples who experience sexual
diculties benet from the expertise of a therapist specialized in both sexual and couple
therapy [119].
CBCT techniques aimed at the improvement of sexual well-being in couples include a variety
of strategies and exercises that allow a broadening and diversication of sexual behaviors
for partners and that have been proven eective for addressing sexual dissatisfaction and
various sexual dysfunctions [128, 129]. For instance, psychoeducation can help clients learn
about sexuality as well as correcting myths, misconceptions or unrealistic notions that part-
ners might have about sexuality through information from the therapist as well as by reading
or watching recommended psychoeducational material [130]. Cognitive interventions can
also be used to address sexual diculties by challenging and nuancing cognitive distor-
tions that could be both automatic and irrational, in order to replace them by more positive
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
and functional cognitions and beliefs towards sexuality [17]. Such cognitive distortions can
include beliefs or standards about how sexual relations “must be” that are unrealistic (e.g.,
“In our sexual relations my partner always has to reach an orgasm”) or negative (e.g., “I have
never had a good sex life with my partner”). Indeed, cognitive interventions can be used to
address these negative or anxiety-provoking thoughts that interfere with the ability to have
satisfying sexual relations with a partner [128].
According to Kelly et al. [131], diculty in expressing sexual needs and desires is common
in couples. Consequently, it is crucial that partners improve their communication skills with
regards to sexuality [132]. The several communication training techniques mentioned above
can be applied to sexuality, with the objective of promoting optimism and sexual pleasure in
the relationship. Indeed, communication training can be used to enhance feelings of love and
aection between partners. This is accomplished by helping partners share their sexual needs
and nd new ways to express aection and caring [128].
Sessions on sexuality can also be dedicated to the exploration of negative emotions that are
experienced during sexual relations. Partners are shown how to detect negative emotions,
such as anxiety, anger, discomfort, as well as fear of rejection or abandonment, any of which
can disrupt intimacy and sexual desire [128]. Identifying and accepting these emotions, the
specic context in which they arise, their underlying beliefs as well as their impact on plea-
sure and intimacy, will increase sexual and sensual exploration and innovation [14]. In addi-
tion, strategies aimed at revealing these emotions in session can be of signicant use as they
allow to explore the underlying beliefs and aachment needs of partners in the sexual prob-
lems or dissatisfactions they experience [133].
Behavioral exercises that broaden a couple’s sexual repertoire, diminish avoidant behav-
iors towards sexuality as well as confront certain cognitive distortions and help partners
refocus on sensations and sensuality [119] are also used to treat sexual dissatisfaction or
dysfunctions and are recognized as leading to positive outcomes and long-term changes
[134]. These exercises are usually explained during session, practiced at home between
sessions and later discussed with the therapist [119]. Such behavioral interventions can
include self-exploration (i.e., exploration of one’s body and/or genitalia) followed by
directed masturbation (i.e., trying dierent ways of masturbating, in dierent positions or
places) that can be practiced alone at rst but then with the partner [119]. Finally, sensate
focus is a behavioral exercise for couples that has been developed by Masters and Johnson
[135] and that is commonly used to emphasize pleasurable sensations and sensuality and
de-emphasize sexual performance, which is considered as being at the root of many sexual
diculties in couples.
6.6. Acceptance and tolerance of dierences
Jacobson and Christensen [16] have underlined the importance of acceptance and toler-
ance in order to enable the integration of new behaviors developed in CBCT. Indeed, the
non-acceptation of basic personal differences between partners might sometimes lead to
arguments or resentment. Interventions developed by Jacobson and Christensen thus aim
at accepting the potential fundamental differences or incompatibilities between partners.
Cognitive Behavioral Therapy and Clinical Applications134
This is accomplished by developing an empathic understanding of the other’s experience
and working together to face common hardships [136]. To achieve this goal, strategies tar-
get three objectives: acceptance, tolerance and change [137]. Strategies to enhance accep-
tance aim at offering partners new ways of looking at their problems through empathic
joining and unified detachment. Empathic joining brings to light each partner’s sense of
vulnerability by allowing them to express their perspective on a problem, while being
listened by the other partner and the therapist, whose task is to encourage the expres-
sion of emotions, rather than accusations or comments on behaviors. Unified detachment
encourages partners to discontinue accusations or blame by helping them develop a more
objective and less emotional consideration of their problems or differences and by consid-
ering them as an “ it ” (e.g., an object, an animal, a nickname) rather than as a deficiency
or a problem in the other. The following example illustrates how this technique can be
Robert and John have sought CBCT as a result of frequent arguments they have experienced in the past
months. Their arguments usually revolve around their nances and lifestyle. Robert typically prefers
staying home and has a frugal lifestyle. John rather enjoys luxuries and spending his evening in trendy
restaurants. During a session, Robert expresses his anxiety over their nancial situation as John has
spent a few hundred dollars in the past week during an evening with friends. John then expresses he
feels Robert is treating him like a child by scolding him every time he comes back home.
Therapist: Robert, I understand you must feel anxious about your nancial situation and John, I un-
derstand you feel as if you are treated as a child. Perhaps we could use this situation to try an exercise
called “ unied detachment ” to help both of you. First, I would like you to identify what part of yourself,
or of your personality, is talking during these arguments. Then, try to imagine what form would take
this part of yourself during conicts if it were to be described as a “ thing ”. It can be an object, an
animal, a country, whatever you want.
John: I would be a glass of champagne! It is luxurious and bubbly, like me!
Robert: You are right John! If I follow your lead on drinks, I would be a cup of freshly brewed coee.
It’s inexpensive but comforting.
Therapist: Perfect! Now, if the glass of champagne and the cup of coee were to discuss on a date they
are planning for Friday night. What would they say to each other?
John: Well the glass of champagne would like to go to the new restaurant on 6th Street.
Robert: The cup of coee would prefer to stay home, order take out and watch a good movie.
Therapist: And considering these dierent wishes, what solution can the glass of champagne and the
cup of coee try to nd together to spend their Friday night together?
John: Robert, I have an idea! You know we often drink champagne as an aperitif in restaurants and
coee with desert. What would you say if we were to do the same?
Robert: The glass of champagne and the cup of coee could grab drinks at the restaurant and then nish
the evening with take out and a movie?
John: Yes! What do you think of that?
Robert: It is a very good idea! Let’s try it!
