Introduction
Cognitive Behavioral Couples Therapy (CBCT) and Cognitive Behavioral Family Therapy (CBFT) are interventions designed to solve couple and family-related challenges. The application of cognitive-behavioral principles to address relationship issues is an effective way of dealing with the multiple and complex disputes encountered by couples (Söylemez, 2017). It is vital to note that at the core of CBCT and CBFT are the social exchange theory, schemas, and social learning theory. This paper will explore the change process, the procedure of case formulation, and the therapeutic techniques that are vital in addressing relationship distress. Finally, a comprehensive review of the self of the therapists, empirical support, and the intricacies of the therapeutic alliance will end the discourse on CBFT.
Underlying Theory
The contemporary practice of CBCT is based on pioneering interventions designed to address various forms of psychological distress. Psychological interventions are designed to help patients to address mental distress and improve their welfare (Rozental et al., 2019). Cognitive Behavior Therapy (CBT) has its origins in Greek thought and in particular Plato’s idealism (Söylemez, 2017). It was developed in the 1960s by Aaron T. Beck, who has gone on to author 600 papers and more than 25 books (Beck & Fleming, 2021). Thereafter, Chomsky and Ellis pioneered the second wave, which formed the foundation for numerous psychiatric interventions (Ruggiero et al., 2018). Behavioral therapy, which was developed in the late 1960s, is based on elementary learning mechanics such as operant conditioning (Söylemez 2017). Its use in contemporary clinical contexts has facilitated the alleviation of numerous illnesses.
CBT is based on the psychological construct that people’s assessments of scenarios affect their reactions to a higher degree than the unfolding situation. In addition, their assessments may be inaccurate and distorted in the context of psychopathology (Beck & Fleming, 2021). The resultant automatic thoughts are usually associated with dysfunctional beliefs people have about the world, themselves, or the future (Beck & Fleming, 2021). It is vital to note that the social exchange theory and the social learning theory were the foundations upon which the principles of behavioral therapy were developed.
CBCT is a reliable intervention that is capable of addressing numerous relationship issues. It uses concepts in social learning to focus on the link between cognition, emotions, and behavior to facilitate the improvement of communication and problem-solving abilities (Bodenmann et al., 2020). The intervention’s creators posited that, on the one hand, successful relationships could be identified by the prevalence of the exchange of positive acts between partners. On the other hand, unsuccessful unions were characterized by a high incidence of negative behaviors. Bodenmann et al. (2020) note that operant conditioning was believed to guide behavior seeing as partners behaved in positive ways provided they experienced positive consequences from their respective partner’s actions.
The development of cognitive models designed to explicate individual psychopathology had an immense influence on the development of CBCT. Cognitive therapists deem it necessary to include family members in the treatment process when addressing relationships and cognitions (Bedrosian, 1983). In essence, an individual’s atypical behavioral and emotional reactions to relationship happenings are impacted by dysfunctions in information processing, which result in the distortion of an individual’s event appraisal capacity. It is often the case that partners are unable to determine the suitability of their reasoning when responding to internal and external occurrences with regard to the relationship. Söylemez (2017) notes that cognitive interventions are designed to facilitate the active observation of automatic thought processes, assumptions, and standards that govern relationships.
Information processing and its influences on social cognition was a central aspect of CBCT development. The attributions that couples use to determine positive and negative relationship events and the stable schemas that they cultivate from past relationship experiences are elements of social cognition that have a bearing on the application of CBCT interventions (Bedrosian, 1983). The factors above significantly impact couple behavior as well as the prevalence of marital distress.
Fundamental Aspects of Theory
The underlying theory presumes that members of a family create differing worldviews based on the events they experience. The therapeutic intervention focuses on addressing the individual problems in a family unit that affects the unit’s wellbeing. The therapist’s primary objective is to help affected individuals realize that specific cognitive distortions and unsound beliefs are the primary causes of emotional anguish (Dattilio, 2001). It is essential to help the affected individuals identify maladaptive behaviors and develop strategies designed to address cognitive distortions.
The Social Exchange Theory
The social exchange theory, which is an essential component of CBCT, highlights specific elements that are critical to understanding human behavior. The first fundamental aspect of the theory is the definition of reinforcement tools, which refers to the rewards and exchange of resources that drive people to participate in social interactions (Davlembayeva & Alamanos, 2021). Rewards refer to the outcomes of interactions that have positive connotations, while resources refer to specific traits that enable individuals to provide rewards that prompt their engagement in social relations. Resources often take the form of money, love, information, status, and goods.
