**4.1. Alleviation of distress and relationship improvement**

Over the years, CBCT has accumulated strong empirical support for its efficiency to alleviate relationship distress and enhance couple functioning [18]. These therapeutic gains would also seem to persist years after the end of treatment [24]. Research has shown that the therapeutic goals couples formulate regarding alleviation of distress revolve around communication problems, dissatisfaction with manifestations of emotions and affection, sexual problems, financial problems as well as decision-making or problem-solving issues [25–27]. Since some of these concerns are quite frequent, they are typically addressed with the common CBCT interventions presented in the fifth section of this chapter. However, many couples also consult for difficulties that require a more distinct approach, some of which include the presence of conflicts and violence, extradyadic affairs, infertility as well as various psychological or health-related problems partners might have.

#### *4.1.1. Conflicts and violence*

**3. The role of CBCT therapists**

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behaviors [17].

other [20].

intervention.

CBCT therapists hold different roles that will vary depending on the stage of therapy and the needs of clients [19]. For instance, during the first sessions of CBCT, the therapist typically uses psychoeducation to inform clients about the approach and related intervention and acts as a facilitator by creating a safe and supporting environment where emotions or concerns may be expressed freely. He/she will also act as a collaborator to develop the treatment goals. However, a more directive approach will also be used by CBCT therapists to address dysfunctional interactions or the escalation of conflicts in order to create and preserve a safe environment for therapy and help partners understand what is going on and learn new ways of dealing with their disagreements [20]. A directive approach might also be needed to deal with crisis interventions (see Section 4.4). Throughout sessions, CBCT therapists can also take a more didactic role, for instance, when they teach communication and problem-solving skills for couples [12]. They will also act as guides when they help partners identify the interrelations between their cognitions, emotions and

In CBCT, the therapist undertakes the responsibility of establishing and maintaining the therapeutic alliance with both partners [19]. In order to lay the foundations for a healthy therapeutic alliance, the therapist is thus expected to swiftly orchestrate sessions by fairly allocating speaking time for each partner to express themselves [20], while demonstrating neutrality and empathy [21]. If situations occur in which therapists feel unable to remain neutral towards a couple and if it significantly hampers their ability to help partners, they should seek supervision. Special consideration must also be given to the management of secrets between one partner and the therapist, for instance, in cases when an ongoing extradyadic affair is admitted by a partner during the individual session of assessment (see Section 5.2 for the phases of the assessment interviews). In such situations, it is advised that the therapist takes a neutral position by explaining to partners that he/she cannot engage in therapy while withholding information that would affect the process of therapy or bring he/she in collusion with one of the partners against the

**4. Possible mandates and motives for consultation in CBCT**

The first step a CBCT therapist undertakes is to question partners' objectives and expectations with regards to therapy. Poitras-Wright and St-Père [22] have proposed three main therapeutic mandates in couple therapy: alleviation of distress, ambivalence resolution and separation intervention. According to Tremblay and colleagues [23], therapeutic mandates can also be reliably classified and revised during the course of treatment to take into account the specific needs of couples which may change over time. The following sections describe how these different mandates are conducted in CBCT, with an additional section allocated to crisis Many couples find it difficult to resolve their conflicts, and this difficulty heavily affects their functioning and satisfaction within the relationship [28]. Yet, it is how a couple handles disagreements that will determine how satisfied partners are with their relationship [29]. Accordingly, unresolved conflicts constitute one of the most frequent consultation motives for couple therapy [25]. As such, CBCT offers techniques aiming at the enhancement of positive interaction patterns in couples as well as the improvement of communication and problem-resolution techniques in order to diminish conflicts within couples [30].

Conflicts between spouses can also spiral into violence [31], for instance, when partners escalate theirs conflicts to a point where they will resort to psychological or physical violence. Indeed, partner violence is a serious challenge that many couples face but that is frequently under-reported or concealed by partners who may, for example, rather report consulting to address difficulties in dealing with conflicts [32]. During the assessment phase of CBCT, the presence of violence must systematically be assessed in order to decide whether or not CBCT should be conducted [33]. For instance, when partner violence is severe or perpetrated by one partner towards the other, couple therapy is usually contraindicated because it could lead to further violence. The therapists should then deliver a crisis intervention (see Section 4.4 for crisis intervention) [32, 33]. On the contrary, when partner violence is situational and minor to moderate and when both partners agree to cease all acts of violence during therapy, CBCT can be useful in preventing the escalation of conflicts to more severe forms of violence [33, 34]. Indeed, a few therapies using a CBCT framework or techniques have been developed to treat moderate intimate partner violence and show promising results in the reduction of mild-to-moderate violent behaviors [35–38]. Such therapies include interventions that promote positive interactions between partners, assertion and communication skills, increased imputability in conflicts and an understanding of the escalation of conflicts into violence. These interventions also seek to challenge the cognitive distortions that are entangled in conflicts and to help partners to better control their anger and other negative emotions as well as to help them negotiate time-outs during conflict.

