Cognitive-behavioral therapy with couples (CBTC) clearly emerged in the past decade as a powerful and effective approach, whether as a mode of integration with other forms of therapy (Dattilio, 1998; Dattilio and Epstein, 2003) or as an independent modality.
It was Albert Ellis who first considered the viability of the application of CBTC (Ellis and Harper, 1961). Ellis and his colleagues acknowledged the important role that cognition plays in marital dysfunction. Ellis offered the premise that relationship dysfunction occurs when partners maintain unrealistic beliefs about their relationship and render extreme negative evaluations of the sources of their dissatisfaction (Ellis, 1977; Ellis et al., 1989). In the 1960s and 1970s, behavior therapists had experimented with applying the principles of learning theory to address problematic behaviors of both adults and children. Many of the behavioral principles and techniques that were used in the treatment of individuals were subsequently applied to distressed couples, and then later to families. For example, Stuart (1969), Liberman (1970), and Weiss et al. (1973) presented the use of social exchange theory and principles from operant learning to facilitate more satisfying interactions among couples who complained of distress. This set the stage for the subsequent research that led marital therapists to recognize the importance of intervening with cognitive factors and behavioral interactional patterns. Prior to the major theories of family therapy, it was noted that cognitions could be used as auxiliary components of treatment within a behavioral paradigm (Margolin and Weiss, 1978); however, it was the 1980s that cognitive factors became a real focus of the couples research and therapy literature. Cognitions began to be addressed in treatment in more direct and systematic fashion than what was being proposed in other theoretical approaches to couples therapy (Epstein and Eidelson, 1981; Epstein, 1982; Weiss, 1984; Baucom, 1987; Fincham et al., 1987; A. T. Beck, 1988; Baucom et al., 1989; Dattilio, 1989). As modified distortion and inappropriate perceptions became the focus with couples, therapists began to direct more of their attention toward the inferences and beliefs that partners held about each other and toward their possible use in finding solutions to relationship impasses (Epstein and Baucom, 1989; Baucom and Epstein, 1990; Epstein, 1992; Dattilio and Padesky, 1995). Cognitive assessment and intervention methods were borrowed from individual therapy and adapted for use with couples. As in individual therapy, cognitive-behavioral marital interventions were designed to enhance the partners’ abilities to evaluate and modify their own problematic cognitions, as well as to develop skills for communicating and solving problems constructively (Baucom and Epstein, 1990; Epstein and Baucom, 2002).
Although substantial empirical evidence has been accumulated from treatment outcome studies to indicate the effectiveness of CBTC, most studies have focused primarily on behavioral interventions and only a handful have examined the impact of cognitive restructuring procedures (refer to Baucom et al., 1998, for a complete review).
The growing use of cognitive-behavioral methods by couple therapists may be attributed to several factors: research that has supported their efficacy; clients, who generally value a proactive approach to solving problems and building skills, respond positively to them; emphasizes the methods a collaborative relationship has between therapist and client; and finally, the ideas are highly compatible with other modalities of therapy. Recent enhancements of CBTC (Epstein and Baucom, 2002) have broadened the contextual factors that are taken into account, such as aspects of the couple's physical and interpersonal environment (e.g., extended family, the workplace, neighborhood violence, national economic conditions). The approach continues to evolve through the creative efforts of its practitioners and the ongoing research that keeps expanding its applicability to the field.
Case conceptualization is paramount in CBTC, especially when attempting to understand the dynamics between two people. Much of the conceptualization used follows the basic theory of dysfunctional schemata, which is outlined in detail below.
Baucom et al. (1989) developed a typology of cognitions that have been applied to distressed relationships. Although each type is a normal form of human cognition, all are susceptible to being distorted (Baucom and Epstein, 1990; Epstein and Baucom, 2002). These types include: (1) selective attention, an individual's tendency to notice particular aspects of the events occurring in his or her relationship and to overlook others; (2) attributions, inferences about the factors that have influenced one's own and one's partner's actions (e.g., concluding that a partner failed to respond to a question because he or she wants to control the relationship); (3) expectancies, predictions about the likelihood that particular events will occur in the relationship (e.g., that expressing feelings will result in the partner's being verbally abusive); (4) assumptions, beliefs about the natural characteristics of people and relationships (e.g., a wife's generalized assumption that men do not need emotional attachment); and (5) standards, beliefs about the characteristics that people and relationships ‘should’ have (e.g., that partners should have no boundaries between them, sharing all of their thoughts and emotions with each other). Because there is typically so much information available in any interpersonal situation, some degree of selective attention is inevitable. Nonetheless, the potential to form biased perceptions of each other must be addressed. Errors in these inferences can often have negative effects on couple relationships, especially when an individual attributes another's actions to negative motives (e.g., malicious intent) or misjudges how the other will react to one's own actions. Assumptions are commonly adaptive when they are realistic representations of people and relationships, and many standards that individuals hold, such as moral standards concerning the avoidance of abuse of others, contribute to the quality of relationships. Nevertheless, inaccurate or extreme assumptions and standards can lead individuals to inappropriate interaction.
Beck and associates (e.g., A. T. Beck et al., 1979; J. Beck, 1995) refer to moment-to-moment stream-of-consciousness ideas, beliefs, or images as automatic thoughts; for example, ‘My wife shares our personal business with others. She doesn't care about my feelings regarding privacy.’ Cognitive-behavior therapists have noted that individuals commonly accept automatic thoughts at face value rather than examining their validity. Although all five of the types of cognition identified by Baucom et al. (1989) can be reflected in an individual's automatic thoughts, cognitive-behavioral therapists have emphasized the moment-to-moment selective perceptions and the inferences involved in attributions and expectancies as being the most apparent within an individual's awareness. Assumptions and standards are thought to involve broader underlying aspects of an individual's world view and are considered to be schemata in Beck's cognitive model (A. T. Beck et al., 1979; J. S. Beck, 1995; Leahy, 1996).
