**6. Intervention techniques commonly used in CBCT**

The following section describes the most common intervention techniques used in CBCT.These strategies include the development of communication, problem-solving and conflict resolution skills, cognitive restructuring, the improvement of the identification and expression of emotions, the improvement of the expression of affection and sensuality between partners as well as enhancement of sexual functioning and the development of acceptation and tolerance of differences and incompatibilities.

#### **6.1. Communication training**

Communication training is a central feature of CBCT and aims to enhance the way in which partners learn to express and listen, without criticism or attack. Interestingly, this type of intervention has demonstrated observable short-term changes, even in highly distressed couples [14, 17]. In order to lead communication training in CBCT, therapists must learn to recognize and identify dysfunctional behaviors expressed by either partner during sessions, as well as identify the emotions and beliefs that underlie such interactions in order to help couples develop more appropriate and functional dialogs [120]. In order to do so, the therapist first helps the couple identify a topic of conversation that is problematic, but does not involve overwhelming emotions [14]. Then, partners are successively assigned the roles of speaker and listener. The speaker is guided in expressing his or her subjective experiences and feelings within the relationship. The listener is directed in demonstrating openness, non-judgment and to respond with empathy and respect through the use of non-verbal demonstrations, reflections and summaries in order to help the speaker further describe his or her feelings and thoughts and feel listened to while doing so [121]. During this exercise, the therapist's role consists of reinforcing partners efforts, providing partners with constructive comments or suggestions and modeling certain speaker or listener behaviors in order to help partners' perfect communication and 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 communication training exercise can take place in CBCT.

*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 them both.*

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

*Melanie: I'll start.*

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

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 collabora-

The following section describes the most common intervention techniques used in CBCT.These strategies include the development of communication, problem-solving and conflict resolution skills, cognitive restructuring, the improvement of the identification and expression of emotions, the improvement of the expression of affection and sensuality between partners as well as enhancement of sexual functioning and the development of acceptation and tolerance

Communication training is a central feature of CBCT and aims to enhance the way in which partners learn to express and listen, without criticism or attack. Interestingly, this type of intervention has demonstrated observable short-term changes, even in highly distressed couples [14, 17]. In order to lead communication training in CBCT, therapists must learn to recognize and identify dysfunctional behaviors expressed by either partner during sessions, as well as identify the emotions and beliefs that underlie such interactions in order to help couples develop more appropriate and functional dialogs [120]. In order to do so, the therapist first helps the couple identify a topic of conversation that is problematic, but does not involve overwhelming emotions [14]. Then, partners are successively assigned the roles of speaker and listener. The speaker is guided in expressing his or her subjective experiences and feelings within the relationship. The listener is directed in demonstrating openness, non-judgment and to respond with empathy and respect through the use of non-verbal demonstrations, reflections and summaries in order to help the speaker further describe his or her feelings and thoughts and feel listened to while doing so [121]. During this exercise, the therapist's role consists of reinforcing partners efforts, providing partners with constructive comments or suggestions and modeling certain speaker or listener behaviors in order to help partners' perfect communication and

while living with the other [36].

128 Cognitive Behavioral Therapy and Clinical Applications

of differences and incompatibilities.

**6.1. Communication training**

tion with the couple and proposes a treatment plan [19].

**6. Intervention techniques commonly used in CBCT**

*Therapist: Ok, I would like you to take the role of the speaker for now and Ethan, that you take the role of the listener. We will then exchange roles ok?*

*Melanie: Ethan, I was hurt last Sunday when you came home late from your hockey game without telling me beforehand because I felt you did not care about us.*

*Ethan: You are saying that you were hurt because I came home late without telling you and you felt as if I did not care about you and Lily.*

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

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

*Melanie: Ok. When you do not tell me when you are going to be late, I feel that Lily and I are not your priorities, and that I am not important to you. This is how I felt last Sunday.*

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

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

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

*Therapist: Tell Ethan….*

*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 did Sunday.*

*Ethan: So if I hear you well, you would like me to call you when I plan on staying longer for a lunch after the game, so that you won't feel as if I do not care about you and Lily.*

*Melanie: Yes, that's it.*

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

#### **6.2. Problem and conflict resolution**

In CBCT, five strategies are commonly used to help couples develop problem-solving skills [17, 98, 121]. First, partners must define and identify one problem on which they want to work. Second, the therapist helps partners understand the meaning this problem holds for them by defining each partners' underlying needs. Third, partners are asked to suggest as many solutions they can think of, using brainstorming, which is known to increase feelings of interest, appreciation and consideration in the relationship as well as being particularly useful in case of serious conflict or strict patterns of interactions. Fourth, partners are asked to select a solution together that will allow to fulfill both partners' wishes, although it is possible they will not be equally satisfied. The fifth and last step involves a trial period that will take place between sessions. A feedback discussion is then held during the following session and, if partners feel unhappy during with the chosen solution, a new solution may be chosen with the therapist.

