**5. Assessment in CBCT**

**4.3. Separation mandate**

124 Cognitive Behavioral Therapy and Clinical Applications

mandate in CBCT.

**4.4. Crisis intervention**

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

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.

As of now, there are clinical and research drawbacks regarding how CBCT can be effectively offered to couples who present specificities that can affect how they experience intimate relationships, such as same-sex or intercultural couples [18, 83]. For instance, in the past decade, the number of intercultural couples has increased in North America [84, 85] but these couples remain understudied [85]. In addition, even if couples from different cultural backgrounds usually experience the same kind of issues than other couples [86, 87], they may also face unique challenges that require specific attention in CBCT. Indeed, studies have reported that

**4.5. Specificities in CBCT for diverse 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 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 and, if applicable, to refine the therapeutic objectives and strategies [97].

indirect influence of such trauma on couple functioning [114–116], it is also central to systematically assess adverse childhood experiences (e.g., Childhood Cumulative Trauma

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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

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

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,

Questionnaire [117]) as part of the standard assessment of couples.

*5.1.3. Direct behavioral observation*

decision-making discussion.

**5.2. Phases of the assessment interviews**

conducted during the first evaluation session.

#### **5.1. Assessment methods**

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.

#### *5.1.1. Clinical interviews*

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 asked to describe their concerns [98].

#### *5.1.2. Self-report measures*

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 indirect influence of such trauma on couple functioning [114–116], it is also central to systematically assess adverse childhood experiences (e.g., Childhood Cumulative Trauma Questionnaire [117]) as part of the standard assessment of couples.