The cognitive model proposes that the content of an individual's perceptions and inferences is shaped by relatively stable underlying schemata, or cognitive structures, such as the personal constructs first described by Kelly (1955). Schemata include basic beliefs about the nature of human beings and their relationships, which are assumed to be relatively stable and may become inflexible. Many schemata about relationships and the nature of couples’ interactions are learned early in life from primary sources, such as family-of-origin, cultural traditions and mores, the mass media, and early dating or other relationship experiences. The ‘models’ of self in relation to others that have been described by attachment theorists appear to be forms of schemata that affect individuals’ automatic thoughts and emotional responses to significant others (Johnson and Denton, 2002). In addition to the schemata that partners bring to a relationship, each member develops schemata specific to the current relationship.
Schemata about relationships are often not articulated clearly in an individual's mind, but nonetheless exist as vague concepts of what is or should be (A. T. Beck, 1988; Epstein and Baucom, 2002). Previously developed ideas affect how an individual currently processes information in new situations, perhaps, for example, influencing what the person selectively perceives, the inferences he or she makes about causes of others’ behavior, and whether the person is pleased or displeased with the relationship. Existing schemata may be difficult to modify, but repeated new experiences with significant others have the potential to change them (Epstein and Baucom, 2002; Johnson and Denton, 2002).
In addition to automatic thoughts and schemata, A. T. Beck et al. (1979) identified cognitive distortions or information-processing errors that contribute to cognitions’ becoming sources of distress and conflict in individuals’ lives. In terms of Baucom et al.'s (1989) typology, such errors result in distorted or inappropriate perceptions, attributions, expectancies, assumptions, and standards.
There has been much more research on attributions and standards than on the other forms of cognition in Baucom et al.'s (1989) typology (see Epstein and Baucom, 2002, for a review of findings). A sizable amount of research on couples’ attributions has indicated that spouses in distressed relationships are more likely than those in nondistressed couples to attribute the partner's negative behavior to global, stable traits; negative intent; selfish motivation; and a lack of affection (see Bradbury and Fincham, 1990 and Epstein and Baucom, 2002, for reviews). In addition, spouses in distressed relationships are less likely to attribute positive partner behaviors to global, stable causes. These biased inferences can contribute to pessimism about improvement in the relationships and to negative communication and faulty problem solving. One area of research on schemata has focused on potentially unrealistic beliefs that individuals may hold about marriage (Epstein and Eidelson, 1981). Baucom et al. (1996a) assessed the relationship standards that individuals hold about boundaries between partners, distribution of control/power, and the degree of investment one should have in the relationship. They found that those who were less satisfied with the manner in which their standards were met within the relationship were more distressed and communicated more negatively with the partner.
A considerable amount of empirical evidence shows that distressed couples exhibit a variety of negative and ineffective patterns of communication involving their expression of thoughts and emotions, listening skills, and problem-solving skills (Walsh, 1998; Epstein and Baucom, 2002). Expression of thoughts and emotions involves self-awareness, appropriate vocabulary to describe one's experiences, freedom from inhibiting factors, such as fear of rejection, and a degree of self-control (e.g., not succumbing to an urge to retaliate against the person who upset you). Effective problem-solving pivots on the abilities to define the characteristics of a problem clearly, generate alternative potential solutions, collaborate with one's spouse in evaluating the advantages and disadvantages of each solution, reach consensus about the best solution, and devise a specific plan to implement the solution.
Weaknesses in communication and problem solving may develop as a result of various processes, such as maladaptive patterns of learning during socialization in the family-of-origin, deficits in cognitive functioning, forms of psychopathology, such as depression, and past traumatic experiences in relationships that have rendered an individual vulnerable to disruptive cognitive, emotional, and behavior responses (e.g., rage, panic) during interactions with significant others. Research has indicated that spouses who communicate negatively in their relationships may exhibit constructive communication skills in external relationships with others, suggesting that chronic issues in the intimate relationship are directly impeding positive communication (Baucom and Epstein, 1990).
Negative and ineffective communication and problem-solving skills are not the only forms of problematic behavioral interaction with distressed couples. Members of close relationships commonly direct a variety of types of nonverbal behavior toward each other (Baucom and Epstein, 1990; Epstein and Baucom, 2002); that is, positive and negative acts that are instrumental (perform a task to achieve a goal, such as completing household chores) or actions intended to affect the other person's feelings (for example, giving a gift). Although there are typically implicit messages conveyed by taciturn behavior, it does not involve the explicit expression of thoughts and emotions. According to the research, partners in distressed relationships direct more negative acts and fewer positive ones toward each other than do members in nondistressed relationships (Epstein and Baucom, 2002). Furthermore, members of distressed couples are more likely to reciprocate negative behaviors, resulting in an escalation of conflict and distress. Consequently, a basic premise of CBTC is that the frequency of negative behavior must be reduced and the frequency of positive behaviors increased. This is particularly important because negative behaviors tend to have a greater impact on the experience of relationship satisfaction than do positive behaviors (Gottman, 1994; Weiss and Heyman, 1997). Negative behaviors have also received more attention from therapists; however, although clients may be distressed in the absence of such behaviors, they still long for more rewarding relationships (Epstein and Baucom, 2002).