*Sandra: Thomas, maybe you could start by taking the weekends off?*

*edgment of Thomas' efforts concerning financial matters.*

and question further cognitive distortions [123].

*used to?*

**6.3. Cognitive restructuring**

*work for the whole weekend. What if I try to come home earlier on weeknights?*

*Thomas: I understand where you are coming from Sandra, but my job makes it difficult for me not to* 

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*Sandra: Hum… Why don't you take Sunday mornings off so that we can brunch together just like we* 

*This brainstorming continues until the most suitable solution is provided and agreed upon by both partners. The therapist encourages partners to be open for a trial period until the next session where the solution will be revaluated based on their feedbacks of the trial period. Since in the first exercise, the couple has addressed a problem that was initially reported by Sandra, the next problem-solving exercise will focus on a problem reported by Thomas, such as his complaints regarding Sandra's lack of acknowl-*

CBCT therapists are interested in identifying and confronting the distorted ways in which partners process information and how these cognitive distortions, namely selective attention, unrealistic or inappropriate attributions, expectations, assumptions and standards, are related to negative emotions and behaviors experienced within the relationship [31, 122]. Cognitive interventions used in CBCT thus aim at helping couples learn to detect and evaluate the appropriateness of their cognitions. They also aim at helping partners to challenge the cognitions they hold that negatively influence their emotional and behavioral responses towards their partner. These interventions thus allow couples to broaden their perspective on the relationship by gaining a mutual understanding of how the other thinks and interprets events. Partners will also begin to anticipate the impact of those interpretations on their interactions [17]. To do so, CBCT therapists often give information to couples on their cognitive distortions and the impact it can have on their interactions. They then solicit feedback from partners to promote integration of these concepts and encourage partner's ability to detect

Since CBCT allows couples' interactions to take place within sessions, therapists have the opportunity to address cognitive distortions as they spontaneously arise between partners, to help them question their way of thinking and to consider different alternative explanations or perspectives on the partner and on the relationship [19]. CBCT therapists also guide partners interacting in ways that will allow them to challenge their distortions by sharing their respective experiences on a particular issue [123]. Typically, cognitive interventions are also used to help partners revaluate the logic or incoherence of their thinking and understand the underlying issues and concerns. For instance, Socratic questioning entails asking questions to partners that help them understand the logic in their inferences or beliefs as well as evidence for their validity. Other cognitive techniques also used in CBCT involve inquiring about the evidence that supports a cognition, weighing its advantages and disadvantages, as well as considering the worst possible outcomes of negative predictions that partners make about their relationship [98, 124]. Cognitive interventions also include helping partners gain a mutual understanding of their difficulties by considering each partner's perspective on the concerns they report [99].

Similar steps as those used in problem-solving can also be used in CBCT to help couples learn how to resolve conflicts [28]. Yet, as conflicts can sometimes involve strong negative emotions, particular attention must be given to the expression of emotions and needs and the exploration of the meaning of the conflict by partners during these exercises [14]. In addition to guiding couples in acquiring these techniques, the therapist also holds the responsibility of observing conflictual interactions that arise in session, for instance, if partners attack or withdraw from an interaction, in order to provide feedback as to the impacts each partners' behavior exert on the other. This will allow the therapist to highlight and challenge the cognitions and emotions that underlie or contribute to these dysfunctional interactions with the intention of decreasing their recurrence [17]. The following case describes how these strategies can be used.

*Thomas and Sandra have sought couple therapy due to constant bickering and frustration resulting from problems they have difficulty resolving together. Sandra blames Thomas for the amount of time he spends at work, especially since he has been working on weekends. Thomas gets home late, is often too tired to engage with his partner and goes to bed shortly thereafter. Thomas admits to being exhausted and criticizes Sandra for constant complaints about financial matters.*

*Therapist: Sandra, why do you want Thomas to spend less time at work?*

*Sandra: Because we would be able to spend more time together, which would help me feel important and like more connected to him.*

*Therapist: And you, Thomas, what are you looking for in spending extra time at work?*

*Thomas: When I'm at work, I don't hear complaints about our financial situation. It would be so great to hear some appreciation of all my efforts to improve our finances and how wearing is my schedule.*

*Therapist: Thomas, I understand that you would like more appreciation for your hard work. Sandra, you've expressed that spending more time with Thomas would help you feel more valued and connected. Now that you've both addressed your needs, I invite you to name of as many possible solutions you can think of that could help resolve the problem expressed by Sandra.*

*Sandra: Thomas, maybe you could start by taking the weekends off?*

*Thomas: I understand where you are coming from Sandra, but my job makes it difficult for me not to work for the whole weekend. What if I try to come home earlier on weeknights?*

*Sandra: Hum… Why don't you take Sunday mornings off so that we can brunch together just like we used to?*

*This brainstorming continues until the most suitable solution is provided and agreed upon by both partners. The therapist encourages partners to be open for a trial period until the next session where the solution will be revaluated based on their feedbacks of the trial period. Since in the first exercise, the couple has addressed a problem that was initially reported by Sandra, the next problem-solving exercise will focus on a problem reported by Thomas, such as his complaints regarding Sandra's lack of acknowledgment of Thomas' efforts concerning financial matters.*

#### **6.3. Cognitive restructuring**

**6.2. Problem and conflict resolution**

130 Cognitive Behavioral Therapy and Clinical Applications

the therapist.

gies can be used.

