Cognitive Behavioural Couple Therapy

Distinctive Features

Michael Worrell

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317520115
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Cognitive Behavioural Couple Therapy (CBCT) is an enhanced and contextually grounded approach that provides evidence-based strategies for working with couple distress, as well as individual psychopathology in the context of a distressed relationship. Cognitive Behavioural Couple Therapy: Distinctive Features explores this truly integrative and experiential way of working. This model has significantly widened the traditional CBT focus on cognition and behaviour to include an equal emphasis on emotion, stable individual differences and vulnerabilities, as well as an awareness of the importance of the environment and the wider context for couple relationships.

Comprising 30 key points, and divided into two parts – Theory and Practice – this concise book includes numerous clinical examples that illustrate the key features of Cognitive Behavioural Couple Therapy. It will offer essential guidance for students, practitioners experienced in individual CBT, as well as practitioners of couple therapy from other theoretical orientations who require an accessible guide to the distinctive theoretical and practical features of this contemporary approach.

Part 1

THE DISTINCTIVE THEORETICAL FEATURES OF CBCT

1

A distinctive focus: couple relationships and well-being

Psychological therapies are increasingly concerning themselves with the issue of ‘well-being’. One of the biggest factors accounting for any individual’s sense of well-being is the quality of their interpersonal relationships. Couple relationships, as a subset of important interpersonal relationships, are one of the most central domains in which people seek a meaningful and rewarding life. Hahlweg et al. (2010) assert that whilst rates of marriage in western countries have declined since the 1970s, and rates of divorce and separation have risen, it remains the case that, across cultures, most people become involved in an intimate couple relationship at some stage in their lives. The recent developments in recognising the validity of same-sex marriages testifies to the importance that individuals and cultures continue to place on long term committed couple relationships.

Why do couples seek the services of a therapist? Gurman (2008) states that the most common concerns centre around issues of emotional disengagement and weakening commitment, struggles around power and control, communication difficulties, issues of infidelity, sexual issues, role and value conflicts and issues involving abuse. Couples may also present to a therapist where one or both partners is experiencing a significant degree of psychopathology such as depression, anxiety and substance misuse problems.

‘Couple distress’ has been found to have a strong and reciprocal relationship with individual psychopathology. To take the example of depression, it has been found that the presence of couple distress is a significant risk factor for the development of depression in one or both partners (Beach et al., 2008). Additionally, the presence of depression in one or both partners is a risk factor for the development of relationship distress (Halford et al., 1999).

Relationship distress and psychopathology can be mutually reinforcing. This relationship is by no means restricted to the case of depression, as it has been found that a wide range of differing forms of psychopathology, as well as physical health problems, are negatively impacted by relationship conflict and distress (Snyder and Whisman, 2003). Relationship distress can be understood as a broad, often chronic, interpersonal stressor that may act as a triggering and maintaining factor for vulnerable individuals to experience forms of psychopathology.

Given this bi-directional influence, it is reasonable to suggest that a focus on alleviating individual symptoms of psychopathology may have a beneficial effect on subsequent relationship distress. Unfortunately, the empirical findings to date do not support this (Whisman and Baucom, 2012). Whilst these interventions may result in the reduction of individual symptoms, this does not generalise to an improvement in relationship functioning and satisfaction. Rather, it has been found that the presence of relationship distress is a poor prognostic factor for the success of treatments that target individual psychopathology. Individually based therapies may not be effective where couple distress is present as they do not directly address this (Whisman and Baucom, 2012).

The evidence that couple therapy, of various orientations, can be effective is impressive. Over 100 clinical trials have demonstrated the efficacy of various forms of couple therapy with the most substantial evidence having been demonstrated for cognitive behavioural forms of couple therapy (Snyder et al., 2006). Intriguingly, in the case of depression, couple therapy can be effective in reducing couple distress and improving levels of depression in one or both partners (Barbato and D’Avanzo, 2008; Whisman and Baucom, 2012).

CBCT proposes that couple distress can be usefully understood and addressed at two levels:

1. Primary distress: This is understood to be the distress that arises where partners are unable to successfully resolve issues that can be traced to their patterns of similarity and difference in terms of basic needs and motives. Partners may experience problematic differences, for example, in needs for closeness versus needs for autonomy. Such differences can become problematic over time as the couple is challenged to adapt to changing life circumstances.

2. Secondary distress: This is understood as the distress which develops as a consequence of the couples’ ineffective interactions, which are expressions of their efforts at coping with and resolving primary distress. Secondary distress often leads couples to feel hopeless regarding the possibility of resolving primary sources of distress and is most immediately encountered by the therapist in the form of the couple’s expressions of hostility and withdrawal.