Couple theorists and researchers have to this point focused on microlevel positive and negative acts, but Epstein and Baucom (2002) propose that in many instances, an individual's relationship satisfaction is based on more macrolevel behavioral patterns. Some core macrolevel patterns involve boundaries between and around a couple (e.g., less or more sharing of communication, activities, and time), distribution of power/control (e.g., how the partners attempt to influence each other and how decisions are made), and the level of investment of time and energy each spouse commits to the relationship. As noted earlier, individuals’ relationship standards concerning these dimensions are associated with relationship satisfaction and communication. The literature suggests that these behavior patterns are core aspects of salubrious interaction (Walsh, 1998; Epstein and Baucom, 2002).
Epstein and Baucom (2002) have also described negative interaction patterns that commonly interfere with the partners’ fulfillment of their needs within the relationship. These patterns include mutual (reciprocal) attack, demand/withdrawal (one person pursues and the other withdraws), and mutual avoidance and withdrawal. Epstein and Baucom suggest that often therapists must help clients to reduce these patterns before they will be able to work collaboratively as a couple to resolve issues in their relationship.
Although the title ‘cognitive-behavior’ does not refer to a couple's emotions, assessment and modification of problematic affective responses are core components of this therapeutic approach. Epstein and Baucom (2002) provide a detailed description of problems that involve either deficits or excesses in the experiencing of emotions within the context of an intimate relationship, as well as in the expression of those feelings to a significant other. The following is a brief summary of those emotional factors in couple's problems.
Some individuals do not pay much attention to their emotional states, and this can result in their feelings being overlooked in close relationships; or alternatively, emotions that are not monitored may suddenly demand expressed attention and be in a destructive fashion, such as in verbally abusive or physically assaultive ways. The reasons for an individual's lack of emotional awareness vary, but they likely include having learned in their family-of-origin that expressing feelings is inappropriate or dangerous, harboring a current fear that expressing even mild emotion will lead to losing control of one's equilibrium (perhaps associated with posttraumatic stress disorder or some other type of anxiety disorder), or maintains the expectation that one's spouse simply does not care how he or she feels (Epstein and Baucom, 2002).
In contrast, some individuals have difficulty with regulating their emotions, and they experience strong emotions in response to even relatively minor life events. Unregulated experience of emotions such as anxiety, anger, and sadness, can result in decreased relationship satisfaction. The person who cannot regulate emotions may also interact in ways that heighten conflict. Factors contributing to unregulated emotional experience may include past personal trauma (e.g., abuse, abandonment), growing up in a family in which others failed to regulate emotional expression, and forms of psychopathology, such as borderline personality disorder (Linehan, 1993).
In addition to the degree to which an individual experiences emotions, the degree and manner in which he or she expresses emotions to significant others can affect the quality of the couple's relationship. Whereas some individuals inhibit their expression, others express feelings in an uncensored manner. Possible factors in the expression of unregulated emotions include past experiences in which strong emotional displays were the only means of effectively gaining attention, temporary relief from intense emotional tension, and limited skills for self-soothing.
An inhibited spouse may find it convenient to not have to deal with the other person's feelings, but others will be frustrated by the lack of communication, and may pursue the partner, with the result that a demand/withdraw pattern develops. Spouses who receive unregulated emotional expressions commonly find it distressing and either respond aggressively or withdraw from the partner. Although unbridled emotional expression may be intended to engage others to meet needs, the pattern often backfires (Epstein and Baucom, 2002; Johnson and Denton, 2002).
Individual and conjoint interviews with couples, self-report questionnaires, and the therapist's behavioral observation of the couple's interactions are the three primary modes of clinical assessment (Dattilio and Padesky, 1990; Snyder et al., 1995; Epstein and Baucom, 2002). Consistent with the concepts that are described above, the goals of assessment are to: (1) identify strengths and problematic characteristics of the individuals, the couple, and the environment; (2) place current individual functioning in the context of their developmental stages and changes; and (3) identify cognitive, affective aspects of couple interaction that could be targeted for intervention. For a more detailed discussion of these ideas, the reader is referred to the extensive coverage of procedures in such sources as Baucom and Epstein (1990), Dattilio and Padesky (1990), and Epstein and Baucom (2002).
One or more conjoint interviews with the couple are an important source of information about past and current functioning. Not only do such interviews provide information about the couple's memories and opinions concerning characteristics and events in their family-of-origin; they also furnish the therapist an opportunity to observe the couple's interactions. While it is time that people may modify their usual behavior in front of a stranger, even during the first interview the couple is likely to exhibit some aspects of typical patterns, especially when the therapist engages them in describing the issues that have brought them to therapy. CBT's approach during the assessment phase uses initial impressions to form hypotheses that must later be tested by gathering additional information in subsequent sessions.
The therapist generally begins the assessment phase by meeting with both partners in order to observe their relationship process and to form hypotheses about patterns that may be contributing to the relationship's dysfunction. The systems theorists refer to this as ‘learning their dance’ (Dattilio, 1998).
During the initial conjoint interview, the therapist asks the couple about their reasons for seeking treatment. Each spouse's perspective is important, both with respect to the concerns and the changes that are deemed necessary. The therapist also inquires into the couple's history (e.g., how and when the couple met, what initially attracted them to each other, when they married, when children were born, and any events that they believe have influenced their relationship over time). By applying a stress and coping model to the assessment, the therapist systematically explores demands that the couple has experienced based on individual characteristics (e.g., a spouse's residual effects from childhood abuse), relationship dynamics (e.g., unresolved differences in the partners’ desires for intimacy and autonomy), and their environment (e.g., heavy job commitments). The therapist poses questions about resources that the couple has available to cope with outlined demands, and any factors that have influenced their use of resources; for example, a belief in self-sufficiency that blocks some people from seeking or accepting help from outsiders (Epstein and Baucom, 2002). Throughout the interview, the therapist gathers information about the spouses’ cognitions, emotional responses, and behaviors toward each other. For example, if a husband becomes withdrawn after his wife criticizes his parenting, the therapist may draw this to his attention and ask what thoughts and emotions he just experienced after hearing his wife's comments. The husband might reveal automatic thoughts such as, ‘She doesn't respect my opinion. This is hopeless,’ and feelings of perhaps anger and despair.