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
Tolerance strategies have also been developed in order to stop partners from trying to
change the other, for instance, by pointing out the benets that can result from certain
behaviors that are considered negative by partners (e.g., a partner’s constant worries and
aempts to predict everything that can go wrong in a situation, typical in anxious people,
can negatively impact a couple’s interactions but can also be very useful when planning
a vacation or when taking nancial decisions). Change strategies aim at reinforcing and
prompting positive behaviors that partners already portray towards each other and include
the improvement of communication and problem-solving skills by recreating a conict they
have already experienced and integrating the acceptance and tolerance strategies they have
learned [137]. Finally, mindfulness-based interventions can also be used to enhance accep-
tance of dierences. These strategies have been proven to increase relationship satisfaction,
sense of relatedness and closeness, acceptance of the partner and to alleviate relationship
distress [138]. They include meditation and touch exercises, aim at enhancing partners’
acceptance of their experiences without judgment as well as their moment-to-moment
awareness of how they feel and behave while interacting with one another, which could
eventually help them develop new ways to connect with one another.
7. Conclusion
The current chapter has provided a comprehensive literature review and description of the
theoretical underpinnings, possible therapeutic mandates and main assessment and interven-
tion methods used in CBCT. This chapter has also highlighted the empirically demonstrated
eectiveness of CBCT for the treatment of a signicant number of couple struggles ranging
from communication diculties and dissatisfaction with expressed aection to the manage-
ment of explosive conicts. This chapter also demonstrated that CBCT can be very eective in
treating individual problems by using the intimate relationship as a therapeutic tool.
The scientic literature suggests that CBCT is a highly eective treatment approach to improve
relational well-being as well as a way to address many diculties and concerns couples may
face. This is especially true for diculties in communication, problem-solving and conict res-
olution as they arise spontaneously between partners or as a result of comorbid psychological
diculties in one or both partners, for which specic techniques have been developed and
are regularly used by couple therapists. Interestingly, CBCT also oers a good foundation on
which therapy can be customized to various needs partners may hold. For instance, recent
developments in CBCT have started to incorporate more complex and specic variables in
the understanding and treatment of couple functioning by considering the roles of aachment
[139], relational schemas [140] and mindfulness [141] as possibly underlying certain couple
Results from psychotherapeutic outcome studies presented in this chapter must be examined
by considering certain drawbacks. Indeed, evidence-based studies have become the gold
standard to evaluate the eectiveness of psychotherapeutic interventions yet, not all studies
Cognitive Behavioral Therapy and Clinical Applications136
on the eectiveness of CBCT include large sample sizes, randomized controlled trials (RCT)
or follow-up data extending beyond 6 or 12 months. As such, the eectiveness of CBCT for
dierent couple diculties must be considered within this reality. In addition, going from
theory to practice can be quite a challenge, especially because in CBCT, clients are two dif-
ferent people who consult together. Indeed, CBCT therapists must learn to work not only
with both parties’ personalities, feelings, cognitions and behaviors but also with the couple’s
dynamics as they take place during and between sessions. The complexity of this type of
therapeutic work also lies in the therapist’s role, as he/she is called to inquire about, and
directly witness, couples’ most intimate moments and feelings while maintaining a respectful
and professional distance.
Finally, it is also important to note that regardless of the concerns for which a couple seeks
therapy, the CBCT process in itself holds certain limitations. Indeed, both partners must be
strongly commied to making their relationship work by demonstrating honesty, open-
ness, caring and interest in the other’s experience. They must also demonstrate commitment
towards the therapeutic process. For instance, in cases when partners do not really want to
see their problem solved (e.g., when changes in the couple are considered as too anxiety-
provoking) or when partners come to therapy to have the therapist determine who is “right”
or “wrong,” it is often dicult to induce change in the relationship and enhance relational
functioning. Fortunately, empirical and clinical work from the past decades has oered pre-
cious insights in the understanding of such dynamics and in the training of CBCT therapists
that are not only aware of these therapeutic intricacies but also use them to further their work
with couples.
Author details
Caroline Dugal, Gaëlle Bakhos, Claude Bélanger* and Natacha Godbout
*Address all correspondence to:
Université du Québec à Montréal, Montreal, Quebec, Canada
[1] Coleman L, Mitcheson J, Casey P, Lloyd G. Couple relationships: Why are they impor-
tant for health and wellbeing? Journal of Health Visiting. 2013;1(3):168-172
[2] Snyder DK, Halford WK. Evidence-based couple therapy: Current status and future direc-
tions. Journal of Family Therapy. 2012;34(3):229-249. DOI: 10.1111/j.1467-6427.2012.00599.x
[3] Epstein NB, Zheng L. Cognitive-behavioral couple therapy. Current Opinion in
Psychology. 2017;13:142-147. DOI: 10.1016/j.copsyc.2016.09.004
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
[4] Kiecolt-Glaser JK, Gouin J-P, Hantsoo L. Close relationships, inammation, and health.
Neuroscience & Biobehavioral Reviews. 2010;35(1):33-38. DOI: 10.1016/j.neubiorev.
[5] Bélanger C, Laporte L, Sabourin S, Wright J. The eect of cognitive-behavioral group
marital therapy on marital happiness and problem solving self-appraisal. American
Journal of Family Therapy. 2015;43(2):103-118. DOI: 10.1080/01926187.2014.956614
[6] Shadish WR, Baldwin SA. Eects of behavioral marital therapy: A meta-analysis of ran-
domized controlled trials. Journal of Consulting and Clinical Psychology. 2005;73(1):6-14.
DOI: 10.1037/0022-006X.73.1.6
[7] Snyder DK, Castellani AM, Whisman MA. Current status and future directions in
couple therapy. Annual Review of Psychology. 2006;57:317-344. DOI: 10.1146/annurev.
[8] Christensen A, Atkins DC, Yi J, Baucom DH, George WH. Couple and individual adjust-
ment for 2 years following a randomized clinical trial comparing traditional versus
integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology.
2006;74(6):1180-1191. DOI: 10.1037/0022-006X.74.6.1180
[9] Stuart RB. Operant-interpersonal treatment for marital discord. Journal of Consulting
and Clinical Psychology. 1969;33(6):675-682. DOI: 10.1037/h0028475
[10] Bandura A. Psychotherapy as a learning process. Psychological Bulletin. 1961;58:
[11] Thibaut JW, Kelley HH. The Social Psychology of Groups. Oxford, England: John Wiley;
[12] Jacobson NS, Margolin G. Marital Therapy: Strategies Based on Social Learning and
Behavior Exchange Principles. New York: Brunner/Mazel; 1979
[13] Wright J, Sabourin S. L’intervention auprès du couple: Diagnostic et traitement [Intervention
with Couples: Diagnostic and Treatment]. Montréal: Les Éditions Consultation; 1985
[14] Wright J, Sabourin S, Lussier Y, Poitras-Wright H. La psychothérapie de couple
d’orientation cognitive-comportementale [Cognitive-behavioral Couple Therapy]. In:
Wright J, Lussier Y, Sabourin S, editors. Manuel clinique des psychothérapies de couple.