*schedule.*

*and like more connected to him.*

In CBCT, five strategies are commonly used to help couples develop problem-solving skills [17, 98, 121]. First, partners must define and identify one problem on which they want to work. Second, the therapist helps partners understand the meaning this problem holds for them by defining each partners' underlying needs. Third, partners are asked to suggest as many solutions they can think of, using brainstorming, which is known to increase feelings of interest, appreciation and consideration in the relationship as well as being particularly useful in case of serious conflict or strict patterns of interactions. Fourth, partners are asked to select a solution together that will allow to fulfill both partners' wishes, although it is possible they will not be equally satisfied. The fifth and last step involves a trial period that will take place between sessions. A feedback discussion is then held during the following session and, if partners feel unhappy during with the chosen solution, a new solution may be chosen with

Similar steps as those used in problem-solving can also be used in CBCT to help couples learn how to resolve conflicts [28]. Yet, as conflicts can sometimes involve strong negative emotions, particular attention must be given to the expression of emotions and needs and the exploration of the meaning of the conflict by partners during these exercises [14]. In addition to guiding couples in acquiring these techniques, the therapist also holds the responsibility of observing conflictual interactions that arise in session, for instance, if partners attack or withdraw from an interaction, in order to provide feedback as to the impacts each partners' behavior exert on the other. This will allow the therapist to highlight and challenge the cognitions and emotions that underlie or contribute to these dysfunctional interactions with the intention of decreasing their recurrence [17]. The following case describes how these strate-

*Thomas and Sandra have sought couple therapy due to constant bickering and frustration resulting from problems they have difficulty resolving together. Sandra blames Thomas for the amount of time he spends at work, especially since he has been working on weekends. Thomas gets home late, is often too tired to engage with his partner and goes to bed shortly thereafter. Thomas admits to being exhausted* 

*Sandra: Because we would be able to spend more time together, which would help me feel important* 

*Thomas: When I'm at work, I don't hear complaints about our financial situation. It would be so great to hear some appreciation of all my efforts to improve our finances and how wearing is my* 

*Therapist: Thomas, I understand that you would like more appreciation for your hard work. Sandra, you've expressed that spending more time with Thomas would help you feel more valued and connected. Now that you've both addressed your needs, I invite you to name of as many possible solutions you can* 

*Therapist: And you, Thomas, what are you looking for in spending extra time at work?*

*and criticizes Sandra for constant complaints about financial matters.*

*think of that could help resolve the problem expressed by Sandra.*

*Therapist: Sandra, why do you want Thomas to spend less time at work?*

CBCT therapists are interested in identifying and confronting the distorted ways in which partners process information and how these cognitive distortions, namely selective attention, unrealistic or inappropriate attributions, expectations, assumptions and standards, are related to negative emotions and behaviors experienced within the relationship [31, 122]. Cognitive interventions used in CBCT thus aim at helping couples learn to detect and evaluate the appropriateness of their cognitions. They also aim at helping partners to challenge the cognitions they hold that negatively influence their emotional and behavioral responses towards their partner. These interventions thus allow couples to broaden their perspective on the relationship by gaining a mutual understanding of how the other thinks and interprets events. Partners will also begin to anticipate the impact of those interpretations on their interactions [17]. To do so, CBCT therapists often give information to couples on their cognitive distortions and the impact it can have on their interactions. They then solicit feedback from partners to promote integration of these concepts and encourage partner's ability to detect and question further cognitive distortions [123].

Since CBCT allows couples' interactions to take place within sessions, therapists have the opportunity to address cognitive distortions as they spontaneously arise between partners, to help them question their way of thinking and to consider different alternative explanations or perspectives on the partner and on the relationship [19]. CBCT therapists also guide partners interacting in ways that will allow them to challenge their distortions by sharing their respective experiences on a particular issue [123]. Typically, cognitive interventions are also used to help partners revaluate the logic or incoherence of their thinking and understand the underlying issues and concerns. For instance, Socratic questioning entails asking questions to partners that help them understand the logic in their inferences or beliefs as well as evidence for their validity. Other cognitive techniques also used in CBCT involve inquiring about the evidence that supports a cognition, weighing its advantages and disadvantages, as well as considering the worst possible outcomes of negative predictions that partners make about their relationship [98, 124]. Cognitive interventions also include helping partners gain a mutual understanding of their difficulties by considering each partner's perspective on the concerns they report [99].

