*4.1.3. Infertility*

According to Sullivan et al. [53], the number of couples who encounter fertility problems is growing, with an average of 10–15% of couples experienced fertility issues. Importantly, for many couples, infertility constitutes a major crisis, and even a significant traumatic event that has important repercussions on partners' individual and relational well-being [54]. Indeed, infertility as well as the many consequences related to its treatment, such as its cost, its time requirements and the uncertainty of its results [53, 54], can lead to psychological consequences, especially high levels of stress [55], depression, low self-esteem, marital and life dissatisfaction [56, 57], sadness and denial [54] as well as feelings of guilt [54]. Some interventions using CBCT techniques have been developed to treat this problem [53, 58] and aim at facilitating disclosure and communication between partners, exploring the meaning and nature of grief (e.g., when partners learn they cannot have children), enhancing the couple's ability to understand and support each other and developing useful strategies for stress reduction and problem solving related to infertility.

### *4.1.4. Individual problems*

In general, studies have demonstrated that couple-based therapies are effective across a wide range of individual problems and disorders that not only address an individual's psychological functioning but also his or her partner's relationship satisfaction. Consequently, CBCT has also been customized to treat a plethora of individual difficulties [19]. This approach argues 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 relationship distress [62].

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

#### **4.2. Ambivalence resolution mandate**

*4.1.2. Infidelity/extradyadic affairs*

122 Cognitive Behavioral Therapy and Clinical Applications

*4.1.3. Infertility*

*4.1.4. Individual problems*

by the other, to "turn the page" and to move forward [52].

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

According to Sullivan et al. [53], the number of couples who encounter fertility problems is growing, with an average of 10–15% of couples experienced fertility issues. Importantly, for many couples, infertility constitutes a major crisis, and even a significant traumatic event that has important repercussions on partners' individual and relational well-being [54]. Indeed, infertility as well as the many consequences related to its treatment, such as its cost, its time requirements and the uncertainty of its results [53, 54], can lead to psychological consequences, especially high levels of stress [55], depression, low self-esteem, marital and life dissatisfaction [56, 57], sadness and denial [54] as well as feelings of guilt [54]. Some interventions using CBCT techniques have been developed to treat this problem [53, 58] and aim at facilitating disclosure and communication between partners, exploring the meaning and nature of grief (e.g., when partners learn they cannot have children), enhancing the couple's ability to understand and support each other and developing useful strategies for stress reduction and problem solving related to infertility.

In general, studies have demonstrated that couple-based therapies are effective across a wide range of individual problems and disorders that not only address an individual's psychological functioning but also his or her partner's relationship satisfaction. Consequently, CBCT has also been customized to treat a plethora of individual difficulties [19]. This approach argues 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 separation.

#### **4.3. Separation mandate**

Whether it results from a decision taken within the course of treatment or whether it is formulated as a primary therapeutic objective, a separation mandate can be put forward to help partners accept and deal with separation [81]. Indeed, albeit difficult, separation can generate alleviation of distress in certain couples [79]. According to Lebow [82], the CBCT techniques used in therapy with a separation mandate usually include psychoeducation on how to deal with the consequences of the separation as well as feelings towards one another after the separation. Problem-solving techniques and communication training are also often conducted in session to alleviate the possible consequences of the separation for couples with a separation mandate in CBCT.

intercultural couples will experience greater difficulties with communication, marital satisfaction and divorce [88, 89]. As such, intercultural couples might need more negotiation skills than others to deal with couple issues (e.g., discussing the language(s) spoken at home, religion and rituals that will be practiced by the children, etc.). Furthermore, parenting and disciplinary styles often involve debates in intercultural couples [85]. Exploring and negotiating the couples' cultural differences could thus potentially foster intimacy between partners and

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Due to widespread heterosexist standards, many lesbian, gay and bisexual couples experience prejudice, rejection, discrimination and lack of social support, which can significantly impede couple satisfaction and functioning [83, 91]. However, research has shown that, in general, same-sex and bisexual couples show more similarities than dissimilarities when compared to heterosexual couples [92] and tend to seek couple therapy for similar reasons [93, 94]. Indeed, most CBCT interventions, such as cognitive restructuring, role playing, assertiveness training, psychoeducation, decision making and negotiation, are used similarly with same-sex, bisexual or heterosexual couples [23]. Communication and problem-solving training can also be of significant importance for certain same-sex or bisexual couples who struggle with internalized homophobia (i.e., refers to negative stereotypes, hate, stigma and prejudice about homosexuality or bisexuality that a person with same-sex attraction turns inward on him/herself), issues regarding disclosure of sexual orientation, conflicts related to relationships or the division of household work and parenting difficulties (for a review, see [83]). Yet, many therapists report difficulties comprehending the unique situations in which same-sex or bisexual partners live [95] or report a lack of confidence about how to intervene with same-sex and bisexual couples. In addition, many therapists have few opportunities to develop their psychotherapeutic expertise with patients from sexual minorities given that the majority of their clients are heterosexual [96]. Therapists must therefore possess a good understanding of the challenges faced by these couples as well as the ability to have a non-discriminatory attitude in order to help their patients overcome prejudice in and out of their relationship [23]. To do so, couple therapists who decide to work with same-sex and bisexual couples should aim at receiving specific training or supervision to further understand and help these populations.

Before conducting CBCT, the couple therapist must inquire on the partners' expectations about therapy, evaluate the level of functioning or distress of the couple as well as the partners' motivation for staying together and in engaging in a therapeutic process [22]. By doing so, the therapist can determine the form of assistance that can be offered and tailor a treatment that will be most beneficial for both partners [2]. The main objective of assessment is to formulate a case conceptualization of the couple. This is accomplished by defining the concerns for which partners have sought assistance, identifying the individual, dyadic and environmental factors at play in the difficulties reported as well as by discerning the couple's existing strengths that might potentially facilitate the therapeutic process [97]. Therapists also aim at understanding both partners' respective goals in therapy and perspectives with regards to the

promote a sense of mutual understanding [90].

**5. Assessment in CBCT**

#### **4.4. Crisis intervention**

Although crisis intervention is not a therapeutic mandate *per se*, it can be required prior to CBCT, for instance, when a partner expresses severe personal difficulties (e.g. manifests a suicidal or homicidal risk), discovers the other has been unfaithful or when severe violence occurs within a relationship. It is thus necessary for therapists to be able to identify, assess and deal with such situations in order to help the couple regain stability and security before conducting any other intervention. To do so, Wright and colleagues [14] have developed guidelines for couple therapists. The first action to be performed is to ensure the safety of each partner, and by extension of their children, if applicable. When a suicidal and/or homicidal risk is present, the same guidelines used in individual psychotherapy are applicable in CBCT with a particular attention given to the safety of both partners. The therapist must then assess whether couple therapy should be continued or if individual therapy with a different therapist would be better suited to address these difficulties before starting or resuming CBCT [68, 77]. If ongoing severe violence occurs within a relationship and especially when it is perpetrated by one partner towards the other, rather than minor and bidirectional (see the Section 4.1.1 on conflicts and violence), couple therapy is usually contraindicated and specific procedures must be undertaken to control aggressive behaviors and protect the victim. Guidelines for such situations have been suggested by Lussier and colleagues [32, 36] and by Bélanger and colleagues [33]. After safety has been ensured and the crisis has started to resolve, the therapist can help couples make sense of this experience and feel validated in their distress, which can potentially strengthen the therapeutic alliance. Only then does the therapist and partners discuss new therapeutic goals if partners decide to remain in therapy.