Cognitive-behavior therapists commonly use standardized questionnaires to collect information regarding the spouses’ views of themselves and their relationships. Often therapists ask spouses to complete several questionnaires before the conjoint and individual interviews, so the therapist can build the interview on the questionnaire responses. Obviously, individual's reports on questionnaires are subject to biases, such as externalizing blame for relationship problems and presenting oneself in a socially desirable light (Snyder et al., 1995); nevertheless, the judicious use of questionnaires can be an efficient means of quickly surveying a couple's perceptions of a wide range of issues that might otherwise be overlooked during interviews. In addition, some couples are more apt to be able to express themselves in writing than verbally. Issues that come to the fore on a questionnaire can be explored in greater depth in subsequent interviews and behavioral observation. Following are some references that contain representative questionnaires that may be useful for assessment within a cognitive-behavioral model, even though many were not developed specifically from that perspective. Resources for reviews of a variety of other relevant measures include Fredman and Sherman (1987), Jacob and Tennenbaum (1988), Grotevant and Carlson (1989), and Touliatos et al. (1990).
A variety of measures have been developed to provide an overview of key areas of couple relationships, such as overall satisfaction, cohesion, communication quality, decision-making, values, and level of conflict. Examples include the Dyadic Adjustment Scale (Spanier, 1976) and the Marital Satisfaction Inventory—Revised (Snyder and Aikman, 1999). Because the items on such scales do not provide specific information about each spouse's cognitions, emotions, and behavioral responses regarding a relationship problem, the therapist must inquire about these during interviews. For example, if scores on a questionnaire indicate limited cohesion between spouses, a CBTC may ask the couple about: (1) their personal standards for types and degrees of cohesive behavior; (2) instances of behavior that did or did not feel cohesive; and (3) positive or negative emotional responses to those actions. Thus, questionnaires can be helpful to a therapist in identifying areas of strength and concern, but a more in-depth analysis is needed to understand specific types of positive and negative interaction and the factors affecting them.
A separate interview with each spouse is often conducted subsequent to gathering information about past and current functioning, including life stresses, psychopathology, overall health, and coping strengths. Often, partners are more open about describing personal difficulties, such as depression, abandonment in a past relationship, and the like, without the spouse present. Such interviews provide the clinician with an opportunity to assess possible psychopathology that may be influenced by problems in the couple's relationships (and in turn may be affecting spousal interactions adversely). Given the high co-occurrence of individual psychopathology and relationship problems (L'Abate, 1998), it is crucial that couple therapists either be skilled in assessing individual functioning or be ready to make referrals to colleagues who can assist in this task. The therapist can then determine whether conjoint therapy should supplement individual therapy. As noted earlier, therapists must set clear guidelines for confidentiality during individual interviews. Keeping secrets, such as a spouse's ongoing infidelity, places the therapist in an ethical bind and undermines the work in conjoint sessions; consequently, couples are informed that the therapist will not keep secrets that affect the well-being of the spouse. This is particularly important as, once the therapist is privy to a secret, it automatically constitutes collusion and affects therapeutic objectives. On the other hand, when the therapist learns that a spouse is being physically abused and appears to be in danger, the focus shifts toward working with that person to develop plans to maintain safety and to exit the home and seek shelter elsewhere if the risk of abuse increases.
In a cognitive-behavioral approach, assessment is ongoing throughout the course of treatment, and the therapist observes the relationship during each session. These relatively unstructured behavioral observations are often supplemented by a structured communication task during the initial conjoint interview (Baucom and Epstein, 1990; Epstein and Baucom, 2002). Based on information the couple provides, the therapist may select a topic that the couple considers to be unresolved and ask them to spend several minutes discussing it while the therapist observes. The couple might be asked merely to express their feelings about an issue and respond to each other's expression in any way they deem appropriate, or they may be asked to try to resolve the issue in the allotted time frame. Typically, the therapist leaves the room to minimize the potential of influencing their interactions. In this case; video or audiotaping may be used. Such taped problem-solving discussions are used routinely in couple-interaction research (Weiss and Heyman, 1997), and even though spouses often behave somewhat differently under these conditions than at home, they commonly become engaged enough in the discussion that pertinent aspects will emerge.
CBT is a collaborative approach in which the therapist continually shares his or her thinking with the clients and develops interventions designed to address their concerns. After collecting information via interviews, questionnaires, and behavioral observations, the therapist meets with the couple and provides a concise summary of the patterns that have emerged, including: (1) their strengths; (2) their major presenting concerns; (3) life demands or stressors that have produced adjustment problems for the family; and (4) constructive and problematic macrolevel patterns in their interactions that seem to be influencing their presenting problems. The therapist and couple then identify their priorities for change, as well as some interventions that may alleviate the problems. This is a vital time for the therapist to explore potential challenges to couple therapy, such as fear of changes that partners anticipate, will be stressful and difficult for them, and to work with them on steps that can be taken to reduce both. The therapist also needs to consider the shift that will occur within the relationship and how it will affect the overall homeostasis. (See section on Challenges.)