The second fundamental aspect of the theory is the mechanics of an exchange. The social exchange theory posits that the exchange of resources is based on the subjective assessment of costs and rewards. The social exchange analysis depends on the extent to which an identical performance has been rewarded in the past and the extent to which the outcome of the exchange is valued by an individual (Davlembayeva & Alamanos, 2021). The two conditions are based on the observation that an increased frequency of rewards for a specific action prompts individuals to engage in similar actions in the future provided the conditions remain the same. Subjectivity plays a critical role in the assessment of value in social interactions. Davlembayeva and Alamanos (2021) note that an in-depth understanding of the differences between people is required to ascertain the relevance of exchange orientation, contextual variations, and the comparison of costs in social interactions.
Social interactions are impacted by social capital and social structures. According to the social exchange theory, people’s reliance on social structures demonstrates how outcomes of interactions are dependent on the initial relationship between the involved parties. Social capital often facilitates and, in some instances, restricts the occurrence of social interactions and their associated outcomes (Davlembayeva & Alamanos, 2021). The most common outcomes are the distribution of equity and power in social contexts. Social capital facilitates corporation between individuals and may serve as a reward for social interactions.
The final fundamental aspect of the social exchange theory is reciprocity, which results in the creation of obligations between the involved parties. It is worth noting that human beings are predisposed to adopt mannerisms that facilitate reciprocation (Davlembayeva & Alamanos, 2021). Individuals are equipped with mental matrices that facilitate the evaluation of costs and rewards when making decisions. Therefore, people engage in activities with the expectation that the favor will be returned at one point in time. These expectations are often based on cultural norms or personal beliefs.
Schemas
The family schema in the CBFT context refers to an individual’s entire set of cognitions regarding families. A schema is defined as a network of structures in an individual’s mind that facilitate the understanding of different phenomena (Bormanaki & Khoshhal, 2017). It includes assumptions about how a family operates and standards regarding specific family activities (Leahy, 2015). However, most individuals are unaware of the nature of their schemas (negative vs. positive), which results in numerous problems. For instance, the prescriptive nature of a schema may be problematic if, for instance, it defines the degree of happiness in a family context, or highlights specific mechanisms that must be applied when carrying out activities. Bormanaki and Khoshhal (2017) note that feelings of success, failure, contentment, and frustration result from personal evaluations of how the current family’s operations compare to the ideal schema.
Piaget highlighted the fact that schemas develop from specific cognitive processes. The first is assimilation, which refers to instances where individuals use an existing schema to contextualize novel information (Bormanaki & Khoshhal, 2017). The second cognitive process is accommodation, which refers to instances where people alter their schemas to fit new information because the presented data does not align with their adopted schemas. The realignment of distorted beliefs is a core element in cognitive therapy interventions because it facilitates the alteration of dysfunctional behaviors. Bormanaki and Khoshhal (2017) note that as a result, the family schema is an essential area to address in CBFT.
Social Learning Theory
The social learning theory is an integral aspect of CBFT interventions. According to Bandura’s social learning theory, a person’s ability to learn by observation facilitates the acquisition of large and integrated units of behavior without the need to engage in the tedious process of trial and error (Alshobramy, 2019). In essence, novel patterns of behavior can be acquired through observation and imitation, especially in instances where positive rewards or desirable consequences may be achieved. The four stages of learning according to Bandura are “attention, retention, reproduction and motivation” (Horsburgh & Ippolito, 2018, p. 2) The social learning theory places emphasis on the ability to learn through observation, modeling, and reinforcement.
Relational Thinking
The role of relationships in shaping routine experiences is an important factor to consider when assessing thought patterns and behavior. It should be noted that participating in fulfilling social interactions helps people develop and maintain emotionally fulfilling relationships (Gurman et al., 2015). The relational perspective posits that stress and emotional distress occur due to previous relational experiences which have the capacity to inhibit the expression of one’s true desires. In addition, empathy plays a critical role in the therapeutic relationship.
Relationship Effectiveness and Dysfunction
Traditional cognitive-behavioral interventions place emphasis on the couple as the unit of evaluation while sidelining the impact of the environment and the affected individuals’ welfare. It is essential to apply a broad contextual perspective when describing a healthy relationship. A healthy relationship is a union that enhances the wellbeing and growth of both partners by augmenting teamwork and facilitating a reasonable adaptation to the social and physical environment (Gurman et al., 2015). It is often the case that traditional approaches emphasize interactive processes designed to distinguish between happy and unhappy unions. It is vital to note that family pathologies can transcend generations (Bedrosian & Brozicas, 1993). Joyless relationships were defined as those with limited positive outcomes, limited problem-resolution skills, and ineffective communication.