#### *4.1.2. Infidelity/extradyadic affairs*

Infidelity is a relational problem that many who consult in couple therapy might eventually face [39]. Indeed, studies have shown that from 20 to 40% of couples will experience infidelity at least once [40] and 20–57% of men and 14–32% of women will report having had an extradyadic affair at least once in their life [41–43]. According to therapists, infidelity represents one of the most prevalent and difficult problems to treat in couple therapy [44, 45]. This is mainly due to the feelings of betrayal and relationship distress that commonly result from extradyadic affairs [46, 47]. This problem is also particularly difficult to address in treatment because it frequently puts partners in a situation where they question their desire to continue their relationship [48, 49]. This being said, many studies have concluded in the effectiveness of CBCT in the treatment of extradyadic affairs in terms of decreased psychological symptoms of depression and relationship distress [40, 50, 51]. Since CBCT commonly addresses infidelity as a form of interpersonal trauma experienced within the intimate relationship [52], interventions for this problem generally aim at dealing with the crisis following disclosure of the extradyadic affair and at the exploration of factors that might have contributed to the affair. This will be accomplished by giving the extradyadic affair a meaning [17, 52]. Since this type of couple difficulty tends to take place when the needs of a partner are not fulfilled in the current relationship [46–48], forgiveness-based interventions can also be used to help partners better understand the circumstances in which infidelity has taken place and repair the relationship. Partners will then learn how to "reconnect" after having been hurt by the other, to "turn the page" and to move forward [52].

that by including the partner in the treatment of an individual's difficulties, the latter will benefit from support from his or her partner, which in turn will enhance the couple's functioning and alleviate personal difficulties [18, 59]. Alcohol use disorder is an example of an individual problem that is widely recognized as exerting a devastating effect on couple functioning and satisfaction [60, 61]. Indeed, adults with an alcohol use disorder are four times more at risk of separation and divorce than those who do not present such problems [62]. The perceived quality of the romantic relationship is also known to modulate the effect of substance use on couple functioning, so that satisfied couples experience less distress caused by substance abuse than dissatisfied couples [63]. Interestingly, support was found for the use of CBCT to reduce alcohol and drug use disorders as well as increase relationship satisfaction [64, 65]. For instance, CBCT for alcohol use disorder, which draws upon cognitive-behavioral methods for the treatment of alcohol use disorders [66] and behavioral couple therapy [67], simultaneously aims at decreasing alcohol use and increasing relationship stability and satisfaction [62]. The underlying assumption of this therapy is that drinking behaviors might be intertwined with the ability to cope with negative couple interactions. As such, by learning new ways to interact with the partner and by staying abstinent, partners are better able to cope with rela-

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Mood disorders, particularly depression, are also known to have a bidirectional association with couple functioning [68], with lower relationship quality leading to higher depressive symptoms and higher depressive symptoms generating lower relationship quality [69]. As such, when depressive symptoms act as risk factors or follow relationship difficulties, couple therapy for depression has been shown to be effective in reducing depressive symptoms and relationship problems [70]. This therapy aims at enhancing positive interactions between partners and diminishing negative interactions as well as improving communication and problem-solving abilities [71]. Couple-based interventions have also shown encouraging results for the co-occurring treatment of couple distress and bipolar disorder [72], emotion dysregulation [73], post-traumatic stress disorder [74, 75], obsessive-compulsive disorder

Sometimes, couples consult in therapy because one or both partners are unsure whether to end the relationship [79]. Drawing from their empirical results, Boisvert and colleagues [25] highlighted that one out of four couples consulting in therapy tend to report such ambivalence. In these situations, CBCT therapists usually suggest an ambivalence resolution mandate in order to help couples take a decision on the future of their relationship [80]. Yet, this mandate is not much addressed in the CBCT literature. Among the few authors offering clinical guidelines on this topic, Wright and colleagues [14] propose to include the exploration of emotions, beliefs and expectations of each partner regarding the continuation of the relationship, while putting any harsh decisions or behaviors about the relationship on hold until a final decision is reached by both partners. The therapist then helps partners define a new therapeutic mandate based on their decision, whether it is relationship improvement or

[76], anxiety disorders [77] as well as anorexia nervosa [78].

**4.2. Ambivalence resolution mandate**

separation.

tionship distress [62].