It is extremely important to educate couples about the cognitive-behavioral model of treatment (Dattilio and Padesky, 1990) if one is employing it. The structure and collaborative nature of the approach necessitates that the couple clearly understand the principles and methods involved. The therapist initially provides a brief didactic overview of the model and periodically refers to specified concepts during therapy. In addition to presenting such ‘mini-lectures’ (Baucom and Epstein, 1990), the therapist often asks spouses to engage in bibliotherapy, reading portions of relevant popular books, such as A. T. Beck's (1988) Love is never enough and Markman et al.'s (1994) Fighting for your marriage. The couples also should be aware that homework assignments will be an essential part of treatment and that bibliotherapy is one type that will help orient them to the treatment model. In this way, all parties stay attuned to the process of treatment and the notion of taking responsibility for their own thoughts and behaviors is reinforced.
The therapist informs the spouses that he or she will structure the sessions in order to keep the therapy focused on achieving the goals that they agreed to pursue during the assessment process (Dattilio, 1994, 1997; Epstein and Baucom, 2002). Part of the structuring process involves the therapist's and the couple's setting an explicit agenda at the beginning of each session. Another aspect is the establishing of ground rules for client behavior inside and outside sessions; some examples include that individuals should not tell the therapist secrets that cannot be shared with other family members, that all family members should attend each session unless the therapist and spouses decide otherwise, and that abusive verbal and physical behavior is unacceptable.
A prerequisite to modifying spouses’ distorted or extreme cognitions about themselves and each other is increasing their ability to identify their automatic thoughts. After introducing the concept of automatic thoughts—those that spontaneously dart through one's mind—the therapist coaches the couple in observing the thought patterns during sessions that are associated with their negative emotional and behavioral responses to each other. In the cognitive-behavioral model, monitoring one's subjective experiences is a skill that can be developed further if necessary. In order to improve the skill of identifying one's automatic thoughts, clients are typically asked to keep a small notebook handy between sessions and to record a brief description of the circumstances in which they felt distressed about the relationship or become engaged in conflict. This log also should include a description of any automatic thoughts, as well as the resulting emotional and behavioral responses to other family members. A modified version of the Daily Records of Dysfunctional Thoughts (A. T. Beck et al., 1979) was initially developed for the identification and modification of automatic thoughts in individual cognitive therapy. Through this type of record keeping, the therapist is able to demonstrate to couples how their automatic thoughts are linked to emotional and behavioral responses and to help them understand the specific macrolevel themes (e.g., boundary issues) that upset them in their relationship. This procedure also increases the spouses’ understanding that their negative emotional and behavioral responses to each other are potentially controllable through systematic examination of the cognitions associated with them. Thus, the therapist is coaching each spouse in taking greater responsibility for his or her own responses. An exercise that often proves quite useful is to have couples review their written logs and identify the links specific among thoughts, emotions, and behavior. The therapist then asks each person to explore alternative cognitions that might produce different emotional and behavioral responses to a situation.
It is helpful for spouses to become adept at identifying the types of cognitive distortions involved in their automatic thoughts. It can be effective to have each partner refer to the list of distortions outlined in the next section and to label any distortions in the automatic thoughts that he or she logged during the previous week. This can be done by using the Daily Dysfunctional Thought Sheet (Figure 11.5, p. 118). The therapist and client can discuss the aspects of the thoughts that were inappropriate or extreme, and how the distortion contributed to any negative emotions and behavior at the time. Such in-session reviews of written logs over the course of several sessions can increase family members’ skills in identifying and evaluating their ongoing thoughts about their relationships.
If the therapist believes that a spouse's cognitive distortions are associated with a form of individual psychopathology, such as clinical depression, he or she must determine whether or not the psychopathology can be treated within the context of the couple relationship, or if the individual needs a referral for individual therapy. As noted earlier, procedures for assessing the psychological functioning of individual spouses are beyond the scope of this chapter, but it is important that couple therapists become familiar with the evaluation of psychopathology and make referrals to other professionals as necessary.
Conclusions that are made in the absence of supporting substantiating evidence; often involved in invalid attributions and expectancies. For example, a man whose wife arrives home from work a half-hour late concludes, ‘She must be doing something behind my back.’ Distressed spouses often make negative attributions about the causes of each other's positive actions.
This is a type of arbitrary inference in which an individual believes he or she knows what another person is thinking or feeling without communicating directly with the person. For example, a husband noticed that his wife had been especially quiet and concluded, ‘She's unhappy with our marriage and must be thinking about leaving me.’
Information is taken out of context and certain details are highlighted while other important information is ignored. For example, a woman whose husband fails to answer her greeting in the morning concludes, ‘He is ignoring me,’ even though the husband had cleared a place for her at the breakfast table when she entered the room.
An isolated incident is considered to be a representation of similar situations in other contexts, related or unrelated; often contributes to selective attention. For example, after having an argument with her husband, a wife concludes, ‘All men are alike!’
A case or circumstance is judged as having greater or lesser importance than is appropriate; often leading to distress when the evaluation violates the person's standards for the ways family members ‘should’ be. For example, an angry husband becomes anxious and enraged when he discovers that his wife used their emergency credit card for miscellaneous purchases so he complains, ‘She has no regard for our finances.’
External events are attributed to oneself when insufficient evidence exists to render a conclusion; a special case of arbitrary inference commonly involves misattributions. For example, a wife states, ‘My husband has little respect for me, therefore, I must be a loser.’
Also labeled ‘polarized thinking,’ experiences are classified into mutually exclusive, extreme categories, such as complete success or total failure; commonly contributing to selective attention, as well as to violation of personal standards. For example, a husband has spent several hours working on cleaning the couple's cluttered basement and removed a considerable number of items for inclusion in a yard sale. However, when the wife enters the basement, she looks around and exclaims, ‘What a mess! When are you going to make some progress?’
