*5.1.3. Direct behavioral observation*

concerns they report in order to assess their level of commitment in their relationship and in therapy. By doing so, the therapist will be able to determine the appropriateness of CBCT for the clients or propose an alternate course of action. For instance, the therapist might recommend that one or both partners should first follow an individual therapy [17, 19]. Assessment can also continue throughout sessions: as partners become more comfortable or familiar with the therapist, they may reveal more about themselves as individuals and as partners, which allows the therapist to get a more precise understanding of the couple's relational dynamics

In the assessment phase of CBCT, the therapist gathers information from different sources in order to understand a couple's functioning. This multi-method approach is highly recommended as it allows the therapist to draw a better portrait of a couple's functioning and concerns.

Throughout evaluation sessions with a couple, the therapist collects information on both partners by means of semi-structured clinical interviews. Clinical interviewing includes therapists' inquiry of the couple's history and environment, as well as of the partners' individual functioning and backgrounds [19], which will be further explained in Section 5.2 on the phases of assessment interviews. Clinical interviews also allow CBCT therapists to question partners' reactions, emotions and cognitions as they occur in session or when couples are

The use of self-report questionnaires is highly valuable in CBCT as an adjunct to clinical interview. It can help therapists have access to information that may otherwise remain unknown. The use of self-report measures constitutes a fast and affordable way to assess numerous constructs [99], and it can also grant access to information that might not be disclosed during sessions [100, 101]. Depending on the problems reported by the consulting couple, self-report questionnaires that may be used in the assessment phase of CBCT can evaluate couple satisfaction and adjustment (e.g., Dyadic Adjustment Scale: [102]), partners' cognitions (e.g., Inventory of Specific Relationship Standards: [103]), communication patterns (e.g., Communication Patterns Questionnaire: [104–106]), sexual satisfaction (e.g., the Global Measure of Sexual Satisfaction Scale: [107]), dyadic coping (e.g., Dyadic Coping Inventory: [108]) and support (e.g., Romantic Support Questionnaire: [109]), as well as psychological symptoms (e.g., Psychiatric Symptom Index: [110]) and levels of violence exhibited by each partner towards the other (e.g., Revised Conflict Tactics Scales: [111]; Coercive Control Scale: [112]). The measurement of attachment (e.g., Experiences in Close Relationships: [113]) can also significantly help therapists understand the internal representations of self and other their patients hold in romantic relationships. Finally, considering the high prevalence of childhood trauma in the clinical population, especially consulting for sexual or relational problems (up to 95% [114]), the lack of spontaneous self-report, and given the direct and

and, if applicable, to refine the therapeutic objectives and strategies [97].

**5.1. Assessment methods**

126 Cognitive Behavioral Therapy and Clinical Applications

*5.1.1. Clinical interviews*

*5.1.2. Self-report measures*

asked to describe their concerns [98].

In CBCT, special attention is also given to the couple's interactions, as they take place during sessions. As such, therapists observe how partners behave towards one another in a problemsolving task. They can take note of the positive and negative behaviors that partners initiate, for instance, with criticism or support when the other speaks [17]. Baucom and colleagues [19] also emphasize the importance of creating tasks or exercises during the assessment phase that will encourage partners to interact in order to allow therapists to better assess the couples' interactions. Couples can thus be asked to discuss a specific concern or problem they report currently having, to share their thoughts on a specific matter as well as try to engage in a decision-making discussion.

### **5.2. Phases of the assessment interviews**

The assessment phase of CBCT is typically formed of three parts: one or two couple sessions in which both partners are present and one individual session with each partner followed by a feedback session for the couple. During the first couple session, the therapist presents his or her qualifications, theoretical orientation as well as the objectives and structure of CBCT [17]. During this session, the therapist also informs partners that all information gathered during individual sessions aims to help design a well-tailored couple intervention so may be discussed during the following couple sessions. The therapist informs the patients that this is a couple therapy process where he/she would not be forced to keep a secret from one partner during treatment [118]. The therapist then collects information on the couple's concerns for which they seek therapy. Assessing each partner's goals is primordial in clinical interviewing since they can be quite dissimilar, for instance, when one partner wants to improve the relationship and the other rather wishes a separation [19]. The therapist then inquires on the couple's relationship history in order to better understand how the relationship has evolved over time. He/she will ask questions on the beginning of the relationship, for instance, by inquiring on the duration of the relationship, on how partners met and what attracted them to one another [118]. The therapist also typically asks partners to describe past hardships or significant events that they have experienced and that might have affected them as a couple and to relate the ways they adapted or the resources they used to overcome them [98]. Finally, assessment of the couple's physical and social environments that are likely to contribute to the couple's problems [19] and evaluation of the couple's sexual functioning [119] are also conducted during the first evaluation session.