The persistence of variations in relationship needs between well-adjusted partners often increases the incidence of relationship distress. For instance, differences in the desire for intimacy, need for control, or planning may result in frustration. The net effect is that partners behave negatively towards each other as they try to meet their needs, thus increasing the incidence of emotional disturbances and inaccurate assessments of behavior. The resultant anguish is referred to as primary distress, which highlights the core reasons for the relationship’s troubles (Gurman et al., 2015). Secondary distress refers to the application of maladaptive behavior in the context of a relationship to augment the achievement of specific unmet needs (Gurman et al., 2015). It is vital to tackle both forms of distress when treating a couple that is determined to save their relationship.
Assessment
The initial assessment is a fundamental aspect of the therapeutic process. It is vital that the therapist works with the couple to identify the main issues and themes that contribute to the development of distress in the relationship. The cognitive-behavioral framework stipulates specific goals that must be achieved during an assessment (Lan & Sher, 2019). The first is the identification of fears and probable areas of growth that the involved parties are seeking help. Secondly, the therapist must prioritize the clarification of behavioral, cognitive, and affective elements that impact the individuals in the union, the couple as a unit, and their immediate environment. The final goal is the clarification of the couple’s goals of treatment and their views concerning the highlighted areas of interest. According to Gurman et al. (2015), the quantification of the couple’s commitment to treatment helps the therapist define and plan the assessment process.
Assessment Processes and Procedures
In instances where the couple is not in crisis, the first three sessions are usually dedicated to evaluation and assessment. The therapist’s focus is on the evaluation of macro-level mannerisms that demonstrate a specific partner’s traits and the nature of the couple’s interaction over time. In addition, the therapist evaluates variance in partner personality traits, values, desires, and responses to conflict. Gurman et al. (2015) note that it is also vital to assess environmental elements such as stressors that the couple has coped with in the past and broad societal elements such as socioeconomic status, racism, and sexual harassment.
Numerous strategies can be applied in the assessment of a distressed couple. The focus is to gather information using questionnaires, self-reports, the observation of behavioral patterns, and clinical interviews. The initial joint couple interview focuses on gathering historical information such as where and when the couple met, the reasons they became attracted to each other, the mechanism through which they developed a deep commitment to each other (Lan & Sher, 2019). In addition, it is vital to identify specific life events that had a positive or negative influence on their relationship, the impact of ethnicity, race, and religion on the union, and an assessment of current concerns. The therapist must familiarize the couple with the process of therapy by describing the conventional structure and procedure of CBCT. The initial assessment is an essential tool for the establishment of an effective working relationship with the couple. It is common practice to conduct an extended 2 to 3-hour session or multiple 50 to 60-minute sessions (Gurman et al., 2015). It is vital to ascertain current relationship concerns and how they have contributed to the relationship’s distress.
There are various procedures involved in the assessment of a couple attending therapy. The first is the collection of a suitable communication sample. The process involves asking the parties involved to engage in a structured discussion, during which critical observations are made. The focus of communication sample collection is the identification of specific emotional, cognitive and behavioral responses to specific behaviors and relationship topics.
Questionnaires are a vital tool in the assessment of couples in the clinical setting because they aid in information collection. Self-assessment facilitates the evaluation of the couple’s contentment with vital aspects of the relationship, individual needs, the impact of environmental demands, communication patterns, cognitive processes, and the existence of any symptoms of psychopathology. The degree of marital satisfaction is best assessed by the Dyadic Adjustment Scale and the Marital Satisfaction Inventory (Gurman et al., 2015). The Need Fulfillment inventory assesses the degree to which partners are fulfilled in the relationship, while the Revised Conflict Tactics Scales assesses the degree of psychological and physical aggression in a relationship (Gurman et al., 2015). It is vital to note that questionnaires are essential tools in patient assessment.
Assessment Process and How It Relates to the Therapeutic Process
The assessment process is critical to the therapeutic process in view of the fact that it guides the goal-setting procedure, which is critical for the success of the treatment intervention. It allows the therapist to explain their understanding of the relationship’s core problems. In addition, the assessment process enables the therapist to describe specific behavioral and cognitive factors that add to the couple’s relationship distress. The translation of relationship hurdles into positive goals impacts the success of the therapeutic process. The identified goals are then related to specific techniques meant to replace desired behavioral patterns with existing ones. In instances where there are significant variations in goals, the therapist and the affected couple collaborate to reach an amicable solution.