The tendency to portray oneself or another person in terms of stable, global traits, on the basis of past actions; negative labels are an integral part of attributions that couples often make about the causes of each other's actions. For example, after a husband has made several errors in the household budgeting and in balancing their checkbook, the wife concludes, ‘He is a careless person,’ and she does not consider situational conditions that may have led to those errors.
The process of restructuring automatic thoughts involves the spouse considering alternative explanations. Such consideration will require that, the spouse examine evidence concerning the validity of various thoughts and/or their appropriateness in a given situation. Identifying a distortion in one's thinking or finding an alternative way to view relationship events may have an impact on emotional and behavioral responses to one's relationship. The following types of questions can be helpful in guiding each spouse in examining his or her thoughts:
From your past experiences or the events occurring recently in your relationship, what evidence exists that supports this thought? How could you get some additional information to help you judge whether or not your thoughts are appropriate?
What might be some alternative explanations for your partner's behaviors? What else might have led him/her to behave that way?
Several types of cognitive distortions have been offered that can influence a person's views of other family members and can contribute to becoming upset with them. Which cognitive distortions, if any, do you see in the automatic thoughts you had about…? For example, a woman who believed that her husband was being unrealistic in his demands reported the automatic thoughts, ‘He enjoys punishing me. I have no autonomy.’ In turn, this interpretation contributed to her anger and resentment toward him. The therapist helped the woman to see that she was, in essence, mind reading, and that it would be important to inquire more about her husband's feelings to reach an accurate conclusion. The therapist encouraged her to ask her husband to describe his feelings, and he said that although he felt guilty about his demandingness, he believed that he would never receive any attention from her unless he behaved in this way. The wife was able to hear that her inference might not have been accurate, and the therapist related that the couple probably would benefit from problem-solving discussions to address the issue of what types of demands are appropriate. Similarly, the therapist coached the wife in examining her automatic thought, ‘He enjoys pushing me,’ leading her to recount several instances in which her husband was less demanding and more caring. Thus, the wife acknowledged that she had engaged in dichotomous thinking. The therapist discussed with the couple the danger of thinking and speaking in extreme terms, which are unrealistic, because very few events occur ‘always’ or ‘never.’ Even so, this is a common distortion found among couples in conflict.
Thus, gathering and weighing the evidence for one's thoughts are an integral part of CBTC. Couples are able to provide valuable feedback that will help each other evaluate the validity or appropriateness of their cognitions, as long as they use good communication skills (described later). After individuals challenge their thoughts, they should rate their belief in the alternative explanations and in their original inference, perhaps on a scale from 0 to 100. The ‘new’ revised thoughts may not be assimilated unless they are considered credible on a deeper level.
Although an individual may use logical analysis successfully to reduce his or her negative expectancies concerning events that will occur in couple or family interactions, often first-hand corroboration is needed. CBT often guides couples in devising ‘behavioral experiments’ in which they test their predictions about particular actions leading to certain responses from other members. For example, a man who expects that his wife and children will resist including him in their leisure activities when he gets home from work can make plans to try to engage with the family when he arrives home during the next few days and see what happens. When these plans are hatched during the conjoint therapy sessions, the therapist can ask the wife, in this case, what she predicts their responses will be during the experiment. The wife may anticipate potential obstacles to success and appropriate adjustments can be made. In addition, when a spouse commits to participating in good faith and the commitment is voiced and witnessed, the likelihood of the experiment's success is increased.
When spouses attempt to identify during their therapy sessions thoughts, emotions, and behavior that emerged in incidents outside sessions, they may have difficulty recalling pertinent information regarding the circumstances and each person's responses. This is particularly true when the couples’ interaction was emotionally charged. Imagery and/or role-playing techniques may be extremely helpful in recalling memories regarding such situations. In addition, these techniques often rekindle spouses’ reactions, and what begins as a role-play may quickly become an in vivo interaction.
For example, the use of deep breathing and relaxation exercises have been used to help spouses recall a particular argument and/or a scenario that upset them. Having them imagine the room that they were in along with the clothes that they were wearing may be helpful in recalling their automatic thoughts at the time. Although recounting past events can provide important information, the therapist's ability to assess and intervene with spouses’ problematic cognitive, affective, and behavioral responses to each other as they occur during sessions affords the best opportunity to changing relationship patterns (Epstein and Baucom, 2002). Imagery sometimes helps to accomplish this goal.
Couples can also be coached in switching roles during role-playing exercises in order to increase empathy (Epstein and Baucom, 2002). For example, spouses can be asked to exchange roles as they recreate a recent argument concerning finances. Focusing on the other person's frame of reference and subjective feelings provides new information that can modify one spouse's view of the other. Thus, in this example, when the husband played the role of his wife he was able to understand better her anxiety about money and her conservative behavior about spending it, which had its roots in her experience of poverty growing up.
Many distressed couples have developed a narrow focus on problems in their relationship by the time they seek therapy, so the therapist may ask them to report their recollections of the thoughts, emotions, and behaviors that occurred between them when they met, dated, and developed amorous feelings toward each other. The therapist can focus on the contrast between past and present experiences as evidence that the couple was able, at one time, to relate in a more satisfying way and may be able to regenerate positive interactions with some appropriate effort.
Imagery techniques should be used with caution and skill, and probably should be avoided if there is a history of abuse in the relationship. Similarly, role-play techniques should not be used until the therapist feels confident that the couple will be able to contain strong emotional responses and refrain from abusive behavior toward each other.