The therapist will then meet with each partner separately in order to gather information on their personal history as well as their current psychological and social functioning. The therapist will therefore inquire on each partners' developmental or family history, anterior romantic relationships, medical or psychological health, substance use, possible stressful or traumatic events, academic or professional functioning and how all these factors affect, or not, their current relationship and perception of their partner [20]. During these individual sessions, specific attention will be given to potential subjects that might not have been explored during couple sessions, such as sexual difficulties, extradyadic affairs or the presence of partner violence [17, 19]. Indeed, potential partner violence, its severity and frequency must be explicitly inquired with both partners, as well as the level of safety victimized partners feel while living with the other [36].

listening techniques [98, 121]. However, in cases where partners bicker during the session, the therapist must quickly take control of the situation and ask them about what did they feel and perceive that triggered the dysfunctional interaction [14]. Following is an example of how a

Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple…

http://dx.doi.org/10.5772/intechopen.72104

129

*Melanie and Ethan are new parents and have decided to consult in CBCT in order to deal with feelings of dissatisfaction resulting from difficulties they experience in adapting to their new life as parents. During a session, Melanie and Ethan mention a situation they have experienced which disappointed* 

*Therapist: I think this situation is a good example we could use to practice the communication skills you have learned last session, don't you think? Remember, when you are the speaker, you must express your subjective experience, by using "I", and focus on your feelings and perceptions. When you are the listener, you must demonstrate openness and respond with reflections and summaries about your* 

*Therapist: Ok, I would like you to take the role of the speaker for now and Ethan, that you take the role* 

*Melanie: Ethan, I was hurt last Sunday when you came home late from your hockey game without* 

*Ethan: You are saying that you were hurt because I came home late without telling you and you felt as* 

*Melanie: Yes, exactly. I wish you would also tell me when you plan on being late, so that I would not* 

*Therapist: Melanie, could you rephrase it so it will not be a request; at this point try to focus on what* 

*Melanie: Ok. When you do not tell me when you are going to be late, I feel that Lily and I are not your* 

*Ethan: So you are saying you don't want me to play hockey on Sundays because you feel hurt, correct?*

*Melanie: (Looking at Ethan) In fact Ethan I know that it is important for you. But if you would tell me when you plan on coming home late after the game, I would not feel hurt or not important like I* 

*Ethan: So if I hear you well, you would like me to call you when I plan on staying longer for a lunch* 

*Therapist: Perfect, now Ethan, would you like to continue as the speaker and Melanie, as the listener?*

*Therapist: Ethan, try to stay focused on what Melanie said; Melanie, is it what you said?*

*priorities, and that I am not important to you. This is how I felt last Sunday.*

*Melanie: No, not exactly. I am not saying I don't want Ethan to play hockey.*

*after the game, so that you won't feel as if I do not care about you and Lily.*

*partner's experience. (Both partner express they do remember). Who would like to begin?*

communication training exercise can take place in CBCT.

*of the listener. We will then exchange roles ok?*

*if I did not care about you and Lily.*

*you felt or thought during this event.*

*feel hurt like last Sunday.*

*Therapist: Tell Ethan….*

*Melanie: Yes, that's it.*

*did Sunday.*

*telling me beforehand because I felt you did not care about us.*

*them both.*

*Melanie: I'll start.*

After both partners' individual sessions, the couple and the therapist meet for another session during which the therapist will offer feedback using a cognitive-behavioral formulation of the couple's functioning and the factors that affect it, namely how each partner's cognitions, emotions and behaviors influence one another and affect couple interactions [118, 120]. The therapist also uses the feedback session to present his or her interpretation of the causes of the couple's concerns and to highlight the positive aspects that partners have expressed about their relationship [20]. The therapist then sets the treatment mandates and goals in collaboration with the couple and proposes a treatment plan [19].