Québec, QC: Presses de l’Université du Québec; 2008. pp. 225-275
[15] Baucom DH, Epstein N. Brunner/Mazel Cognitive Therapy Series. Cognitive-Behavioral
Marital Therapy. Philadelphia: Brunner/Mazel; 1990
[16] Jacobson NS, Christensen A. A Norton Professional Book. Integrative Couple Therapy:
Promoting Acceptance and Change. New York: W W Norton & Co.; 1996
[17] Epstein NB, Baucom DH. Enhanced cognitive-behavioral therapy for couples: A con-
textual approach. Washington, DC: American Psychological Association; 2002. DOI: 10.
Cognitive Behavioral Therapy and Clinical Applications138
[18] Fischer MS, Baucom DH, Cohen MJ. Cognitive-behavioral couple therapies: Review of
the evidence for the treatment of relationship distress, psychopathology, and chronic
health conditions. Family Process. 2016;55(3):423-442. DOI: 10.1111/famp.12227
[19] Baucom DH, Epstein NB, Kirby JS, LaTaillade JJ. Cognitive-behavioral couple therapy.
In: Gurman AS, Lebow JL, Snyder DK, editors. Clinical Handbook of Couple Therapy.
New York: Guilford Press; 2015. pp. 23-60
[20] Sabourin S, Lorange J, Wright J, Lefebvre D, Poitras-Wright H. Le diagnostic en psy-
chothérapie de couple: vers un nouveau dialogue [Diagnosis in couples psychotherapy:
towards a new dialogue]. In: Wright J, Lussier Y, Sabourin S, editors. Manuel clinique des
psychothérapies de couple. Québec: Presses de l'Université du Québec; 2008. pp. 99-195
[21] Wolska M. Marital therapy/couples therapy: Indications and contraindications. Archives
of Psychiatry and Psychotherapy. 2011;13(3):57-64
[22] Poitras-Wright H, St-Père F. Grille d’évaluation des mandats en thérapie pour la
recherche sur l’ecacité de la thérapie conjugale [A Therapeutic Mandate Evaluation
Grid for Use in Research on the Eectiveness of Couple Therapy]. 2004. pp. 168-172.
Unpublished document
[23] Tremblay N, Fortier C, Leblond de Brumath A, Julien D. L’intervention auprès des
couples de même sexe [Intervention with same-sex couples]. In: Wright J, Lussier Y,
Sabourin S, editors. Manuel clinique des psychothérapies de couple. Québec: Presses de
l'Université du Québec; 2008. pp. 397-444
[24] Christensen A, Atkins DC, Baucom B, Yi J. Marital status and satisfaction ve years fol-
lowing a randomized clinical trial comparing traditional versus integrative behavioral
couple therapy. Journal of Consulting and Clinical Psychology. 2010;78(2):225-235. DOI:
[25] Boisvert M-M, Wright J, Tremblay N, McDu P. Couples' reports of relationship prob-
lems in a naturalistic therapy seing. The Family Journal. 2011;19(4):362-368. DOI:
[26] Doss BD, Simpson LE, Christensen A. Why do couples seek marital therapy? Professional
Psychology: Research and Practice. 2004;35(6):608-614. DOI: 10.1037/0735-7028.35.6.608
[27] Miller RB, Yorgason JB, Sandberg JG, White MB. Problems that couples bring to therapy:
A view across the family life cycle. American Journal of Family Therapy. 2003;31(5):395-
407. DOI: 10.1080/01926180390223950
[28] Stinson MA, Bermúdez JM, Gale J, Lewis D, Meyer AS, Templeton GB. Marital satisfac-
tion, conict resolution styles, and religious aendance among latino couples: Using
the actor-partner interdependence model. The Family Journal. 2017;25(3):215-223. DOI:
[29] Grieger R. The Couples Therapy Companion: A Cognitive Behavior Workbook.
New York: Routledge/Taylor & Francis Group; 2015
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
[30] Fruzei A. The High Conict Couple: A Dialectic Behavior Therapy to Finding Peace,
Intimacy, and Validation Tech Pour: Transform Conict into Closeness. Oakland, California,
United States: New Harbinger Publications; 2006
[31] Marshall AD, Jones DE, Feinberg ME. Enduring vulnerabilities, relationship aribu-
tions, and couple conict: An integrative model of the occurrence and frequency of inti-
mate partner violence. Journal of Family Psychology. 2011;25(5):709-718. DOI: 10.1037/
[32] Lussier Y, Brassard A, Godbout N, Sabourin S, Wright J, Duon D. Spousal violence:
Useful parameters for assessment and intervention. Integrating Science and Practice. 2013;
[33] Bélanger C, Bergeron Y, Lafontaine MF, Julien D. Protocole pour l’évaluation des couples
présentant un problème de violence conjugale [Protocol for the assessment of couples
with partner violence]. Perspectives on Psychological Science. 2011;50(3):263-270
[34] O'Leary KD. Couple therapy and physical aggression. In: Gurman AS, editor. Clinical
Handbook of Couple Therapy. 4th ed. New York: Guilford Press; 2008. pp. 478-498
[35] LaTaillade JJ, Epstein NB, Werlinich CA. Conjoint treatment of intimate partner violence:
A cognitive Behavioral approach. Journal of Cognitive Psychotherapy. 2006;20(4):393-
410. DOI: 10.1891/jcpiq-v20i4a005
[36] Lussier Y, Wright J, Lafontaine MF, Brassard A, Epstein N. L’évaluation et le traitement
de la violence conjugale [Assessment and Treatment of Partner Violence]. In: Wright J,
Lussier Y, Sabourin S, editors. Manuel clinique des psychothérapies de couple. Ste-Foy,
QC: Presses de l’Université du Québec; 2008. pp. 445-505
[37] O'Leary KD, Heyman RE, Neidig PH. Treatment of wife abuse: A comparison of gender-
specic and conjoint approaches. Behavior Therapy. 1999;30(3):475-505
[38] Stith SM, Rosen KH, McCollum EE, Thomsen CJ. Treating intimate partner violence
within intact couple relationships: Outcomes of multi-couple versus individual couple
therapy. Journal of Marital and Family Therapy. 2004;30(3):305-318. DOI: 10.1111/j.1752-
[39] Scuka RF. A clinician's guide to helping couples heal from the trauma of indelity.