*Nancy and Jacob began their relationship before Jacob left a former partner (Sarah). Jacob's history of infidelity is the subject of several arguments with Nancy. Jacob repeatedly told Nancy of his regrets at having been unfaithful with Sarah, and of his feeling that his relationship with Nancy is completely different. However, in the past few months, Nancy has been getting angry and has expressed jealousy when Jacob goes out with friends, convinced that infidelity might be an issue.*

will also encourage partners to express feelings and detect how they affect their way of thinking and behaving. When emotions have been identified and understood, partners are encouraged to express them by using the communication skills previously learned. Therapists can also access repressed or minimized emotions by asking partners to describe in detail specific experiences, by using reflections or questions or by encouraging partners to use metaphors and images to describe what they experience [19]. Techniques also include normalizing the expression of both positive and negative emotions, encouraging partners to care and support the other when he/she expresses emotions and guiding partners to stay focused on their emotional experiences rather than concentrating solely on more cognitive or behavioral aspects of

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Sometimes, therapists also meet couples that struggle with difficulties in regulating negative emotions. These partners will express them in a more dysfunctional manner, potentially leading to serious arguments and even partner violence. With these couples, scheduling times to discuss subjects that trigger such interactions can be useful in order to contain the expression of negative emotions to a specific time and place [125]. Skills specifically addressing emotion regulation as proposed in dialectical behavior therapy [126] have also been included in CBCT. Such interventions include the development of skills that enhance both partners' tolerance to strong or negative emotions and decrease their emotional reactivity in order to provide couples with the ability to deal with emotional interactions they may face

Lack of emotional affection or sensuality and dissatisfaction in the quality or frequency of sexual relations are frequently invoked when consulting in couple therapy. Many sexual problems can also be put forward by couples consulting in CBCT, some of which include various sexual dysfunctions, such as erectile disorders, orgasmic disorders, genito-pelvic pain/penetration disorder and sexual desire/arousal disorder [119]. Indeed, sexuality holds a decisive place in a couple's functioning and satisfaction [127], and thus, it is generally important to address the sexual domain in CBCT. However, since the various biological, social and psychological factors that contribute to the development and the persistence of sexual dysfunctions make their treatment complex [128], it is recommended that couples who experience sexual difficulties benefit from the expertise of a therapist specialized in both sexual and couple

CBCT techniques aimed at the improvement of sexual well-being in couples include a variety of strategies and exercises that allow a broadening and diversification of sexual behaviors for partners and that have been proven effective for addressing sexual dissatisfaction and various sexual dysfunctions [128, 129]. For instance, psychoeducation can help clients learn about sexuality as well as correcting myths, misconceptions or unrealistic notions that partners might have about sexuality through information from the therapist as well as by reading or watching recommended psychoeducational material [130]. Cognitive interventions can also be used to address sexual difficulties by challenging and nuancing cognitive distortions that could be both automatic and irrational, in order to replace them by more positive

an experience, for instance, during a conflict with the partner [19].

**6.5. Expression of affection and sexual problems**

together [73].

therapy [119].

*Therapist: I understand you are angry when Jacob goes out with friends. What do you think will happen?*

*Nancy: That Jacob will meet someone and cheat on me.*

*Therapist: What makes you think Jacob might cheat on you?*

*Nancy: Nothing that I can think of … except what happened with Sarah.*

*Therapist: Do you think that Jacob could be unfaithful to you, even though that has not happened?*

*Nancy: I don't know…Jacob told me that the relationship with Sarah was not a happy one.*

*Therapist: Do you think Jacob is happy with you?*

*Nancy: …. seems happy….*

*Therapist: You are saying that the cheating with Sarah was because Jacob was unhappy in that relationship. You also believe Jacob is happy in the relationship with you. Explain to Jacob why do you think he might be unfaithful to you?*

*Nancy: Actually, there are no concrete signs that indicate that you would cheat on me… I think I'm just afraid of losing you.*

*Therapist: I understand you care a lot about Jacob and do not want to lose the relationship. Jacob, how does it make you feel to hear that?*

#### **6.4. Identification and expression of emotions**

In CBCT, emotions that are minimized, avoided, repressed or excessively expressed by partners are known to negatively impact a couple's relational functioning and satisfaction [120]. Indeed, individuals who do not express their emotions are generally more distant and less involved in their relationship, which ultimately leads to less intimacy and satisfaction between partners [30]. As such, CBCT intervention techniques have been developed to identify, modify and enhance tolerance of negative emotions [19]. By enhancing partners' identification, expression and tolerance of negative emotions, CBCT therapists can also help couples identify the sources of their relational dissatisfaction and, eventually, foster higher levels of intimacy between partners.

