Lecture 5. CBT theories, models and methods of

couple relationshipsCouple Counselling Skills

Kevin Standish

Learning outcomes1. Phases of Development in CBT couple therapy2. How CBT for Couples Works Generally3. Comparison of CBT Couples therapy with Integrative behavioural

couples therapy

Overview1. Phases of Development in CBT couple therapy2. How CBT for Couples Works

Phases of Development in CBT couple therapy• Behavioral couple therapy (BCT), launched by the work of Stuart and Jacobson has itself passed through quite

distinct periods: • The “Old BCT” phase emphasized skills training (e.g., communication and problem solving) and change in overt

behavior (e.g., behavioural exchanges), and the therapist’s role was highly psychoeducational and directive. • “New BCT” phase, marked by the development of “Integrative Behavioral Couple Therapy” (Christensen,

Jacobson, & Babcock, 1995) shifted to a more balanced position of changing self as well, marked by new interventions to facilitate the development of greater mutual acceptance, especially around repetitive patterns of interaction and persistent partner characteristics or what Gottman (1999) called “perpetual issues.”

• The “Self-Regulation Phase,” focused on the very salient impact of partners’ affective self- regulation capacity, as sometimes highlighted in clinical work with volatile, “difficult” couples, in which, for example, one of the partners has with a demonstrably significant personality disorder, often, but not always, borderline personality disorder. This self-regulation phase overlaps with the very current phase of BCT’s evolution which has made significant contributions to the treatment of a wide variety of psychological/psychiatric disorders in their intimate relational context (e.g., alcoholism and drug abuse, sexual dysfunction, depression, and bipolar disorder).

Cognitive Behavioral Couples Therapy (CBCT) • has become one of the most well researched approaches for the

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

Cognitive Behavioral Couple Therapy • begins with education, from a scientific perspective, on the biological and psychological

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

Based on Gottman• Research by John Gottman a leading marital therapist, shows that

the success or failure of a relationship can be predicted with 96% accuracy. This is based on the presence or absence of four simple behaviours. • Criticism: Attacking your partner’s personality or character, usually

with the intent of making someone right and someone wrong.• Contempt: Attacking your partner’s sense of self with the intention

to insult or psychologically abuse him/her.• Defensiveness: Seeing one's self as the victim and continuously

warding off a perceived attack.• Stonewalling: Withdrawing from the relationship as a way to avoid

conflict.

Cognitive-Behavioral Couples Therapy

• Based on a belief that people evaluate their relationship and partners according to unreasonable standards.• If people’s appraisals of events are altered then there will be positive

changes in behavior and emotion accordingly.• Two different stresses: primary distress and secondary distress.

Cognitive-Behavioral Couples Therapy

• Primary distress comes from one partner’s unmet needs (affiliation, intimacy, autonomy...).• Secodary distress emerges when that partner uses wrong strategies to

address the conflict coming from unmet needs (ignoring, verbally or physically attacking).

Cognitive-Behavioral Couples Therapy

• Delivered within 8-25 sessions.• First 2-3 sessions are for the assessment and followed by a feedback

session. The couple and the therapist define the treatment goals together.• Socratic questioning and guided discovery techniques may be used.

Cognitive-Behavioral Couples Therapy

• Socratic questioning involves asking the client a series of questions to reevaluate the logic behind his/her certain beliefs.• Guided discovery involves creating experiences (role playing, pros and

cons of the relationship) to have different perspectives.

Integrative Behavioral Couples Therapy

• Adds “emotional acceptance” to BCT to increase positive feelings.• Jacobson and Christensen (1996) say that in the early stages, partners

tolerate the differences in personality and see it them as the source of attraction.• In time, these differences become sources of discontent and concern,

and result in polarization, vilification.

Integrative Behavioral Couples Therapy

• This therapy is interested in the agent of behavior and the receiver together.• According to this therapy increased acceptance reduces

conflict and is a catalyst for change.• Acceptance techniques’ aim is to soften the adversarial

attitudes partners take toward each other.

Integrative Behavioral Couples Therapy

• Gottman says that some problems cannot be solved. Instead of aiming to solve them the sources of conflict can be turned into sources of intimacy.• IBCT therapists determine a central theme which summarizes the

central issue.• They believe that as partners try to change each other, polarization

occurs. This is called the mutual trap.

Integrative Behavioral Couples Therapy• The effort to change eachother creates a defense,

therefore the partner who want to change the other experiences a frustration and hopelessness.• The theme+polarization+mutual trap= the

formulation.• Interested in the history of the relationship, the

individual’s family, and individual’s previous relationships.

How CBT for Couples Works

• Cognitive Behavioural Therapy is used to identify these behaviours , understand the triggers, expectations, beliefs and attitudes that keep them going and identify and practise healthy a realistic alternatives.