Journal of Couple & Relationship Therapy. 2015;14(2):141-168. DOI: 10.1080/15332691.
[40] Marin RA, Christensen A, Atkins DC. Indelity and behavioral couple therapy:
Relationship outcomes over 5 years following therapy. Couple and Family Psychology:
Research and Practice. 2014;3(1):1-12. DOI: 10.1037/cfp0000012
[41] Allen ES, Atkins DC. The association of divorce and extramarital sex in a representa-
tive U.S. sample. Journal of Family Issues. 2012;33(11):1477-1493. DOI: 10.1177/0192
Cognitive Behavioral Therapy and Clinical Applications140
[42] Mark KP, Janssen E, Milhausen RR. Indelity in hetero-sexual couples: Demographic,
interpersonal, and personality-related predictors of extradyadic sex. Archives of Sexual
Behavior. 2011;40(5):971-982. DOI: 10.1007/s10508-011-9771-z
[43] Vaillancourt-Morel M-P, Dugal C, Poirier Stewart R, Godbout N, Sabourin S, Lussier
Y, Briere J. Extradyadic sexual involvement and sexual compulsivity in male and
female sexual abuse survivors. The Journal of Sex Research. 2016;53(4-5):614-625. DOI:
[44] Wilkinson RT, Lilebear S, Reed S. A review of treatment with couples post-aair: An
emphasis on the use of disclosure. The Family Journal. 2012;20(2):140-146. DOI: 10.1177/
[45] Picard L, Sabourin S. Indélité, mensonge et trahison [Indelity, lies and betrayal]. In:
Lussier Y, Bélanger C, Sabourin S, editors. Les fondements de la psychologie du couple.
Québec: Presses de l’Université du Québec; 2017. pp. 591-615
[46] Allen ES, Atkins DC, Baucom DH, Snyder DK, Gordon KC, Glass SP. Intrapersonal,
interpersonal, and contextual factors in engaging in and responding to extramarital
involvement. Clinical Psychology. 2005;12(2):101-130
[47] Atkins DC, Baucom DH, Jacobson NS. Understanding indelity: Correlates in a national
random sample. Journal of Family Psychology. 2001;15(4):735-749
[48] Leone C. Helping couples heal from indelity: A self psychological, intersubjective
approach. International Journal of Psychoanalytic Self Psychology. 2013;8(3):282-308.
DOI: 10.1080/15551024.2013.796608
[49] Snyder DK, Baucom DH, Gordon KC, Doss BD. Indelity and other relationship betray-
als. In: Snyder DK, Monson CM, editors. Couple-Based Interventions for Military and
Veteran Families: A Practitioner's Guide. New York: Guilford Press; 2012. pp. 90-121
[50] Atkins DC, Eldridge KA, Baucom DH, Christensen A. Indelity and behavioral couple
therapy: Optimism in the face of betrayal. Journal of Consulting and Clinical Psychology.
2005;73(1):144-150. DOI: 10.1037/0022-006X.73.1.144
[51] Baucom DH, Gordon KC, Snyder DK, Atkins DC, Christensen A. Treating aair cou-
ples: Clinical considerations and initial ndings. Journal of Cognitive Psychotherapy.
2006;20(4):375-392. DOI: 10.1891/jcpiq-v20i4a004
[52] Gordon KC, Khaddouma A, Baucom DH, Snyder DK. Couple therapy and the treatment
of aairs. In: Gurman AS, Lebow JL, Snyder DK, editors. Clinical Handbook of Couple
Therapy. New York: Guilford Press; 2015. pp. 412-444
[53] Sullivan MJL, Adams H, Gauthier N. Couples aux prises avec l’infertilité [Couples
struggling with infertility]. In: Wright J, Lussier Y, Sabourin S, editors. Manuel cli-
nique des psychothérapies de couple. Québec: Presses de 1'Université du Québec; 2008.
pp. 657-696
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
[54] Hassani F. Psychology of infertility and the comparison between two couple therapies,
in infertile pairs. International Journal of Innovation, Management and Technology.
[55] Benyamini Y, Gozlan M, Kokia E. Variability in the diculties experienced by women
undergoing infertility treatments. Fertility and Sterility. 2005;83:275-283
[56] Ramezanzadeh F, Aghssa MM, Abedinia N, Zayeri F, Khanafshar N, Shariat M,
Jafarabadi M. A survey of relationship between anxiety, depression and duration of
infertility. BMC Women's Health. 2004;4(9). DOI: 10.1186/1472-6874-4-9
[57] Slade P, Raval H, Buck P, Lieberman BE. A 3-year follow-up of emotional, marital, and
sexual functioning in couples who were infertile. Journal of Reproductive and Infant
Psychology. 1992;10:233-243
[58] Pasch LA, Sullivan KT. Stress and coping in couples facing infertility. Current Opinion
in Psychology. 2017;13:131-135. DOI: 10.1016/j.copsyc.2016.07.004
[59] Godbout N, Run M, MacIntosch H, Briere J. Childhood trauma and couple relation-
ships. Integrating Science and Practice. 2013;3(2):14-17
[60] Fleming CB, White HR, et Catalano RF. Romantic relationships and substance use in
early adulthood: An examination of the inuences of relationship type, partner substance
use, and relationship quality. Journal of Health and Social Behavior. 2010;51(2):153-167.
DOI: 10.1177/0022146510368930
[61] Whisman MA. Marital distress and DSM-IV psychiatric disorders in a population-based
national survey. Journal of Abnormal Psychology. 2007;116(3):638-643
[62] McCrady BS. Treating alcohol problems with couple therapy. Journal of Clinical
Psychology. 2012;68(5):514-525. DOI: 10.1002/jclp.21854
[63] Leonard KE, et Homish GG. Predictors of heavy drinking and drinking problems over
the rst 4 years of marriage. Psychology of Addictive Behaviors. 2008;22(1):25-35. DOI:
[64] Powers MB, Vedel E, Emmelkamp PMG. Behavioral couples therapy (BCT) for alcohol
and drug use disorders: A meta-analysis. Clinical Psychology Review. 2008;28(6):952-
962. DOI: 10.1016/j.cpr.2008.02.002
[65] Epstein E, McCrady BS, Morgan TJ, Cook SM, Kugler G, Ziedonis D. The successive
cohort design: A model for developing new behavioral therapies for drug use disorders,
and application to behavioral couple treatment. Addictive Disorders & Their Treatment.