The ‘downward arrow’ is a technique used by cognitive therapists (e.g., A. T. Beck et al., 1979; J. S. Beck, 1995) to track the associations among an individual's automatic thoughts, in which an apparently benign initial thought may be upsetting owing to its being linked to other more significant thoughts. For example, a husband may report experiencing anxiety associated with the automatic thought: ‘My wife will leave me if I do not bring home enough money.’ The intensity of the emotional response becomes clarified when the therapist asks a series of questions such as, ‘And if that happened, what would it mean to you?’ or ‘What might that lead to?’ The husband responds with, ‘It will mean I'm a failure.’ Couples can evaluate how likely it is that the expected catastrophe will occur. In some cases, this will lead to modification of the individual's underlying catastrophic expectancy; in other cases, it may uncover a real problem in the relationship, such as a need for the wife to consider the emphasis that she places on money.
The downward arrow technique also is used to identify the assumptions and standards underlying one's automatic thoughts. This is accomplished by identifying the initial thought, having the individual ask himself or herself, ‘If so, then what?’ and moving downward until the individual locates the relevant core belief. Thus, the husband in the above example might also have developed a general insecurity and an issue regarding his sense of self-worth.
The major forms of intervention used to reduce negative behavior and to increase positive behavior are: (1) communication training regarding expressive and listening skills; (2) problem-solving training; and (3) behavior change agreements. These are briefly described below, and readers can consult texts such as Guerney (1977), Robin and Foster (1989), Dattilio and Padesky (1990), Jacobson and Christensen (1996), and Epstein and Baucom (2002) for detailed procedures.
Improving couples’ skills for expressing thoughts and emotions, as well as for listening effectively to each other, is one of the most common forms of intervention therapy. In CBTC, it is viewed as a cornerstone of treatment because it can have a positive impact on problematic behavioral interactions, reduce partners’ distorted cognitions about each other, and contribute to the regulated experience and expression of emotion. Therapists begin by presenting instructions to couples about the specific behaviors involved in each type of expressive and listening skill. Speaker guidelines include acknowledging the subjectivity of one's own views; describing one's emotions, as well as one's thoughts; pointing out positives, as well as problems; speaking in specific rather than global terms; being concise so that the listener can absorb and remember one's message; and using tact and diplomacy (e.g., not discussing important topics when one's partner is preparing to retire for the evening). The guidelines for empathic listening include exhibiting attentiveness through nonverbal acts (e.g., eye contact, nods), demonstrating acceptance of the speaker's message (the person's right to have his or her personal feelings) whether or not the listener agrees, attempting to understand or empathize with the other's perspective, and reflecting back one's understanding by paraphrasing what the speaker says. Each spouse receives handouts describing the communication guidelines so that he or she can refer to them during sessions and at home. Over time, it is hoped that these guidelines will become part of the couple's repertoire.
Therapists often model good expressive and listening skills for clients. They may use videotape examples, such as those that accompany Markman et al.'s (1994) book Fighting for your marriage. During sessions, the therapist coaches the couple or family in following the communication guidelines, beginning with discussions of relatively benign topics so negative emotions will not interfere with constructive skills. As the clients demonstrate these skills, they are asked to practice them as homework, with increasingly conflictual topics. As couples practice communication skills, they gain more information about each other's motives and desires, which will then aid them in diffusing distorted cognitions about each other. Following the guidelines may also bolster each individual's perception that the other is respectful and motivated by goodwill.
Cognitive-behavioral therapists also use verbal and written instructions, modeling, and behavioral rehearsal and coaching to facilitate effective problem solving with couples. The major steps involve achieving a clear and specific definition of the problem in terms of behaviors that are or are not occurring, generating specific behavioral solutions to the problem without evaluating one's own or one's spouse's ideas, weighing the advantages and disadvantages of each alternative solution and selecting a solution that appears to be feasible and attractive to all members involved, and agreeing on a trial period for implementing the selected solution and assessing its effectiveness. Homework is integral to learning and integrating skills (Dattilio, 2002; Epstein and Baucom, 2002).
Contracts that are used to exchange desired behavior still have an important role in CBTC. Therapists try to avoid making one spouse's behavior change contingent on another's, so the goal is for each person to identify and enact specific behavior that would likely be pleasurable to the other, regardless of what actions the other spouse takes. The major challenge facing the therapist is to encourage the spouses to avoid ‘standing on ceremony’ by waiting for others to take the initiative to be positive. Brief didactic presentations on negative reciprocity in distressed relationships on the fact that one can only have control over one's own actions, and on the importance of making a personal commitment to improve the relationship atmosphere may help to reduce individuals’ reluctance to make the first positive contribution. An example of using a behavior change agreement may involve the therapist negotiating for equal effort on the part of both spouses to take the initial step forward conjointly. This is with the attempt to have each partner focus on the change they need to make with themselves rather than what they want their spouse to change. A verbal or sometimes even a written agreement that both spouses sign may help to solidify their commitment to taking the first step forward conjointly.
Although CBT is sometimes characterized as neglecting emotions, this is not the case, and a variety of interventions are used, either to enhance the emotional experiences of inhibited individuals or to moderate extreme responses (see Dattilio, 2002; Epstein and Baucom, 2002, for detailed procedures). For couples who report experiencing little emotion, the therapist can establish clear guidelines for behavior inside and outside of sessions in which expressing oneself will not lead to recriminations as well as use downward-arrow questioning to inquire about underlying emotions and cognitions, coach the person in noticing internal cues to his or her emotional states, repeat phrases that have emotional impact on the person, refocus attention on emotionally relevant topics when the individual attempts to change the subject, and engage the individual in role-plays concerning important relationship issues in order to elicit emotional responses. Individuals who experience intense emotions that affect him or her and significant others adversely, can be helped by the therapist compartmentalizing emotional responses by scheduling specific times to discuss distressing topics. The therapist may also coach the individual in self-soothing activities such as relaxation techniques, attempt to improve the person's ability to monitor and challenge upsetting automatic thoughts, encourage him or her to seek social support from others, develop the ability to tolerate disturbing feelings, and enhance skills for expressing emotions constructively so others will pay attention.