• There are five steps in the CBT for couples process:1. Identifying and acknowledging individual expectations and perceptions.2. Exploring counter-productive triggers, beliefs and behaviours.3. Agreeing differences and acceptable tolerance ranges.4. Identifying and practising new behaviours based on shared values, mutual respect, empathy, trust

and tolerance.5. Agreeing a new "emotional contract". This expresses the changes that each partner commits to and

forms the basis of the future relationship.Couples are encouraged to adopt a positive emotional tone by actively building a shared vision for the future. Relationship resilience is developed by shifting the focus and over-riding conflict with a willingness to respect and tolerate each other's differences.

Integrative Behavioral Couple Therapy• Integrative Behavioral Couple Therapy is "integrative" in at least two

senses: • First, it integrates the twin goals of acceptance and change as positive

outcomes for couples in therapy. Couples who succeed in therapy usually make some concrete changes to accommodate the needs of the other but they also show greater emotional acceptance of the other. • Second, IBCT integrates a variety of treatment strategies under a

consistent behavioral theoretical framework.

Integrative Behavioral Couple Therapy• Both the integrative and traditional behavioral couples therapy

models have origins primarily in behaviorism.• While traditional behavioral couples therapy has more roots in social

learning principles and the later model in Skinnerian behaviorism. • The Integrative model draws heavily on the use of functional analysis

(psychology) and the Skinnerian distinction between contingency shaped and rule governed behavior to balance acceptance and change in the relationship

Comparative Framework.• 1. Background of the Approach• 2. The Healthy/Well-Functioning versus Pathological/Dysfunctional

Couple/Marriage• 3. The Role of the Therapist• 4. Assessment and Treatment Planning• 5. Goal Setting• 6. Process and Technical Aspects of Couple Therapy• 7. Curative Factors/Mechanisms of Change• 8. Treatment Applicability and Empirical Support

1. Background of the Approach

Cognitive-Behavioral Couple Therapy (CBCT)• developed from the confluence of three major

influences:• (1) behavioral couple therapy• (2) cognitive therapy (CT)• (3) information processing in the field of

cognitive psychology regarding attributions that individuals make about determinants of positive and negative events in their relationships and relatively stable schemas that individuals develop on the basis of past relationship experiences and subsequently apply in understanding current relationship events.

Integrative behavioral couples therapy(IBCT) third-wave behavioral therapies• IBCT grew principally from traditional behavioural

couple therapy (TBCT): skills-• based, change-oriented treatment that relies on two

primary intervention components: (1) behavior exchange, and (2) communication and problem-solving training.

• problems that represented basic and irreconcilable differences between partners appeared to be less amenable to traditional change strategies.

• the key to a better result was to promote emotional acceptance of the other and not emphasize change so much. Jacobson and Christensen (1998) see acceptance as the “missing link” in couple intervention.

2. The Healthy/Well-Functioning versus Pathological/Dysfunctional Couple/Marriage

Cognitive-Behavioral Couple Therapy (CBCT)• CBCT employs a broader contextual

perspective in defining a healthy relationship,• A “healthy relationship” is defined as one in

that contributes to the growth and well-being of both partners, in which the partners function well together as a team and relate to their physical and social environment in an adaptive fashion

• A healthy couple relationship is one thatcontributes to the growth, development, wellbeing, and needs fulfillment of each partner.

Integrative behavioral couples therapy(IBCT)• Distress is caused by the destructive ways that

some couples respond to areas of difference and disagreement, which are assumed to be both normal and inevitable.

• Differences between partners are likely to create difficulties when these differences spring from vulnerabilities within each partner rather than mere differences in preference.

• Three destructive patterns frequently characterize distressed couples’ conflicts over their differences: 1.mutual coercion, 2.vilification, and 3.polarization.

2. The Healthy/Well-Functioning versus Pathological/Dysfunctional Couple/MarriageCognitive-Behavioral Couple Therapy (CBCT)• partners in distressed relationships are more likely to

track negative behavior selectively in the other, to make negative attributions for such behavior and to reciprocate negative behavior with negative behaviour. As partners continue to engage in negative reciprocity and perceive the other in a negative way, they may develop “sentiment override,” or global negative emotions, toward each other. This sentiment override increases the likelihood of subsequent negative behavior and the development of partners’ negative expectancies or predictions that the other person will engage in negative acts. A cycle of self-maintaining process of relationship discord that often typifies distressed couple.

Integrative behavioral couples therapy(IBCT)• distressed couples experience an

erosion in their willingness to accept, tolerate, and compromise around one another’s differences, they no longer look upon each other’s styles as sources of attraction; they begin to exert efforts to change their partners• Happy couples are able to confront

their differences with greater acceptance and tolerance.

3. The Role of the Therapist

Cognitive-Behavioral Couple Therapy (CBCT)• during the assessment and the early stages of therapy, the

therapist assumes a didactic role, striking a balance between directiveness and collaboration with the couple in setting goals and applying cognitive-behavioural strategies toward achieving them.