For Wright and colleagues [14], since certain negative or strong emotions that affect couple interactions, such as anger or fear, are often avoided by partners, the therapist must help partners clarify and regulate avoided emotions. To address this, strategies used in CBCT hold the purpose of accessing and heightening partners' emotional experiences as well as helping them receive the emotions expressed by the partner. To do so, therapists generally address spontaneous emotions, as they arise in session or as they are expressed non-verbally by partners. They will also encourage partners to express feelings and detect how they affect their way of thinking and behaving. When emotions have been identified and understood, partners are encouraged to express them by using the communication skills previously learned. Therapists can also access repressed or minimized emotions by asking partners to describe in detail specific experiences, by using reflections or questions or by encouraging partners to use metaphors and images to describe what they experience [19]. Techniques also include normalizing the expression of both positive and negative emotions, encouraging partners to care and support the other when he/she expresses emotions and guiding partners to stay focused on their emotional experiences rather than concentrating solely on more cognitive or behavioral aspects of an experience, for instance, during a conflict with the partner [19].

Sometimes, therapists also meet couples that struggle with difficulties in regulating negative emotions. These partners will express them in a more dysfunctional manner, potentially leading to serious arguments and even partner violence. With these couples, scheduling times to discuss subjects that trigger such interactions can be useful in order to contain the expression of negative emotions to a specific time and place [125]. Skills specifically addressing emotion regulation as proposed in dialectical behavior therapy [126] have also been included in CBCT. Such interventions include the development of skills that enhance both partners' tolerance to strong or negative emotions and decrease their emotional reactivity in order to provide couples with the ability to deal with emotional interactions they may face together [73].

#### **6.5. Expression of affection and sexual problems**

*Nancy and Jacob began their relationship before Jacob left a former partner (Sarah). Jacob's history of infidelity is the subject of several arguments with Nancy. Jacob repeatedly told Nancy of his regrets at having been unfaithful with Sarah, and of his feeling that his relationship with Nancy is completely different. However, in the past few months, Nancy has been getting angry and has expressed jealousy* 

*Therapist: I understand you are angry when Jacob goes out with friends. What do you think will* 

*Therapist: Do you think that Jacob could be unfaithful to you, even though that has not happened?*

*Therapist: You are saying that the cheating with Sarah was because Jacob was unhappy in that relationship. You also believe Jacob is happy in the relationship with you. Explain to Jacob why do you think* 

*Nancy: Actually, there are no concrete signs that indicate that you would cheat on me… I think I'm* 

*Therapist: I understand you care a lot about Jacob and do not want to lose the relationship. Jacob, how* 

In CBCT, emotions that are minimized, avoided, repressed or excessively expressed by partners are known to negatively impact a couple's relational functioning and satisfaction [120]. Indeed, individuals who do not express their emotions are generally more distant and less involved in their relationship, which ultimately leads to less intimacy and satisfaction between partners [30]. As such, CBCT intervention techniques have been developed to identify, modify and enhance tolerance of negative emotions [19]. By enhancing partners' identification, expression and tolerance of negative emotions, CBCT therapists can also help couples identify the sources of their relational dissatisfaction and, eventually, foster higher levels of

For Wright and colleagues [14], since certain negative or strong emotions that affect couple interactions, such as anger or fear, are often avoided by partners, the therapist must help partners clarify and regulate avoided emotions. To address this, strategies used in CBCT hold the purpose of accessing and heightening partners' emotional experiences as well as helping them receive the emotions expressed by the partner. To do so, therapists generally address spontaneous emotions, as they arise in session or as they are expressed non-verbally by partners. They

*Nancy: I don't know…Jacob told me that the relationship with Sarah was not a happy one.*

*when Jacob goes out with friends, convinced that infidelity might be an issue.*

*Nancy: Nothing that I can think of … except what happened with Sarah.*

*Nancy: That Jacob will meet someone and cheat on me.*

*Therapist: Do you think Jacob is happy with you?*

*Nancy: …. seems happy….*

132 Cognitive Behavioral Therapy and Clinical Applications

*he might be unfaithful to you?*

*does it make you feel to hear that?*

**6.4. Identification and expression of emotions**

*just afraid of losing you.*

intimacy between partners.

*Therapist: What makes you think Jacob might cheat on you?*

*happen?*

Lack of emotional affection or sensuality and dissatisfaction in the quality or frequency of sexual relations are frequently invoked when consulting in couple therapy. Many sexual problems can also be put forward by couples consulting in CBCT, some of which include various sexual dysfunctions, such as erectile disorders, orgasmic disorders, genito-pelvic pain/penetration disorder and sexual desire/arousal disorder [119]. Indeed, sexuality holds a decisive place in a couple's functioning and satisfaction [127], and thus, it is generally important to address the sexual domain in CBCT. However, since the various biological, social and psychological factors that contribute to the development and the persistence of sexual dysfunctions make their treatment complex [128], it is recommended that couples who experience sexual difficulties benefit from the expertise of a therapist specialized in both sexual and couple therapy [119].