2007;6(1):1-19. DOI: 10.1097/01.adt.0000210707.49703.2c
[66] Epstein EE, McCrady BS. A Cognitive-Behavioral Treatment Program for Overcoming
Alcohol Use Problems: Therapist Guide. New York, NY: Oxford University Press; 2009
[67] Epstein NB, Baucom DH. Couple therapy. In: Leahy RL, editor. Roadblocks in Cognitive-
Behavioral Therapy: Transforming Challenges into Opportunities for Change. New York:
Guilford Press; 2003. pp. 217-235
Cognitive Behavioral Therapy and Clinical Applications142
[68] Bélanger C, El Baalbaki G, Leduc A, Coyne J. Couples et dépression: Évaluation et trait-
ement [Couples and depression: Evaluation and treatment]. In: Wright J, Lussier Y,
Sabourin S, editors. Manuel clinique des psychothérapies de couple. Québec: Presses de
l'Université du Québec; 2008. pp. 623-655
[69] Whisman MA. Relationship discord and the prevalence, incidence, and treatment of
psychopathology. Journal of Social and Personal Relationships. 2013;30:163-170
[70] Whisman MA, Beach SRH. Couple therapy for depression. Journal of Clinical Psychology.
2012;68(5):526-535. DOI: 10.1002/jclp.21857
[71] Whisman MA, Beach SRH. Couple therapy and depression. In: Gurman AS, Lebow JL,
Snyder DK, editors. Clinical Handbook of Couple Therapy. New York: Guilford Press;
2015. pp. 585-605
[72] Fredman SJ, Baucom DH, Boeding SE, Miklowi DJ. Relatives’ emotional involvement
moderates the eects of family therapy for bipolar disorder. Journal of Consulting and
Clinical Psychology. 2015;83(1):81-91. DOI: 10.1037/a0037713
[73] Kirby JS, Baucom DH. Integrating dialectical behavior therapy and cognitive-behav-
ioral couple therapy: A couples skills group for emotion dysregulation. Cognitive and
Behavioral Practice. 2007;14(4):394-405. DOI: 10.1016/j.cbpra.2006.09.006
[74] Macdonald A, Pukay-Martin ND, Wagner AC, Fredman SJ, Monson CM. Cognitive-
behavioral conjoint therapy for PTSD improves various PTSD symptoms and trauma-
related cognitions: Results from a randomized controlled trial. Journal of Family
Psychology. 2016;30(1):157-162. DOI: 10.1037/fam0000177
[75] Monson CM, Fredman SJ, Macdonald A, Pukay-Martin ND, Resick PA, Schnurr PP.
Eect of cognitive-behavioral couple therapy for PTSD: A randomized controlled trial.
JAMA: Journal of the American Medical Association. 2012;308(7):700-709. DOI: 10.1001/
[76] Abramowi JS, Baucom DH, Wheaton MG, Boeding S, Fabricant LE, Paprocki C, Fischer MS.
Enhancing exposure and response prevention for OCD: A couple-based approach.
Behavior Modication. 2013;37(2):189-210. DOI: 10.1177/0145445512444596
[77] Bélanger C, Leduc A, Fredman S, El-Baalbaki G, Baucom D. Couples et troubles
anxieux: Évaluation et intervention [Couples and anxiety disorders: Evaluation
and intervention]. In: Wright J, Lussier Y, Sabourin S, editors. Manuel clinique
des psychothérapies de couple. Québec: Presses de l'Université du Québec; 2008.
pp. 507-539
[78] Bulik CM, Baucom DH, Kirby JS, Pisetsky E. Uniting couples (in the treatment of)
anorexia nervosa (UCAN). International Journal of Eating Disorders. 2011;44(1):19-28
[79] Mondor J, Wright J, Eid P. Psychothérapie de couple [Couple Psychotherapy]. In: Lussier Y,
Bélanger C, Sabourin S, editors. Les fondements de la psychologie du couple. Québec:
Presses de l’Université du Québec; 2017. pp. 735-764
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
[80] Mondor J, Sabourin S, Wright J, Poitras-Wright H, McDu P, Lussier Y. Early termi-
nation from couple therapy in a naturalistic seing: The role of therapeutic mandates
and romantic aachment. Contemporary Family Therapy: An International Journal.
2013;35(1):59-73. DOI: 10.1007/s10591-012-9229-z
[81] Côté G. La médiation familiale [Family mediation]. In: Wright J, Lussier Y, Sabourin S,
editors. Manuel clinique des psychothérapies de couple. Sainte-Foy (Québec): Presses de
l'Université du Québec; 2008. pp. 697-730
[82] Lebow JL. Separation and divorce issues in couple therapy. In: Gurman AS, Lebow JL,
Snyder DK, editors. Clinical Handbook of Couple Therapy. New York: Guilford Press;
2015. pp. 445-463
[83] Gabbay N, Lafontaine M-F, Péloquin K, Flesh JL, Fipatrick RJ. Fonctionnement de
couple chez les individus en relation de même sexe [Couple functioning in individu-
als from same-sex couples]. In: Lussier Y, Bélanger C, Sabourin S, editors. Les fonde-
ments de la psychologie du couple. Québec: Presses de l’Université du Québec; 2017.
pp. 455-477
[84] Estrada D. Supervision of cross-cultural couples therapy: Giving voice to the code of silence
in the supervision and therapy room. Journal of Family Psychotherapy. 2008;16:17-30
[85] Killian KD. Couple therapy and intercultural relationships. In: Gurman AS, Lebow JL,
Snyder DK, editors. Clinical Handbook of Couple Therapy. New York: Guilford Press;
2015. pp. 512-528
[86] Biever JL, Bobele M, North M-W. Therapy with intercultural couples: A postmod-
ern approach. Counselling Psychology Quarterly. 1998;11(2):181-188. DOI: 10.1080/
[87] Ho MK, Rasheed JM, Rasheed MN. Family Therapy with Ethnic Minorities. 2nd ed.
Thousand Oaks, CA: Sage; 2004
[88] Troy AB, Lewis-Smith J, Laurenceau J-P. Interracial and intraracial romantic rela-
tionships: The search for differences in satisfaction, conflict, and attachment style.