CBCT addresses both primary and secondary sources of couple distress. CBCT is distinct from both individually focussed forms of CBT and non-CBT approaches to couple therapy in a variety of ways. The form of CBCT being presented here can be considered to be both an ‘enhanced’ and an ‘integrative’ model that seeks to do full justice to the complexity of couple relationships. Rather than seeking to ‘reduce’ our understanding of couple distress and well-being to the role of cognition (or any one alternative factor), the model has expanded its scope to include a wider range of interacting domains (Baucom et al, 2002).

In addition to these distinctive conceptual aspects of CBCT, there are important aspects of the practice of CBCT that can be highlighted. These include:

• The model is ‘principle’ based. Due to the complexity of work with couples, it is not realistic to present the model in a highly manualised session-by-session format. Cognitive behavioural work with couples calls for therapist flexibility and ability to adapt interventions in response to the couple’s in-session responding in a way that embodies its central principles.

• An active-directive therapist style. Whilst allowing for differences in therapists preferred style, work with couples calls for the ability to compassionately, and at times assertively, intervene, in order to manage the overall structure of the session and to maintain a focus on key intervention targets. Maintaining this stance and avoiding a range of pitfalls (such as siding with one partner or giving them a disproportionate amount of time in session) is part of the art of CBCT.

For the therapist, CBCT can be both challenging and rewarding. It is an effective intervention for reducing couple distress and improving couple well-being, as well as an effective strategy for working with individual psychopathology in cases where this is affected by, and in turn affects, the couple relationship.

2

A distinctive history

This chapter describes the principal historical antecedents to the form of CBCT presented in this book as well as the main influences from other CBT and non-CBT models of couple therapy.

Traditional behavioural couple therapy (BCT)

Traditional BCT first emerged in the 1960s as part of the broader project to apply the principles of classical and operant conditioning to clinical problems. Authors such as Stuart (1969) applied Exchange Theory as well as classical and operant conditioning and Social Learning Theory and proposed that distressed couples could be distinguished upon the basis of observable differences in the frequency of exchange of positive and negative behaviours.

BCT emphasised the detailed functional analysis of micro level interactions. That is, present interactions in specific contexts. These analyses revealed sequences of mutual reinforcement and punishment that are responsible for maintaining couple distress. Interventions were designed to help partners define, shape and reinforce desirable behaviour in highly specific operationalised terms. The traditional BCT model also posits that couple distress may be maintained due to the partners not having developed, or failing to utilise, specific behavioural skills of communication (Jacobson and Margolin, 1979). BCT includes procedures to assist couples in learning these skills within therapy sessions, combined with homework assignments to assist in generalisation and maintenance of these skills into the couple’s normal environment.

The use of skill training as well as the detailed functional analysis of couple interaction patterns has been maintained in CBCT. However, an exclusive focus on behavioural skills building has been found to be too restrictive to account for the complexity of couple distress and couple interaction.

Cognitive therapy

Cognitive therapy emphasises that individuals’ behavioural and emotional responses are mediated by cognitive content and processes (Beck et al., 1979). Given that intimate relationships are very frequently a focus for both emotional distress and behavioural difficulties, cognitive therapists have applied the cognitive hypothesis to relational distress in a highly productive fashion.

Cognitive therapists such as Beck (1988) and Dattilio (2010) have identified a range of cognitive content (beliefs and assumptions, such as ‘In order for me to be happy you should never be angry with me!’) and processes (selective attention, catastrophising) and explored how these influence couple distress and satisfaction. As will be discussed in Chapters 5 and 6, CBCT has significantly developed the cognitive understanding of couple distress and satisfaction

Social cognition

The field of social cognition, a program of research within social psychology and not tied primarily to the clinical domain or to ‘abnormal psychology’, has explored a range of social-cognitive processes that are important in understanding the maintenance of couple distress as well as couple satisfaction. CBCT has developed a number of these insights and applied these to distressed couples. This development is described more fully in Chapter 5. Two clear examples of this are the work on ‘attributions’ and ‘schemas’. Attributions refer to the theories people generate to account for the causes for their own and others’ behaviour, such as ‘The reason you are late is that you want to avoid spending any time with me!’ Schemas refer to long-standing and stable fundamental beliefs about the self and relationships, such as ‘My relationships inevitably fail as I am not worthy of being loved’.

Acceptance and mindfulness

At the same time as Baucom, Epstein and colleagues were formulating CBCT, Jacobson and Christensen (1996) were developing a revised cognitive behavioural model that also sought to overcome the perceived limitations of a purely behavioural model. Their model of ‘integrative behavioural couple therapy’ (IBCT) proposes that all relationships will include areas of incompatibility between partners that are not amenable to change and that it is frequently the couple’s persistence in seeking to change these areas that is responsible for the maintenance of distress. This approach includes both behavioural strategies intended to help foster change in those areas that are amenable to this, as well as ‘acceptance’ strategies focussing on those factors that are not.