CBCT techniques aimed at the improvement of sexual well-being in couples include a variety of strategies and exercises that allow a broadening and diversification of sexual behaviors for partners and that have been proven effective for addressing sexual dissatisfaction and various sexual dysfunctions [128, 129]. For instance, psychoeducation can help clients learn about sexuality as well as correcting myths, misconceptions or unrealistic notions that partners might have about sexuality through information from the therapist as well as by reading or watching recommended psychoeducational material [130]. Cognitive interventions can also be used to address sexual difficulties by challenging and nuancing cognitive distortions that could be both automatic and irrational, in order to replace them by more positive and functional cognitions and beliefs towards sexuality [17]. Such cognitive distortions can include beliefs or standards about how sexual relations "must be" that are unrealistic (e.g., "In our sexual relations my partner always has to reach an orgasm") or negative (e.g., "I have never had a good sex life with my partner"). Indeed, cognitive interventions can be used to address these negative or anxiety-provoking thoughts that interfere with the ability to have satisfying sexual relations with a partner [128].

This is accomplished by developing an empathic understanding of the other's experience and working together to face common hardships [136]. To achieve this goal, strategies target three objectives: acceptance, tolerance and change [137]. Strategies to enhance acceptance aim at offering partners new ways of looking at their problems through empathic joining and unified detachment. Empathic joining brings to light each partner's sense of vulnerability by allowing them to express their perspective on a problem, while being listened by the other partner and the therapist, whose task is to encourage the expression of emotions, rather than accusations or comments on behaviors. Unified detachment encourages partners to discontinue accusations or blame by helping them develop a more objective and less emotional consideration of their problems or differences and by considering them as an " it " (e.g., an object, an animal, a nickname) rather than as a deficiency or a problem in the other. The following example illustrates how this technique can be

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*Robert and John have sought CBCT as a result of frequent arguments they have experienced in the past months. Their arguments usually revolve around their finances and lifestyle. Robert typically prefers staying home and has a frugal lifestyle. John rather enjoys luxuries and spending his evening in trendy restaurants. During a session, Robert expresses his anxiety over their financial situation as John has spent a few hundred dollars in the past week during an evening with friends. John then expresses he* 

*Therapist: Robert, I understand you must feel anxious about your financial situation and John, I understand you feel as if you are treated as a child. Perhaps we could use this situation to try an exercise called " unified detachment " to help both of you. First, I would like you to identify what part of yourself, or of your personality, is talking during these arguments. Then, try to imagine what form would take this part of yourself during conflicts if it were to be described as a " thing ". It can be an object, an* 

*Robert: You are right John! If I follow your lead on drinks, I would be a cup of freshly brewed coffee.* 

*Therapist: Perfect! Now, if the glass of champagne and the cup of coffee were to discuss on a date they* 

*Therapist: And considering these different wishes, what solution can the glass of champagne and the* 

*John: Robert, I have an idea! You know we often drink champagne as an aperitif in restaurants and* 

*Robert: The glass of champagne and the cup of coffee could grab drinks at the restaurant and then finish* 

*John: Well the glass of champagne would like to go to the new restaurant on 6th Street.*

*Robert: The cup of coffee would prefer to stay home, order take out and watch a good movie.*

*feels Robert is treating him like a child by scolding him every time he comes back home.*

*John: I would be a glass of champagne! It is luxurious and bubbly, like me!*

*are planning for Friday night. What would they say to each other?*

*cup of coffee try to find together to spend their Friday night together?*

*coffee with desert. What would you say if we were to do the same?*

*animal, a country, whatever you want.*

*the evening with take out and a movie?*

*John: Yes! What do you think of that?*

*Robert: It is a very good idea! Let's try it!*

*It's inexpensive but comforting.*

used.

According to Kelly et al. [131], difficulty in expressing sexual needs and desires is common in couples. Consequently, it is crucial that partners improve their communication skills with regards to sexuality [132]. The several communication training techniques mentioned above can be applied to sexuality, with the objective of promoting optimism and sexual pleasure in the relationship. Indeed, communication training can be used to enhance feelings of love and affection between partners. This is accomplished by helping partners share their sexual needs and find new ways to express affection and caring [128].

Sessions on sexuality can also be dedicated to the exploration of negative emotions that are experienced during sexual relations. Partners are shown how to detect negative emotions, such as anxiety, anger, discomfort, as well as fear of rejection or abandonment, any of which can disrupt intimacy and sexual desire [128]. Identifying and accepting these emotions, the specific context in which they arise, their underlying beliefs as well as their impact on pleasure and intimacy, will increase sexual and sensual exploration and innovation [14]. In addition, strategies aimed at revealing these emotions in session can be of significant use as they allow to explore the underlying beliefs and attachment needs of partners in the sexual problems or dissatisfactions they experience [133].