• Once treatment begins, the therapist at times assumes a didactic role and provides rationales for treatment recommendations and the assignment of homework;

• reviews assignments and events that occurred in the relationship during the past week;

• models skills and coaches the partners in practicing them in and outside of sessions; and continually fosters partners’ motivation.

• The therapist’s level of directiveness varies according to the partners’ presenting concerns ; their ability to self-monitor their behaviors, emotions, and cognitions; and their preference for structure in therapy

Integrative behavioral couples therapy(IBCT)• IBCT therapist is frequently very active

and directive in sessions, the particular form of the therapist’s interventions will vary

• therapist requires comfort with a high degree of flexibility and change

• the highest priority for the IBCT therapist is maintaining a focus on the case formulation of the couple

• therapist is to attend to and highlight the function of behaviors.

3. The Role of the TherapistCognitive-Behavioral Couple Therapy (CBCT)• the CBCT therapist also sets the pace of sessions, so that the

goals of treatment are addressed in a timely and reasonable fashion.

• In collaboration with the couple, the therapist typically initiates setting the agenda for each session, contributing particular agenda items such as review of homework and practice of a particular skill, always soliciting the couple’s preferences for the agenda.

• The therapist then monitors the use of time during the session and ensures that the agenda is followed to the degree appropriate

• The therapist also adopts the role of facilitator, creating a safe and supportive environment in which the couple can address difficult issues.

• it is important the therapist’s direction and imposition of structure gradually diminish over time, as the partners assume increasing responsibility for managing their concerns.

Integrative behavioral couples therapy(IBCT)• Using this historical context, the

therapist suggests that these histories have occasioned the current behaviors and associated feelings• Multiple roles of educator, teacher;

Coach; skills provider; facilitator; • The IBCT therapist uses language as an

important intervention tool, because impactful language is one important way to alter a couple’s relationship context

4. Assessment and Treatment PlanningCognitive-Behavioral Couple Therapy (CBCT)• The primary goals of a clinical assessment are:• (1) to identify the concerns and potential areas of

enrichment/ growth for which a couple has sought assistance;• (2) to clarify the cognitive, behavioral, and affective factors

associated with the two individuals, the couple as a dyad, and the couple’s environment, that contribute to their presenting concerns;

• (3) to determine the appropriateness of couple therapy in addressing these concerns.

• The therapist clarifies partners’ goals for treatment and their respective positions and perspectives regarding the areas of concern.

• the therapist determines each partner’s emotional investment and motivation for continuing with the relationship.

Integrative behavioral couples therapy(IBCT)• A comprehensive and structured assessment

process provides the foundation• The foundation of any truly behavioral

assessment process is the functional analysis • With that information,the clinician can then

alter the controlling stimuli and change the problematic behaviour

• the therapist seeks to understand the variables that control dissatisfaction, which are more often broad response classes of behaviour to see the common thread in diverse complaints and problems

4. Assessment and Treatment PlanningCognitive-Behavioral Couple Therapy (CBCT)• the focus is on strengths, as well as

problems, the questions posed by the therapist often draw partners’ attention to the positive aspects of their relationship.

• Distressed couples entering therapy often selectively track negative behaviors and events, so refocusing on the positive can increase

• common methods are used in self-report, interview, and observational approaches to assessment.

Integrative behavioral couples therapy(IBCT)• A functional analysis in IBCT emphasizes

not only the broad class of behaviors by the “agent” that is a source of dissatisfaction for the recipient but also the reactions of the recipient partner.

• The primary goal of the functional analysis is the development of a case formulation and a resultant treatment plan.

• the “formulation” comprises three primary components: the theme, the polarization process, and the mutual trap.

5. Goal Setting

Cognitive-Behavioral Couple Therapy (CBCT)• The therapist also describes behavioral,

cognitive, and affective response patterns that the assessment has indicated are contributors to the couple’s relationship difficulties.

• The therapist asks the partners for feedback about this case conceptualization,checking to see whether it matches their views of their difficulties.

• The therapist then collaborates with the couple in translating descriptions of relationship problems into statements of positive goals.

Integrative behavioral couples therapy(IBCT)• The major treatment goals in IBCT are to

help couples better understand and accept one another as individuals and to develop a collaborative set whereby each partner is willing to make necessary changes to improve the quality of the relationship.

• Specific goals for treatment are determined collaboratively by the therapist and couple, and are explicitly discussed during the feedback session.

5. Goal SettingCognitive-Behavioral Couple Therapy (CBCT)• The therapist relates these goals to specific

intervention techniques designed to substitute desired patterns for the existing ones.

• Explicit goal setting is important• It is important that the therapist• caution the partners that it is not unusual for

additional concerns to present themselves as therapy progresses, particularly if a pressing problem has distracted them from noticing other issues.