Journal of Social and Personal Relationships. 2006;23(1):65-80. DOI: 10.1177/026540
[89] Fu X, Tora J, Kendall H. Marital happiness and inter-racial marriage: A study in a
multi-ethnic community in Hawaii. Journal of Comparative Family Studies. 2001;32(1):
[90] Usita PM, Poulsen S. Interracial relationships in Hawaii: Issues, benets, and thera-
peutic interventions. In: Thomas V, Karis TA, Wetchler JL, editors. Clinical Issues
with Interracial Couples: Theories and Research. New York: Haworth Press; 2003.
pp. 73-83
[91] Heller PE, Wood B. The inuence of religious and ethnic dierences on marital inti-
macy: Intermarriage versus intramarriage. Journal of Marital and Family Therapy.
2000;26(2):241-252. DOI: 10.1111/j.1752-0606.2000.tb00293.x
Cognitive Behavioral Therapy and Clinical Applications144
[92] Martell CR, Safren SA, Prince SE. Cognitive-Behavioral Therapies with Lesbian, Gay,
and Bisexual Clients. New York: The Guilford Press; 2004
[93] Kurdek LA. What do we know about gay and lesbian couples? Current Directions in
Psychological Science. 2005;14(5):251-254. DOI: 10.1111/j.0963-7214.2005.00375.x
[94] Peplau LA, Veniegas RC, Campbell SM. Gay and lesbian relationships. In: Savin-
Williams RC, Cohen KM, editors. The Lives of Lesbians, Gays, and Bisexuals: Children
to Adults. Orlando, FL: Harcourt Brace College; 1996. pp. 250-273
[95] Bepko C, Johnson T. Gay and lesbian couples in therapy: Perspectives for the contem-
porary family therapist. Journal of Marital and Family Therapy. 2000;26(4):409-419.
DOI: 10.1111/j.1752-0606.2000.tb00312.x
[96] Green R-J, Mitchell V. Gay, lesbian and bisexual issues in couple therapy. In: Gurman AS,
Lebow JL, Snyder DK, editors. Clinical Handbook of Couple Therapy. New York:
Guilford Press; 2015. pp. 489-511
[97] Lafrenaye-Dugas A-J, Bolduc R, Godbout N, Hébert M, Goulet M. Trauma cumulatif
et tâches thérapeutiques: Le rôle modérateur de l’aachement évitant dans un échan-
tillon d’adultes consultant en thérapie sexuelle [Cumulative trauma and therapeutic
tasks: The moderating role of avoidant aachment in a sample of adults Consulting
in sex Therapy]. In: Oral Presentation at the 6th Annual Meeting ÉVISSA, Montreal,
Canada. 2016
[98] Dailio FM. Cognitive-Behavioral Therapy with Couples and Families: A Compre-
hensive Guide for Clinicians. New York: Guilford Press; 2010
[99] Epstein NB, Baucom DH, Wright J. L’évaluation et la modication des cognitions
en thérapie conjugale: une approche cognitive-comportementale contextuelle [The
evaluation and modication of cognitions in couple therapy: A contextual cognitive-
behavioral approach]. In: Wright J, Lussier Y, Sabourin S, editors. Manuel clinique
des psychothérapies de couple. Québec: Presses de l'Université du Québec; 2008.
pp. 313-358
[100] Van Selm M, Jankowski NW. Conducting online surveys. Quality and Quantity. 2006;
[101] Paulhus DL, Vazire S. The self-report method. In: Robins RW, Fraley RC, Krueger RF,
editor. Handbook of Research Methods in Personality Psychology. New York, NY:
Guilford Press; 2007. pp. 224-239
[102] Spanier GB. Measuring dyadic adjustment: New scales for assessing the quality of mar-
riage and similar dyads. Journal of Marriage and the Family. 1976;38(1):15-28
[103] Baucom DH, Epstein N, Rankin LA, Burnett CK. Assessing relationship standards:
The inventory of specific relationship standards. Journal of Family Psychology.
1996;10(1):72-88. DOI: 10.1037//0893-3200.10.1.72
[104] Christensen A, Sullaway M. Communication Paerns Questionnaire. Texte inédit.
University of California: Etats-Unis; 1984
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
[105] Christensen A. Detection of conict paerns in couples. In: Hahlweg K, Goldstein M,
editors. Understanding Major Mental Disorder. New York, NY: Family Process; 1987.
pp. 250-265
[106] Christensen A. Dysfunctional interaction paerns in couples. In: Noller P, Fipatrick
MA, editors. Perspectives on Marital Interactions. Philadelphia, PA: Multilingual
Maers; 1988. pp. 31-52
[107] Lawrance K-A, Byers E. Sexual satisfaction in long-term heterosexual relationships:
The interpersonal exchange model of sexual satisfaction. Personal Relationships. 1995;
2:267-285. DOI: hp://
[108] Bodenmann G. Dyadisches Coping Inventar: Testmanual [Dyadic Coping Inventory:
Test Manual]. Bern, Suisse: Huber; 2008
[109] Brassard A, Houde F, Lussier Y. Élaboration et validation du questionnaire de Soutien
conjugal (QSC) [Elaboration and validation of the questionnaire de Soutien conjugal
(QSC)]. Canadian Journal of Behavioural Science/Revue canadienne des sciences du
comportement. 2011;43(2):69-77. DOI: 10.1037/a0021390
[110] Ilfeld FW. Further validation of a psychiatric symptom index in a normal population.
Psychological Reports. 1976;39(3):1215-1228
[111] Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conict tactics
scales (CTS–2): Development and preliminary psychometric data. Journal of Family
Issues. 1996;17(3):283-316. DOI: 10.1177/019251396017003001
[112] Johnson MP, Leone JM, Xu Y. Intimate terrorism and situational couple violence in gen-
eral surveys: Ex-spouses required. Violence Against Women. 2014;20(2):186-207. DOI:
[113] Lafontaine M-F, Brassard A, Lussier Y, Valois P, Shaver PR, Johnson S. Selecting the
best items for a short-form experiences in close relationships questionnaire. European
Journal of Psychological Assessment. 2016;32(2):140-154. DOI: 10.1027/1015-5759/
[114] Dugal C, Godbout N, Bélanger C, Hébert M, Goulet M. Cumulative childhood mal-
treatment and psychological intimate partner violence: The role of emotion dysregula-
tion. Partner Abuse. 2018;9(1):16-38. DOI:10.1891/1946-6560.9.1.16
[115] Bigras N, Godbout N, Hébert M, Run M, Daspe M-È. Identity and relatedness as
mediators between child emotional abuse and adult couple adjustment in women.