Behavioral exercises that broaden a couple's sexual repertoire, diminish avoidant behaviors towards sexuality as well as confront certain cognitive distortions and help partners refocus on sensations and sensuality [119] are also used to treat sexual dissatisfaction or dysfunctions and are recognized as leading to positive outcomes and long-term changes [134]. These exercises are usually explained during session, practiced at home between sessions and later discussed with the therapist [119]. Such behavioral interventions can include self-exploration (i.e., exploration of one's body and/or genitalia) followed by directed masturbation (i.e., trying different ways of masturbating, in different positions or places) that can be practiced alone at first but then with the partner [119]. Finally, sensate focus is a behavioral exercise for couples that has been developed by Masters and Johnson [135] and that is commonly used to emphasize pleasurable sensations and sensuality and de-emphasize sexual performance, which is considered as being at the root of many sexual difficulties in couples.

#### **6.6. Acceptance and tolerance of differences**

Jacobson and Christensen [16] have underlined the importance of acceptance and tolerance in order to enable the integration of new behaviors developed in CBCT. Indeed, the non-acceptation of basic personal differences between partners might sometimes lead to arguments or resentment. Interventions developed by Jacobson and Christensen thus aim at accepting the potential fundamental differences or incompatibilities between partners. This is accomplished by developing an empathic understanding of the other's experience and working together to face common hardships [136]. To achieve this goal, strategies target three objectives: acceptance, tolerance and change [137]. Strategies to enhance acceptance aim at offering partners new ways of looking at their problems through empathic joining and unified detachment. Empathic joining brings to light each partner's sense of vulnerability by allowing them to express their perspective on a problem, while being listened by the other partner and the therapist, whose task is to encourage the expression of emotions, rather than accusations or comments on behaviors. Unified detachment encourages partners to discontinue accusations or blame by helping them develop a more objective and less emotional consideration of their problems or differences and by considering them as an " it " (e.g., an object, an animal, a nickname) rather than as a deficiency or a problem in the other. The following example illustrates how this technique can be used.

*Robert and John have sought CBCT as a result of frequent arguments they have experienced in the past months. Their arguments usually revolve around their finances and lifestyle. Robert typically prefers staying home and has a frugal lifestyle. John rather enjoys luxuries and spending his evening in trendy restaurants. During a session, Robert expresses his anxiety over their financial situation as John has spent a few hundred dollars in the past week during an evening with friends. John then expresses he feels Robert is treating him like a child by scolding him every time he comes back home.*

*Therapist: Robert, I understand you must feel anxious about your financial situation and John, I understand you feel as if you are treated as a child. Perhaps we could use this situation to try an exercise called " unified detachment " to help both of you. First, I would like you to identify what part of yourself, or of your personality, is talking during these arguments. Then, try to imagine what form would take this part of yourself during conflicts if it were to be described as a " thing ". It can be an object, an animal, a country, whatever you want.*

*John: I would be a glass of champagne! It is luxurious and bubbly, like me!*

*Robert: You are right John! If I follow your lead on drinks, I would be a cup of freshly brewed coffee. It's inexpensive but comforting.*

*Therapist: Perfect! Now, if the glass of champagne and the cup of coffee were to discuss on a date they are planning for Friday night. What would they say to each other?*

*John: Well the glass of champagne would like to go to the new restaurant on 6th Street.*

*Robert: The cup of coffee would prefer to stay home, order take out and watch a good movie.*

*Therapist: And considering these different wishes, what solution can the glass of champagne and the cup of coffee try to find together to spend their Friday night together?*

*John: Robert, I have an idea! You know we often drink champagne as an aperitif in restaurants and coffee with desert. What would you say if we were to do the same?*

*Robert: The glass of champagne and the cup of coffee could grab drinks at the restaurant and then finish the evening with take out and a movie?*

*John: Yes! What do you think of that?*

and functional cognitions and beliefs towards sexuality [17]. Such cognitive distortions can include beliefs or standards about how sexual relations "must be" that are unrealistic (e.g., "In our sexual relations my partner always has to reach an orgasm") or negative (e.g., "I have never had a good sex life with my partner"). Indeed, cognitive interventions can be used to address these negative or anxiety-provoking thoughts that interfere with the ability to have

According to Kelly et al. [131], difficulty in expressing sexual needs and desires is common in couples. Consequently, it is crucial that partners improve their communication skills with regards to sexuality [132]. The several communication training techniques mentioned above can be applied to sexuality, with the objective of promoting optimism and sexual pleasure in the relationship. Indeed, communication training can be used to enhance feelings of love and affection between partners. This is accomplished by helping partners share their sexual needs

Sessions on sexuality can also be dedicated to the exploration of negative emotions that are experienced during sexual relations. Partners are shown how to detect negative emotions, such as anxiety, anger, discomfort, as well as fear of rejection or abandonment, any of which can disrupt intimacy and sexual desire [128]. Identifying and accepting these emotions, the specific context in which they arise, their underlying beliefs as well as their impact on pleasure and intimacy, will increase sexual and sensual exploration and innovation [14]. In addition, strategies aimed at revealing these emotions in session can be of significant use as they allow to explore the underlying beliefs and attachment needs of partners in the sexual prob-

