Cognitive-behavioral couples therapy (CBT) revolves around maladaptive thoughts, behaviors, and emotions; plus the interplay of these in relationships. CBCT takes into account the influence of both nature and nurture (e.g., social learning theory). Epstein and Baumcom’s enhanced CBCT is ecological and contextual (Epstein & Zheng, 2017). CBCT is an expansion of behavioral theories and cognitive behavioral therapy (CBT) created by Beck. An example of a behavioral principle incorporated in CBCT is positive reinforcement (Baucom et al., 2015). CBT’s premise of human nature is foundational to CBCT. The basic assumption when using CBT is that a certain pattern of dysfunctional thinking underlies each disorder (Beck, 2011). In relationships, individuals are also driven by patterns of negative thinking and reacting. Beck (1963) asserted that thoughts precede affect. Furthermore, he stated thoughts often have systematic errors (i.e., “cognitive distortions”) like arbitrary inference, selective abstraction, overgeneralization, exaggeration, and exact labeling. The cognitive model can be used to understand that interpretations of a situation, based on beliefs and expressed through automatic thoughts, lead to emotional, behavioral, and physiological consequences (Beck, 2011). Moreover, individual physiological reactions (.e.g, sweating) and partner responses (e.g., withdrawal) reinforce negative beliefs leading to a cycle of dysfunction. Notably, individuals can have many automatic thoughts throughout the day that may go unnoticed; intermediate beliefs and core beliefs underlie these thoughts and are even less discernible (Beck, 2011). Increasing awareness of thoughts can be very helpful to distressed partners. According to Beck (2011) core beliefs are global, rigid, and overgeneralized like “I am unlovable.” He described intermediate beliefs as rules, attitudes, and assumptions. CBCT focuses on five cognitions, three that are automatic thoughts: selective attention, attributions, expectancies, assumptions, and standards (Epstein & Zheng, 2017). For example, a couple may have unreachable relationship standards that are problematic; in CBCT this would be addressed.
To address problematic thoughts, emotions, and behaviors key change factors must be targeted. Epstein and Zheng (2017) argued CBCT is effective since it addresses key change factors like communication, problem-solving, and pleasing behaviors and tracks interaction cycles. In CBT for addiction, couples are encouraged to focus on the context (i.e., what is maintaining behavior now – situations, cognitions, affects, contingencies) and to change circumstances for managing behavior (psychotherapy.net, 2000). Thus, the environment is a key factor. Positive outlook is another key change factor. CBT therapists modify clients’ cognitions about how the world works; reframing can be used to increase positive outlook (psychotherapy.net, 2002). Changing thinking, especially core beliefs, to be more realistic and adaptive helps alleviate symptoms and increase functioning (Beck, 2011). CBCT for aggression focuses on communication, problem-solving, negative cognitions, poor regulation, and poor coping skills (Epstein et al., 2015). Acceptance of partner’s behavior and increase of perceived positive communication and decrease of negative communication also predicted relationship improvements (Baucom et al., 2015). Epstein and Zheng (2017) argued CBCT is effective since it addresses communication, problem-solving, and pleasing behaviors and tracks interaction cycles. Key change factors are various and the factors of most importance depend on the issue and goals of therapy. Nevertheless, these are factors that should be addressed to elicit positive change. It is vital to include these factors in treatment planning.
Intervention strategies are designed according to the clients specific needs and desires. Baucom et al. (2015) stated areas of growth and cognitive, behaviors, and affective factors related to the individual(s) and environment are assessed to come up with a treatment plan. Furthermore, he explained the therapist assesses degrees of difference in partners’ personalities, needs, and values. Bacuom et al. also described that goals are collaborative, for example, a goal that is vital to clients can be to increase intimacy; however, any hostility, criticism, and disengagement must be worked on first for therapy to be successful. They also stated when disorder is present, the primary goal is to assist the individual with the disorder and improving the relationship is secondary. CBCT therapists must be mindful of how to best prioritize goals for effective treatment. Dr. Masek stated he would first take care of any type of chronic somatic pain if present; then, get chief complaints and clients’ understanding of illness (psychotherapy.net, 2002). Once main issues and goals are identified then interventions can be planned. Interventions can include problem-solving, relaxation, coping techniques, homework, pros and cons lists, and more. For example, guided discovery can be used to identify thoughts (Beck, 2011). Intervention strategies that target emotions, thoughts, or behaviors can be used. Thus, CBCT is highly adaptable to a variety of issues.