Child Abuse & Neglect. 2015;50:85-93. DOI: 10.1016/j.chiabu.2015.07.009
[116] Vaillancourt-Morel M-P, Godbout N, Sabourin S, Briere J, Lussier Y, Run M. Adult
sexual outcomes of child sexual abuse vary according to relationship status. Journal of
Marital and Family Therapy. 2016;42(2):341-356. DOI: 10.1111/jmft.1215
[117] Godbout N, Bigras N, Sabourin S. Childhood cumulative trauma questionnaire
(CCTQ). In: Unpublished Questionnaire, Department of Sexology. Montreal, Canada:
University of Quebec in Montreal; 2017
Cognitive Behavioral Therapy and Clinical Applications146
[118] Fredman SJ, Shnaider P, Pentel KZ, Monson CM. Cognitive behavioral couple therapy
for the treatment of relationship distress. In: Petersen TJ, Sprich SE, Wilhelm S, edi-
tors. Current Clinical Psychiatry. The Massachuses General Hospital Handbook of
Cognitive Behavioral Therapy. 2016. pp. 277-287. DOI: 10.1007/978-1-4939-2605-3_20
[119] Bergeron B, Benazon N, Jodoin M, Brousseau M. Sexualité et dysfonction sexuelle [sex-
uality and sexual dysfunction]. In: Wright J, Lussier Y, Sabourin S, editors. Manuel
clinique des psychothérapies de couple. Québec: Presses de l'Université du Quebec;
2008. pp. 361-396
[120] Christensen A. A unied protocol for couple therapy. In: Hahlweg K, Grawe-Gerber M,
Baucom DH, editors. Enhancing Couples: The Shape of Couple Therapy to Come.
Göingen: Hogrefe; 2010. pp. 33-46
[121] Oliver PH, Margolin G. Communication/problem-solving skills training. In: O'Donohue WT,
Fisher JE, editors. General Principles and Empirically Supported Techniques of Cognitive
Behavior Therapy. Hoboken, NJ: John Wiley; 2009. pp. 199-206
[122] Clements K, Holworth-Munroe A. Aggressive cognitions of violent versus non-
violent spouses. Cognitive Therapy and Research. 2008;32(3):351-369. DOI: 10.1007/
[123] Epstein NB, Dailio FM, Baucom DH. Cognitive-behavior couple therapy. In: Sexton TL,
Lebow J, editors. Handbook of Family Therapy. New York: Routledge/Taylor & Francis
Group; 2016. pp. 361-386
[124] Oliver M, Castillo Y. Behavioral and cognitive-behavioral theories: Approaches and
applications. In: Capuzzi D, Stauer MD, editors. Foundations of Couples, Marriage,
and Family Counseling. Hoboken, NJ: John Wiley; 2015. pp. 261-285
[125] Worrell M. CBT Distinctive Features. Cognitive Behavioural Couple Therapy:
Distinctive Features. New York: Routledge/Taylor & Francis Group; 2015
[126] Linehan MM. Diagnosis and Treatment of Mental Disorders. Cognitive-Behavioral
Treatment of Borderline Personality Disorder. New York: Guilford Press; 1993
[127] Randall AK, Bodenmann G. The role of stress on close relationships and marital satis-
faction. Clinical Psychology Review. 2009;29(2):105-115
[128] Weeks GR, Gambescia N. Couple therapy and sexual problems. In: Gurman AS, Lebow JL,
Snyder DK, editors. Clinical Handbook of Couple Therapy. New York: Guilford Press;
2015. pp. 635-656
[129] Corsini-Munt S, Bergeron S, Rosen NO, Mayrand M-H, Delisle I. Feasibility and pre-
liminary eectiveness of a novel cognitive-behavioral couple therapy for provoked
vestibulodynia: A pilot study. Journal of Sexual Medicine. 2014;11(10):2515-2527 hp://
[130] Camacho ME, Reyes-Ortiz CA. Sexual dysfunction in the elderly: Age or disease?
International Journal of Impotence Research. 2005;17(Suppl 1):S52-S56. DOI: hps://
Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…
[131] Kelly MP, Strassberg DS, Turner CM. Communication and associated relationship
issues in female anorgasmia. Journal of Sex & Marital Therapy. 2004;30(4):263-276. DOI:
[132] Schwar P, Young L. Sexual satisfaction in commied relationships. Sexuality Research
& Social Policy: A Journal of the NSRC. 2009;6(1):1-17. DOI: 10.1525/srsp.2009.6.1.1
[133] Johnson S, Zuccarini D. Integrating sex and aachment in emotionally focused
couple therapy. Journal of Marital and Family Therapy. 2010;36(4):431-445. DOI:
[134] Ledley DR, Huppert JD. Behavior therapy. In: Kazanis N, L'Abate L, editors. Handbook
of Homework Assignments in Psychotherapy: Research, Practice, Prevention. 2007.
pp. 19-34. DOI: 10.1007/978-0-387-29681-4_2
[135] Masters WH, Johnson VE. Human Sexual Inadequacy. Boston: Lile, Brown; 1970
[136] Fischer DJ, Fink BC. Clinical processes in behavioral couples therapy. Psychotherapy.
2014;51(1):11-14. DOI: 10.1037/a0033823
[137] Christensen A, Dimidjian S, Martell CR. Integrative behavioral couple therapy. In:
Gurman AS, Lebow JL, Snyder DK, editors. Clinical Handbook of Couple Therapy.
New York: Guilford Press; 2015. pp. 61-94
[138] Carson JW, Carson KM, Gil KM, Baucom DH. Mindfulness-based relationship
enhancement. Behavior Therapy. 2004;35(3):471-494. DOI: 10.1016/S0005-7894(04)
[139] McBride C, Atkinson L, Quilty LC, Bagby RM. Attachment as moderator of treat-
ment outcome in major depression: A randomized control trial of interpersonal
psychotherapy versus cognitive behavior therapy. Journal of Consulting and
Clinical Psychology. 2006;74(6):1041-1054. DOI: 10.1037/0022-006X.74.6.1041
[140] Simeone-DiFrancesco C, Roediger E, Stevens BA. Schema therapy with couples: A prac-
titioner's guide to healing relationships. Chichester: John Wiley & Sons Ltd; 2015. DOI:
[141] Gehart DR. Mindfulness and acceptance in couple and family therapy. New York:
Guilford; 2012. DOI: 10.1007/978-1-4614-3033-9
Cognitive Behavioral Therapy and Clinical Applications148
... By way of history, CBCT originated from operant-interpersonal treatment approaches for marital discord. Back in the 1960's and 1970's, behaviour therapists experimented with the principles of learning theory to address problematic behaviours of adults and children (Dugal, et al, 2018). Many of the behavioural principles and techniques that were used in the treatment of individuals found their way to being applied to couples in distress. ...