There are substantial areas of overlap between CBCT and IBCT in both theory and practice, and in their evolution they have also clearly informed and influenced each other. One area of difference is the relative importance placed on the notion of ‘acceptance’ in IBCT. In this model, acceptance is viewed as a primarily emotional experience and one that often mediates positive therapeutic change. For CBCT increases in acceptance of differences within a couple relationship are seen as a likely outcome of cognitive and behavioural changes (Baucom, 2014, personal communication).

IBCT can rightly be regarded as an evidence-based approach to couple therapy (Christensen et al., 2004). A range of other contemporary CBT approaches have also been presented that emphasise processes of acceptance and mindfulness in couple functioning and distress. Acceptance and commitment therapy, or ACT (Hayes et al., 1999) is a contextual behavioural science approach that has recently been extended from individual therapy to couple therapy interventions (Harris, 2009; Dahl et al., 2013). Additionally, mindfulness-based CBT approaches have recently been extended for work with couples (Gehart, 2012).

Non-CBT-based approaches: emotion and insight

There are a great number of approaches to work with couples. Few of these have been subjected to the degree of empirical testing necessary to be regarded as being evidence-based approaches. Two non-CBT approaches are significant, however, in that they have gained some evidence for effectiveness. These approaches also offer distinctive points of emphasis that in turn have influenced the evolution of CBCT into its current ‘enhanced’ version.

Emotion-focussed couple therapy (EFCT)

EFCT is an integration of core philosophical assumptions and strategies from humanistic-experiential therapies with concepts from Systems Theory and Attachment Theory. Developed by Johnson and Greenberg (1985), the approach privileges the role of emotion in organising partners’ subjective experiences and behavioural responses to each other. The approach provides an important corrective to the over-emphasis on cognition and behaviour to be found in earlier cognitive-behavioural approaches. The model makes substantial use of Attachment Theory (Bowlby, 1989) and proposes that couple distress can be understood primarily in terms of ‘insecure’ attachment styles and difficulties couples experience in understanding and responding to each other’s attachment needs. Whilst eschewing direct attempts at behavioural skills building, the EFCT therapist uses strategies to assist each partner in communicating their own attachment needs and emotions more clearly as well as responding empathically to the attachment needs of their partner. It is assumed that improvements in partners’ ability to recognise and respond to their own and their partners attachment needs will lead to constructive behaviour change in the relationship.

Insight-oriented couple therapy (IOCT)

Whilst BCT, CBCT, IBCT and EFCT place a relatively greater emphasis on present interaction patterns in understanding couple distress, insight-oriented couple therapy, or IOCT (Snyder and Wills, 1989), consistent with its psychodynamic base, places emphasis on the role of past developmental processes for each individual in the relationship. The approach emphasises the importance of each partner developing insight into both their own and their partner’s developmental history and how current couple distress is related to defensive strategies each partner has learned, to avoid the activation of emotional states associated with past hurts. This model assumes that insight into these individual developmental factors will facilitate, through a process of ‘affective reconstruction’, the dropping of unhelpful defensive strategies in the current relationship. Partners are aided in differentiating past from present relationships and developing more helpful strategies for interacting with their partner in the present.

3

Enhancements to CBCT

This chapter discusses a number of key domains that have been integrated into the enhanced CBCT model, to provide a more flexible and complete model of couple distress and functioning.

Emotion

Whilst behavioural and cognitive behavioural approaches to couple therapy have not ignored the role of emotion, typically emotion had been relegated to a secondary status, and was seen as an outcome of behavioural or cognitive processes. Consistent with developments in the field of CBT more generally, the enhanced model of CBCT now places an equal emphasis on the role of emotional factors and includes interventions focussed on working directly with emotions in therapy. As will be discussed in Chapters 7 and 24, CBCT includes a range of interventions that may be focussed on assisting partners to manage excessive and unregulated emotion, as well as assist in learning skills to more effectively identify and communicate emotional experience as an important source of information about personal needs and values. This increased emphasis on emotion is consistent with some of the propositions of EFT from which CBCT has drawn helpful concepts as well as technical strategies. This increased focus on emotion is also consistent with recent work in CBT where problems with dysregulation of emotions are seen as a central maintaining factor for psychopathology (Linehan, 1993).

A micro and a macro level focus

Earlier versions of CBCT tended to emphasise a tight focus on ‘micro’ level behavioural interactions as well as the effects of specific cognitive content and processes. This micro level focus has been highly productive and continues to remain a feature of this approach. This perspective has been significantly enhanced, however, by an additional focus on more ‘macro’ level themes in couple distress.

One example of this has been an increased emphasis on understanding what each individual brings to the relationship from their developmental hist...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Preface
• Acknowledgements
• Abbreviations
• Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF CBCT
• Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF CBCT
• References
• Index