CBCT can also be used to conceptualize a wide array of mental health issues. Baucom et al. (2015) explained a dysfunctional relationship when using CBCT is defined as one that does not contribute to the growth and well-being of individuals in the unit; partners should work as a team and be adaptive. They also defined unmet needs, due to individual differences, e.g., in autonomy, control, and achievement, as the primary problem and maladaptive coping as a response to this. They explained how dysfunctional responses to life events are caused by idiosyncratic interpretations due to cognitive distortions. Interpretation of thoughts can have a negative bias common in some disorders like depression. Specifically when it comes to relationships, CBCT users look at attributions and schemas individuals have about relationship events (Baucom et al., 2015). The typical schema of depressed clients has themes of low self-esteem, self-blame, overwhelming responsibilities, and desires to escape (Beck, 1963). This may translate to thoughts related to a partner not being loving, caring, or doing enough. Furthermore, research shows there is a bidirectional relationship between depression and relationship distress (Epstein & Zheng, 2017). Baucom et al. stated dysfunction may also be related to unreasonable standards (e.g., always or never). Sexual issues can be conceptualized as related to distortions about standards, expectations, and meaning(s) related to sex (Weeks & Gamescia, 2015). Issues are also conceptualized by identifying demand-withdraw patterns (Baucom et al., 2015). Aggression is conceptualized as an issue related to overlearned behavior, skill deficits, negative thoughts about gender role, and poor emotion regulation and coping (Baucom et al., 2015). Those with aggression, for example, will need to work on constructive expression. An integrative CBCT approach for affairs includes a trauma-based perspective and addresses impact of affair, meaning and reason of the affair, and moving forward (Baucom et al., 2015). Those that have experienced affairs will work on processing and forgiveness. For OCD, CBCT focuses on psychoeducation, confronting feared situations, and working together (Baucom et al., 2015). For PTSD, CBCT addresses behaviors like aggression; cognitions like self-blame; and emotions like fear (Epstein & Zheng, 2017). Thus, disorders are conceptualized based on unique factors related to emotions, thoughts, and behaviors that hamper growth and well-being. However, CBCT does not only focus on negative health factors it also enhances positive health factors.
There are more than a few key factors that contribute to healthy couples and families and are of import in CBCT. For example, forgiveness is a positive factor that should be increased. Williams (2012) warned, couples that do not work through forgiveness may revert to dysfunctional behaviors. Gordon et al. (2015) explained the importance of forgiveness to increase empathy and decrease hostility. Williams (2012) further explained individuals often have misconceptions about forgiveness that need to be worked through. Thus, any misconceptions, e.g., forgiveness is excusing behavior, must be addressed to ensure couples can master this skill. Williams (2012) also suggested that couples work on communication skills, reasonable expectations, and compromise. These factors are essential to relationship satisfaction. Additionally, Williams (2012) stated problem solving is essential: the steps are to define the problem, find common ground, propose solutions, weigh solutions, try out solutions, and review effectiveness. Without the ability to problem solve couples would be stuck repeating dysfunctional patterns; for example, they would keep arguing about household chores. Baucom et al. (2015) explained the importance of community, intimacy, altruism, understanding, and support or attention in relationships. These factors are essential for individuals to feel loved and appreciated. Epstein and Zheng (2017) stated coping is another factor that contributes to healthy couples and families. They explained the more negative appraisals are the worse coping will be; furthermore, couple’s judge each other’s appraisals. Thus, healthy couples will have more positive appraisals, judgements, and coping methods. Epstein and Zheng asserted positive interactions, cognitions, and emotions as essential. Functional relationships are not merely an absence of problems, they are a surplus of positives. The therapist must be highly skilled to facilitate the use of constructive exchanges.
CBCT therapists should have a number of qualities and skills to enhance the therapeutic alliance, elicit change, and contribute overall to effective therapy. Monson and Fredman (2015) stated, for example, curiosity and a non judgemental attitude are essential; if a client becomes agitated in session the therapist should be able to use this opportunity to talk about underlying thoughts and feelings. Furthermore, they asserted clinicians must have good conflict management skills and not collude with the client in avoidance. Baucom et al. (2015) stated the ability to join simultaneously with both individuals of a couple is essential; empathetic reflective listening can help with this. They also argued that conveying confidence and credibility is essential for controlling sessions. CBCT therapists should also be creative, creativity is necessary to tailor interventions to unique situations and clients. Baucom et al. (2015) stated therapists must also be skilled at creating a rich conceptualization of couples. Furthermore, they stated CBCT therapists must be active, directive, and skilled at handling strong emotions. These skills are necessary for each therapy session to be productive and fruitful. Without these skills clients may become lost in their distress and lack the clarity to progress. In CBCT, the therapist is responsible for ensuring the client has direction.