... Initially the therapist aims to identify the couples' concerns, expectations, motivation for therapy and the areas of enrichment/growth. This assessment is coupled with psycho educating the couple on what to expect in therapy (Dugal, et al, 2018). The second step involves a clarification of the cognitive, behavioural, and effective factors associated with the two individuals, the couple as a dyad, and the couple's environment that contribute to their presenting concern. ...
... The therapist can ask the partners to engage in many kinds of conversations, example discussing an area of moderate concern in their relationship, so the therapist can observe how they make decisions. The aim is to formulate a case conceptualization to intervene adequately (Dugal, et al, 2018). ...
This book contains a collection of selected papers on topics in intimate partner violence, family therapy and racial micro-aggressions. In putting together this collection, papers that have therapeutic relevance to the people of African descent were selected. The book is divided into two parts. Part one presents papers on intimate partner violence. While these papers deal specifically with violence confronted by the African population as individuals, the socio-cultural context of the abused is also crucial to note. The papers contribute to a clinician's understanding of how the clients came to be the way they are. Part two presents papers that touch on psychotherapy. The first paper provides the therapist with one viable option for family therapy. The second paper guides the therapist when conducting therapy across different racial groups. Each chapter includes an extensive list of resources that can be consulted by readers interested in the relevant topics. Discussions on intimate partner violence as well as Western healing methods and their relevance to African populations continue to be an important focus area for academic research. The book aims to add to the discourse. It also aims to provide a resource for students and practitioners interested in issues that relate to individuals of African descent as clients in need of intervention or as therapists. Gratitude is expressed towards the individuals who contributed chapters to the book.
... Literature supports that the treatment approach is effective in the field of marital relations and deals with different aspects of this relationship [22]. Also, previous results show that cognitive-behavioral therapy had a significant impact on the intimacy and marital satisfaction of betrayed women [19] and has a significant effect on increasing marital satisfaction, especially in improving communication and marital conflict, marital burnout resolution skills of couples, and their sexual relationships [23,24]. Also, this approach is effective in enhancing marital satisfaction and sexual satisfaction in postmenopausal women [25] and is effective in improving women's quality of life and happiness [26,27]. ...
Full-text available
Introduction: If couples do not acquire communication and conflict resolution skills, their disagreements will continue at first verbally and then behaviorally. Thus, the gradual destruction in marital intimacy will begin. Objectives: This study aimed to investigate the effectiveness of cognitive-behavioral psychotherapy on the couple's intimacy and identification of basic psychological needs in couples referring to counseling centers. Materials and Methods: This is a quasi-experimental study with a Pre-test-Post-test design and control group. The study population consisted of all couples referring to counseling centers of Ahvaz City, Iran, in the year 2018-2019. The sample was recruited with a convenience sampling method consisting of 40 couples that were randomly assigned to the experimental and control groups (20 in each group). To collect information, we used Thompson and Walker's (1983) marital intimacy scale and Glaser basic need questionnaire. The experimental group underwent cognitive-behavioral psychotherapy (eight 90-minute sessions), but the control group received no intervention. The data were analyzed using descriptive and inferential statistics (repeated measure ANOVA). Results: The cognitive-behavioral psychotherapy was effective in increasing marital intimacy and identifying the basic needs of the couples (P
Britain has increasingly become a multi-cultural society. In order to improve access to primary care psychological therapy including cognitive behavioural therapy (CBT), there has been an increase in focus on cultural adaptation and cultural responsiveness. To date, these adaptations have focused on domains such as language, beliefs and values. In this case, familism was the focus for adaptation. The client was a 22-year-old female from a black African-British background. She presented with severe symptoms of chronic depression as measured on routine standard questionnaires and the interview. She had minimal success from previous interventions and was struggling to make progress. Therapy was guided by the client’s views on what issues had a bearing on her difficulties. The client hypothesised that familism factors with themes around ‘my parents’ culture’ and ‘family comes first’ were interacting with her cognitive behavioural factors to maintain her problem. She requested the involvement of her family in her treatment plan. In line with the Improving Access to Psychological Therapies–Black, Asian and Minority Ethnic service user Positive Practice Guide, this was integrated as part of her formulation. Upon involvement of her father in a single session, the client attained reliable improvement. She attributed her improvement to this involvement. By the end of therapy, she reached recovery, which was maintained at 3-month follow-up. This study was responsive to the client’s own perceived cultural needs through the integration of familism into her CBT formulation. It illustrates a client-led cultural adaptation of CBT to treat chronic depression. Key learning aims It is hoped that the reader will increase their understanding of the following from reading this case study: (1) Creating an environment where clients can freely discuss their perceived cultural factors from the outset. (2) Client-led cultural responsiveness to their expressed cultural needs. (3) Familism as a domain for adapting CBT.
Full-text available
Several kinds of marital conflict might be solved through constructive communication, development of interaction skills, and behavioral and thought modification. The aim of this study was to show results of the application of a protocol based on cognitive behavioral couple therapy (CBCT) on dyadic adjustment, marital social skills, depression, and anxiety symptoms. The sample consisted of 32 participants (16 couples) divided in two groups by length of marriage: Group 1 (1-7 years) and Group 2 (8-12 years). All subjects recruited were older than 18 and reported having communication problems in their relationship. The ages were M = 30.4, SD = 4.13. The measures were Dyadic Adjustment Scale (DAS), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Marital Social Skills Inventory (Inventário de Habilidades Sociais Conjugais [IHSC]), and the Socio-demographic Questionnaire. Participants were assessed pre-and postintervention and had a 6-month follow-up. The intervention consisted of twelve 50-min sessions per couple. Based on three time analyses, both groups obtained the following results: DAS (p = .001), BDI-II (p = .000), BAI (p = .000), and IHSC (p = .001). We conclude that the CBCT protocol developed for this study, resulted in statistically significant improvements in the couple's relationship for all variables studied in both groups.