Behavioral exercises that broaden a couple's sexual repertoire, diminish avoidant behaviors towards sexuality as well as confront certain cognitive distortions and help partners refocus on sensations and sensuality [119] are also used to treat sexual dissatisfaction or dysfunctions and are recognized as leading to positive outcomes and long-term changes [134]. These exercises are usually explained during session, practiced at home between sessions and later discussed with the therapist [119]. Such behavioral interventions can include self-exploration (i.e., exploration of one's body and/or genitalia) followed by directed masturbation (i.e., trying different ways of masturbating, in different positions or places) that can be practiced alone at first but then with the partner [119]. Finally, sensate focus is a behavioral exercise for couples that has been developed by Masters and Johnson [135] and that is commonly used to emphasize pleasurable sensations and sensuality and de-emphasize sexual performance, which is considered as being at the root of many sexual

Jacobson and Christensen [16] have underlined the importance of acceptance and tolerance in order to enable the integration of new behaviors developed in CBCT. Indeed, the non-acceptation of basic personal differences between partners might sometimes lead to arguments or resentment. Interventions developed by Jacobson and Christensen thus aim at accepting the potential fundamental differences or incompatibilities between partners.

satisfying sexual relations with a partner [128].

134 Cognitive Behavioral Therapy and Clinical Applications

and find new ways to express affection and caring [128].

lems or dissatisfactions they experience [133].

**6.6. Acceptance and tolerance of differences**

difficulties in couples.

*Robert: It is a very good idea! Let's try it!*

Tolerance strategies have also been developed in order to stop partners from trying to change the other, for instance, by pointing out the benefits that can result from certain behaviors that are considered negative by partners (e.g., a partner's constant worries and attempts to predict everything that can go wrong in a situation, typical in anxious people, can negatively impact a couple's interactions but can also be very useful when planning a vacation or when taking financial decisions). Change strategies aim at reinforcing and prompting positive behaviors that partners already portray towards each other and include the improvement of communication and problem-solving skills by recreating a conflict they have already experienced and integrating the acceptance and tolerance strategies they have learned [137]. Finally, mindfulness-based interventions can also be used to enhance acceptance of differences. These strategies have been proven to increase relationship satisfaction, sense of relatedness and closeness, acceptance of the partner and to alleviate relationship distress [138]. They include meditation and touch exercises, aim at enhancing partners' acceptance of their experiences without judgment as well as their moment-to-moment awareness of how they feel and behave while interacting with one another, which could eventually help them develop new ways to connect with one another.

on the effectiveness of CBCT include large sample sizes, randomized controlled trials (RCT) or follow-up data extending beyond 6 or 12 months. As such, the effectiveness of CBCT for different couple difficulties must be considered within this reality. In addition, going from theory to practice can be quite a challenge, especially because in CBCT, clients are two different people who consult together. Indeed, CBCT therapists must learn to work not only with both parties' personalities, feelings, cognitions and behaviors but also with the couple's dynamics as they take place during and between sessions. The complexity of this type of therapeutic work also lies in the therapist's role, as he/she is called to inquire about, and directly witness, couples' most intimate moments and feelings while maintaining a respectful

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Finally, it is also important to note that regardless of the concerns for which a couple seeks therapy, the CBCT process in itself holds certain limitations. Indeed, both partners must be strongly committed to making their relationship work by demonstrating honesty, openness, caring and interest in the other's experience. They must also demonstrate commitment towards the therapeutic process. For instance, in cases when partners do not really want to see their problem solved (e.g., when changes in the couple are considered as too anxietyprovoking) or when partners come to therapy to have the therapist determine who is "right" or "wrong," it is often difficult to induce change in the relationship and enhance relational functioning. Fortunately, empirical and clinical work from the past decades has offered precious insights in the understanding of such dynamics and in the training of CBCT therapists that are not only aware of these therapeutic intricacies but also use them to further their work

[1] Coleman L, Mitcheson J, Casey P, Lloyd G. Couple relationships: Why are they impor-

[2] Snyder DK, Halford WK.Evidence-based couple therapy: Current status and future directions. Journal of Family Therapy. 2012;**34**(3):229-249. DOI: 10.1111/j.1467-6427.2012.00599.x

[3] Epstein NB, Zheng L. Cognitive-behavioral couple therapy. Current Opinion in

tant for health and wellbeing? Journal of Health Visiting. 2013;**1**(3):168-172

Psychology. 2017;**13**:142-147. DOI: 10.1016/j.copsyc.2016.09.004

Caroline Dugal, Gaëlle Bakhos, Claude Bélanger\* and Natacha Godbout

\*Address all correspondence to: belanger.claude@uqam.ca

Université du Québec à Montréal, Montreal, Quebec, Canada

and professional distance.

with couples.

**References**

**Author details**
