**2. A brief history of the theoretical underpinnings and objectives of CBCT**

The origins of CBCT stem mainly from Stuart's [9] work on behavioral exchanges between partners. He based his analysis of couple interactions on learning principles [10] and social exchange theory [11], postulating that individuals' evaluation of their relationships would depend on the ratio of benefits to costs, resulting from positive and negative exchanges with others. Stuart [9] thus proposed a behavioral exchanges paradigm where successful relationships could be differentiated from dysfunctional ones by the frequency of positive and negative behavioral exchanges. Positive behaviors include constructive problem solving as well as empathically expressing and listening to each other, whereas negative behaviors refer to the expression of criticism, hostility, contempt or withdrawal from interactions with the partner. Early behavioral couple therapies [12, 13] focused primarily on behavior changes and the acquisition of skills aimed at increasing the frequency of positive behaviors and reducing aversive behavioral interactions through the development of effective communication and problem-solving strategies [14].

During the last decades, behavioral couple therapy expanded by including interventions that also addressed emotions and cognitions contributing to conflicts and dissatisfaction. This was achieved by highlighting the importance of attributions, dysfunctional beliefs and distorted cognitions in romantic partners' evaluation of their relationship [15]. For instance, by selectively attending to specific behaviors or characteristics in the partner or by approaching the partner with expectations or standards about how he or she should be or act, individuals will see variations in their appreciation of their partner and of their relationship. Cognitions also depict the way partners process information originating from the others' behaviors, which guide their interpretation of events as well as expectations towards the other and the relationship [15].

Cognitive-behavioral couple therapy (CBCT) aims at assisting romantic partners who report distress in their relationship. Over the years, CBCT has been extensively evaluated in treatment outcome studies, which have repeatedly concluded in its effectiveness for decreasing couple distress and dissatisfaction as well as for addressing communication or problem-solving difficulties [5–7]. Studies have also found that such improvements seem to be maintained

In this chapter, a comprehensive literature review of the theoretical underpinnings and clinical practices of CBCT will be presented. First, a description of the theory underlying CBCT and the role of CBCT therapists will be offered. Possible mandates and motives for consulting in CBCT will then be described, with particular attention to the specificities in CBCT for diverse populations. The assessment process used in CBCT will also be addressed, allowing readers to understand the particularities of psychotherapeutic work with couples. Subsequently, the main intervention techniques used in CBCT will be defined: communication training, problem and conflict resolution, cognitive restructuring, identification and expression of emotions, expression of affection and sexual problems as well as acceptance and tolerance of differences. The chapter will conclude with a critical analysis of CBCT and

**2. A brief history of the theoretical underpinnings and objectives of** 

The origins of CBCT stem mainly from Stuart's [9] work on behavioral exchanges between partners. He based his analysis of couple interactions on learning principles [10] and social exchange theory [11], postulating that individuals' evaluation of their relationships would depend on the ratio of benefits to costs, resulting from positive and negative exchanges with others. Stuart [9] thus proposed a behavioral exchanges paradigm where successful relationships could be differentiated from dysfunctional ones by the frequency of positive and negative behavioral exchanges. Positive behaviors include constructive problem solving as well as empathically expressing and listening to each other, whereas negative behaviors refer to the expression of criticism, hostility, contempt or withdrawal from interactions with the partner. Early behavioral couple therapies [12, 13] focused primarily on behavior changes and the acquisition of skills aimed at increasing the frequency of positive behaviors and reducing aversive behavioral interactions through the development of effective communication and

During the last decades, behavioral couple therapy expanded by including interventions that also addressed emotions and cognitions contributing to conflicts and dissatisfaction. This was achieved by highlighting the importance of attributions, dysfunctional beliefs and distorted cognitions in romantic partners' evaluation of their relationship [15]. For instance, by selectively attending to specific behaviors or characteristics in the partner or by approaching the partner with expectations or standards about how he or she should be or act, individuals will

for up to 2 years by most couples [8].

118 Cognitive Behavioral Therapy and Clinical Applications

suggestions for future clinical developments.

problem-solving strategies [14].

**CBCT**

Work from Jacobson and Christensen [16] increased focus on acceptance strategies as a way to help partners recognize that they are different and eventually learn to respond constructively to difficulties or incompatibilities within the relationship. In 2002, Epstein and Baucom further enhanced CBCT by including work on partners' needs for intimacy and increased attention to emotions, not only as a result of modifications in the dysfunctional behaviors but also as a primary target of therapy. According to these authors, emotions can significantly impact relationships through various means: in their expression, through their impact on the interpretations (cognitions) made as well as by affecting behaviors expressed towards the other. Epstein and Baucom [17] also emphasized the importance of considering partners' vulnerabilities and the impact of the couple's environment as part of the multiple factors that can alter partners' cognitions, emotional responses and behaviors.

A specificity of CBCT lies in its dynamic understanding that cognitions can influence intimate relationships through each partner's interpretations or appraisals of stressors and of their partner's behaviors [3]. Moreover, the interpretations partners make about the behaviors of the other will determine the positive and negative emotions experienced towards the other. As shown in **Figure 1**, these emotions are considered to influence future cognitions and behaviors [14]. As such, in CBCT, behaviors, cognitions and emotions are observed as interrelated and equally important in relationship functioning [18].

In summary, the main objective of CBCT is to help couples understand their difficulties in order to enhance their relational well-being by identifying and challenging the processes at play in partners' interactions while taking into account the external factors that can affect them. To do so, CBCT not only relies on behavioral interventions in the treatment of couple difficulties, but also emphasizes the importance of working on various cognitive, emotional and environmental factors that affect a couple's functioning [18]. CBCT interventions also aim at helping couples identify, regulate and express intense or negative emotions when they arise in and out of sessions. By doing so, CBCT therapists help couples develop their ability to observe and change their automatic thoughts, assumptions and standards as well as identify the impact that their ways of behaving, thinking, interpreting and feeling have on their relationship [3].

**Figure 1.** Interrelations of behaviors, cognitions and emotions in cognitive-behavioral couple therapy.