Homework assignments are a central feature of CBTC. Because the actual therapy sessions are limited to only 1 or 2 hours per week, outside activities that support the treatment process are essential if the new behavior is to become permanent. Self-help assignments can serve as a strategy to reinforce what is learned in the treatment process. Homework is also an integral part of the collaborative process between the therapist and spouses. Assignments typically include the techniques and strategies listed throughout this chapter. Such assignments may also be tailored to specific problems and to accommodate results from the collaborative processing during the therapy session that week. For a detailed overview of homework assignments in couple and family therapy, the reader is referred to Dattilio (2002).
In a recent text by R. E. Leahy (2003), the issue of roadblocks in cognitive therapy is addressed across various populations. The discussion of couples highlights the factors that may interfere with the levels of engagement and progress in therapy. Epstein and Baucom (2003) outline several factors, including partners’ negativity and hopelessness about change in the relationship, discomfort about participating in conjoint therapy, distress about changing the homeostasis in the relationship, failure to take personal responsibility for change, and individual psychopathology.
Dattilio (2003) further outlines a number of roadblocks that therapists may encounter when working with couples, one of which he labels ‘Therapists Roadblocks,’ which are obstacles that may include the therapist's own resistance or defense mechanisms that emerge during the course of treatment. Sometimes, the therapist varies the work through his or her own issues from his or her family-of-origin or his or her own marriage. It is one of the less recognized roadblocks that occur during the course of treatment. Nonetheless, these are issues that may impede progress in therapy and every therapist should be aware of it. Another is unrealistic expectations that the couple may develop during the course of treatment, particularly early on. Setting realistic expectations is essential in couples therapy so that spouses don't become overzealous about what they anticipate being able to accomplish in treatment. One way of overcoming such obstacles is to be as realistic and flexible as possible as to what can be accomplished in treatment and when to discuss this collaboratively with the couple. Other areas of roadblocks may involve cultural obstacles. Therapists must and should familiarize themselves with various cultural aspects in the literature as well as with environments from which individuals hail in order to avoid stumbling blocks due to cultural issues. Racial issues go hand-in-hand with this topic, although this is reported to be less an issue in the literature than with cultural matters.
Environmental forces may also expose couples to issues that inhibit or impede change during the course of treatment. This may involve family members or other aspects of their environment that work against the process of treatment. Psychopathology is clearly one of the major hurdles in treatment with couples, particularly significant psychopathology that exists with one or both partners. Personality disorders particularly raise a challenge for a therapist and need to be addressed in more specific detail, perhaps on a one-to-one basis. If not, it is strongly recommended that spouses are referred out for individual psychotherapy.
Factors such as low intellectual and cognitive functioning that can affect the previous treatment are also areas that draw concern. These also may yield individuals who are not particularly amenable to treatment. In addition, it is stated by Dattilio (2003) that the inadequate use of homework assignments may also be a roadblock, particularly with not allowing couples enough out-of-session assignments to support and reinforce that which is obtained during the course of treatment. Homework, which is discussed in the aforementioned section is a hallmark of CBT and is something that very much should be used strategically on a regular basis.
Therapists need to be aware of such challenges in order for headway to be made in treatment. Many of the aforementioned techniques and interventions may be used to address these challenges during the course of therapy with couples.
CBT has received more extensive evaluations in controlled outcome studies than any other form of couple or family therapy, and a review of outcome studies that employed stringent criteria for efficacy indicated that cognitive-behavioral treatment is efficacious for reducing relationship distress (Baucom et al., 1998). Most studies on couples therapy have been restricted to evaluations of the behavioral components of communication training, problem-solving training, and behavioral contracts, and they have found that these interventions are more effective in reducing distress than wait-list control and placebo conditions. A small number of studies with other approaches such as emotionally focused and insight-oriented couple therapies (e.g., Snyder et al., 1991; Johnson and Talitman, 1997) suggest that they have comparable or, in some cases, better outcomes than behaviorally/ oriented approaches, but there is a need for additional research. Only a few studies have examined the impact of adding cognitive restructuring interventions to behavioral protocols (e.g., Baucom et al., 1990). Typically, some cognitive interventions have been substituted for behaviorally/oriented sessions in order to keep the total number of sessions equal across the treatments that are compared. In Case studies in couples and family therapy (Dattilio, 1998), cognitive-behavioral strategies are integrated with more than 16 modalities of couple and family therapy. A review of those studies indicate that combined CBT was as effective as the behavioral conditions, although cognitively/focused interventions tend to produce more cognitive change whereas behavioral interventions are more apt to foster modified behavioral interactions (Baucom et al., 1998). Dattilio and Epstein (2005) has noted that there is a need for research on a truly integrated CBT that targets each couple's particular cognitive, behavioral, and affective problems in proportion to their intensity, rather than providing a fixed number of sessions of each type of intervention to all couples. Also, Whisman and Snyder (1997) argue that tests of cognitive interventions have been limited by a failure to assess the range of problematic cognitions (selective attention, expectancies, attributions, assumptions, and standards) identified by Baucom et al. (1989). Studies also have been limited to samples of predominantly white, middle-class couples, so the effectiveness with other racial and socioeconomic groups is unknown. Thus, research on the effectiveness of CBT for couples has been encouraging; however, there are still areas that need to be investigated.
Overall, CBT has proven its effectiveness with difficult couples and is also destined to be a modality that is frequently used by mental health practitioners in the future. It is already regarded by many in the field as integrating nicely with other modalities of couples treatment.