The CBCT practitioner-client relationship is highly collaborative. However, Baucom et al. (2015) stated the therapist sets the pace and initiates and monitors the agenda. In line with traditional CBT, throughout therapy the therapist will focus on strengths and positives with the goal of helping clients feel better by the end of each session (Beck, 2011). Focusing on strengths will reinforce positive behaviors in the relationship like displays of affection. Furthermore, Beck (2011) stated a good alliance can help the client feel likeable, less alone, more optimistic, and with a greater sense of self-efficacy. CBCT practitioners will form a fair alliance with both individuals for the benefit of the couple as a unit. According to Baucom et al. (2015), the therapist has a didactic role: he or she argues reasons for treatment and assignments, models skills, and fosters motivation. They stated the therapist must balance the roles of director, educator, facilitator, collaborator, and advocate. These roles may vary depending on client variables. Nonetheless, the CBCT therapist must be comfortable with leading therapy as an expert when necessary while also encouraging engagement, growth, and autonomy. This method has been shown to be highly efficacious.
There is a lot of evidence and rationale to support the use of CBCT. According to Baucom et al. (2015), CBCT is the most widely evaluated couple treatment and it has been found to be effective in thorough well-controlled research. They stated CBCT lessened distress and improved communication in couples with results maintained after 2-year and 5-year follow-up. Bergeron et al. (2021) found in a randomized clinical trial that CBCT improved women’s sexual pain unpleasantness, pain anxiety, and pain catastrophizing and was more effective overall than topical lidocaine. CBCT has also been shown to help veterans with PTSD and their partners (Ahmady et al., 2009). Gordon et al. (2015) suggested the use of CBCT and insight-oriented couple therapy for trauma (e.g., affairs). They stated CBCT uses skills-based interventions to target negative cognitions; while, insight of the past improves understanding of each partner’s actions. CBCT facilitates integration which can increase positive outcomes. Durães et al. (2020) found that after CBCT participants improved in dyadic adjustment, marital social skills, depression, and anxiety symptoms. Fischer et al. (2016) stated multiple meta-analyses have confirmed the efficacy of CBCT and it appears to be as effective as CBT or more when partners are highly engaged. It is evident that CBCT has been adapted for a variety of issues and has been shown to be more effective than other treatments. CBCT is especially applicable to moderate couple maladjustment, however, it can also be used to treat complex cases.
Ahmady, K., Karami, G., Noohi, S., Mokhtari, A., Gholampour, H., & Rahimi, A.-A. (2009). The efficacy of cognitive behavioral couple’s therapy (cbct) on marital adjustment of ptsd-diagnosed combat veterans. Europe’s Journal of Psychology, 31–40.
Baucom, Epstein, Kirby, & LaTaillade. (2015). Cognitive-behavioral couple therapy. In Gurman, A. S., Lebow, J. L., & Snyder, D. K. (Eds). Clinical handbook of couple therapy. The Guilford Press.
Beck, A. T. (1963). Thinking and depression I: Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9(1), 324–333. https://doi.org/10.1001/archpsyc.1963.01720160014002
Beck, J. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.
Bergeron, S., Vaillancourt-Morel, M.-P., Corsini-Munt, S., Steben, M., Delisle, I., Mayrand, M.-H., & Rosen, N. O. (2021). Cognitive-behavioral couple therapy versus lidocaine for provoked vestibulodynia: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 89(4), 316–326. https://doi.org/10.1037/ccp000063
Durães, R. S. S., Khafif, T. C., Lotufo-Neto, F., & Serafim, A. de P. (2020). effectiveness of cognitive behavioral couple therapy on reducing depression and anxiety symptoms and increasing dyadic adjustment and marital social skills: An exploratory study. Family Journal, 28(4), 344–355. https://doi.org/10.1177/1066480720902410
Epstein, B., Werlinich, C., LaTaillade, J. (2015). Couple therapy for partner aggression. In Gurman, A. S., Lebow, J. L., & Snyder, D. K. (Eds). Clinical handbook of couple therapy. The Guilford Press.
Epstein, N. B., & Zheng, L. (2017). Cognitive-behavioral couple therapy. Current Opinion in Psychology, 13, 142–147. https://doi.org/10.1016/j.copsyc.2016.09.004
Fischer, M. S., Baucom, D. H., & Cohen, M. J. (2016). Cognitive-behavioral couple therapies: review of the evidence for the treatment of relationship distress, psychopathology, and chronic health conditions. Family Process, 55(3), 423. https://doi.org/10.1111/famp.12227
Gordon, K., Khaddouma, A., Baucom, D., & Snyder, D. (2015) Couple therapy and treatment of affairs. In Gurman, A. S., Lebow, J. L., Snyder, D. K. Clinical handbook of couple therapy. The Guilford Press.
Monson, C. M., & Fredman, S.J. (2015). Couple therapy and posttraumatic stress disorder. In Gurman, A. S., Lebow, J. L., & Snyder, D. K. (Eds). Clinical handbook of couple therapy. The Guilford Press.
Psychotherapy.net. (Producer). (2002). Cognitive-behavioral child therapy [Video file]. United States: Author.
Psychotherapy.net. (Producer). (2000). Couples therapy for addictions: A cognitive-behavioral approach [Video file]. United States: Author.