• Goals for therapy often evolve over time.

Integrative behavioral couples therapy(IBCT)• The formulation is so important that it

forms an overarching goal to get couples to see their relationship through the lens of the formulation, as it relates to their daily struggles and joys, the therapist helps the couple process their interactions throughout the treatment

• Implicit in the goals of understanding, acceptance, and collaboration is the acknowledgment that staying together is not always the right outcome for all couples

6. Process and Technical Aspects of Couple Therapy

Cognitive-Behavioral Couple Therapy (CBCT)• it is important to recognize that

behavior, cognitions, and emotions are integrally related.• Changes in one domain typically

produce changes in the other domains

Integrative behavioral couples therapy(IBCT)• Interventions fall into three

categories: 1. acceptance strategies, 2. tolerance strategies, 3. change strategies.• 1. acceptance strategies: empathic

joining; unified detachment; these strategies aim to help couples turn their problems into vehicles for greater intimacy.

6. Process and Technical Aspects of Couple TherapyCognitive-Behavioral Couple Therapy (CBCT)• Interventions for Modifying Behavior:

Guided Behavior Change; Skills-Based Interventions; • Interventions That Address

Cognitions: Socratic Questioning; Guided Discovery; • Interventions Focused on Emotions:

Restricted or Minimized Emotions; Containing the Experience/Expression• of Emotions;

Integrative behavioral couples therapy(IBCT)• 2. tolerance strategies: allow partners to

let go of their efforts to change one another. Techniques such as pointing out the positive features of negative behavior, practicing negative behavior in the therapy session, faking negative behavior between sessions, and self-care

• 3. change strategies: behavior exchange techniques and communication/problem-solving training

• Acceptance through Empathic Joining

7. Curative Factors/Mechanisms of Change

Cognitive-Behavioral Couple Therapy (CBCT)• different couples might need

different types of intervention, and mechanisms of change vary accordingly• relationship schematic

processing (RSP) refers to the degree to which an individual processes information in terms of circular relationship processes

Integrative behavioral couples therapy(IBCT)• all the strategies in IBCT come

from a behavioural theoretical perspective• it integrates strategies for change

with strategies for acceptance. • IBCT focuses as much on the

recipient of behavior as on the agent of behavior.

7. Curative Factors/Mechanisms of ChangeCognitive-Behavioral Couple Therapy (CBCT)• Therapists who are able to

process information quickly and respond in the moment are most effective with this approach.

Integrative behavioral couples therapy(IBCT)• three major reasons for the shift in emphasis in IBCT from the

agent to the recipientof behavior: • 1. there are in every relationship some “unsolvable” problems

that the agent is unwilling or unable to change to the level the recipient desires. Improvement in these cases will be mediated by increased acceptance and tolerance.

• 2. Paradoxically, increased acceptance in one partner may at times also mediate increased change. The pressure for change from one partner that contributes to the maintenance of the undesirable partner behavior. Thus, when the pressure to change is eliminated by increased acceptance or tolerance, change may follow. As partners let go of their efforts to change one another, they become less emotionally reactive; as a result, change becomes more likely.

• 3.the reaction to an offending behaviour is as much a problem as the offending behaviour itself.: “crimes of the heart are usually misdemeanors”

8. Treatment Applicability and Empirical Support

Cognitive-Behavioral Couple Therapy (CBCT)• CBCT is the most widely evaluated couple

treatment• findings suggest that between roughly 33

and 67% of couples are in the nondistressed range of marital satisfaction after receiving CBCT.

• Most couples appear to maintain these gains for short time periods (6–12 months); however, long range follow-up results are not as encouraging. 30% of couples who had recovered during therapy subsequently relapsed

Integrative behavioral couples therapy(IBCT)• Improvements in relationship satisfaction

and stability come about through changes in behavior, and changes in the emotional reactivity (acceptance) of that behaviour

• IBCT improved or recovered (80%) compared to couples treated with TBCT (64%).

• 69% of IBCT couples demonstrated clinically significant improvement at the 2-year follow-up relative to their initial status

Readings• Core Readings: • Gurman (2008) : • Chapter 2. Cognitive- behavioral Couple Therapy by Donald H. Baucom , Norman B. Epstein,

Jaslean J. LaTaillade , and Jennifer S. Kirby.• Chapter 3: . integrative behavioral Couple Therapy Sona Dimidjian, Christopher R. Martell,

and Andrew Christensen• Patterson (2005) CBT couple therapy• Advanced reading:• Gurman (2008) Chapter 13: integrative Couple Therapy: a depth- behavioral approach • Mairal & Cela (2015) Integrative Behavioural couple therapy• Davila (2003) chapter 7 attachment processes in couple therapy: informing behavioural

models found in Johnson and Whiffen (2003).