Change Theory
CBFT is based on the premise that behaviors and thoughts are key determinants of a family’s functioning. Therefore, an individual’s behavior prompts the emergence of certain cognitions and behaviors in other members of the family. The creation of a feedback loop leads to specific emotional and behavioral reactions in the original individual as a result of exposure to the other family members’ behavior (Lan & Sher, 2019). It is vital to note that the most effective pathways to change are the ones that directly impact negative cognitions and behavioral expressions seen in a family at the relationship and individual levels. The behaviorism principle posits that behavior is sustained by its ramifications. According to Lan and Sher (2019), CBFT is designed to help individuals identify distortions associated with thought processes, restructure them, and alter their behavior in order to improve their relationships.
The CBFT model encourages therapists to assume the role of experts and trainers who help individuals locate dysfunctional thoughts and behaviors. The next step is the formulation of specific cognitive-behavioral interventions that are necessary to facilitate change. Lan and Sher (2019) also point out that therapists are often actively engaged in the therapeutic process as a means of ensuring behavior change is achieved.
Change as a Systemic Process
Psychotherapeutic interventions are designed to encourage new learning and transition individuals from entrenched patterns of behavior to more functional patterns of behavior. Psychotherapy can be viewed as an attractor state in which the interaction between cognition, physiology, and emotions is the norm (Hayes & Andrews, 2020). Therefore, therapeutic targets are the processes and patterns responsible for maintaining clinical challenges rather than symptoms that constitute a larger system. It is vital to note that change in psychotherapy takes numerous forms. The first is making slight and consistent adjustments to abnormal behavior (Hayes & Andrews, 2020). For instance, equipping clients with mindfulness skills, and positive emotional activation techniques facilitate the alteration of the threshold of activation for pathological behavior. Change is also seen in instances where an individual switches from a pathological behavior to a productive one. According to Hayes and Andrews (2020), the probability of switching from harmful behavior to a productive one is enhanced by the presence of an alternative switch.
A system’s view of the change in therapy empathizes the fact that harmful behavior patterns may still be adopted in instances where individuals are exposed to stressful life events. (Hayes & Andrews, 2020). Mechanisms such as repetition and practicing in varied contexts are useful in enhancing inhibitory learning. Activation in numerous contexts increases an individuals’ strength which is necessary for the displacement of undesirable behavior.
Factors that Facilitate the Change Process
There are numerous factors that facilitate the change process in CBFT. The first is structure, which refers to the common understanding between the therapist and the couple in question on issues involving the procedures, and activities involved in the counseling process. Structure helps define the features of the formal process and helps make the clients more comfortable with the therapeutic process (Schwebel & Fine, 1992). In addition, structure helps to define the boundaries of the relationship between the therapist and clients in the therapeutic relationship. The physical setting is an important determinant of the success of the change process. It is essential that the therapy venue offers clients privacy, silence, confidentiality, and a degree of comfort. The client’s willingness to engage in the therapeutic process is an important determinant of the success of the change process. Individuals who are unwilling to cooperate with the therapist are likely to experience minimal benefits from the interaction. Finally, the therapist’s traits are an essential aspect to consider in the change process (Moors & Zech, 2017). Professionalism, empathy, and trust are essential traits that determine the success of the change process.
Behaviors that Demonstrate Change
There are several behaviors that demonstrate a client’s change process. The first behavior that demonstrates change is the alteration of a client’s mood and emotions. The second element of change is a shift in thought processes as demonstrated by avoidance of previous maladaptive behaviors (Schwebel & Fine, 1992). In addition, clients who embrace change often relate better with their partners. There is evidence of better use of communication, conflict resolution, assertiveness, and negotiation skills. Finally, demonstrating assertion and the ability to take constructive criticism demonstrates change.
Factors that Inhibit and Facilitate the Change Process
There are numerous factors that influence the change process during a therapeutic interaction. An individual’s ability to accept their partner’s behavior predicted the improvement in a couple’s relationship all through treatment (Schwebel & Fine, 1992). It is also worth noting that an increased rate of self-reported deleterious communication determined the degree of change in distressed relationships. The above factors demonstrate that targeted changes are key to the success of CBFT interventions. According to Bodenmann et al. (2020), counselors must also prioritize the cultivation of effective communication techniques to facilitate the development of healthy relationships.
Conditions Necessary for Change
There are a variety of conditions necessary for change to occur. The first is the presence of psychological contact between the therapist and the clients. The barriers to psychological contact include severe mental illness or learning disabilities. It can only be established in instances where trust has been established. It is vital to note that differences between an individual’s self-image and lived experiences increases their vulnerability to fears and anxiety. Another condition necessary for change is the therapist’s congruence. It is important that the therapist remains self-aware and genuine when interacting with clients. Gurman et al. (2015) note that rather than demonstrate a picture-perfect persona, therapists should be transparent and foster a genuine therapeutic relationship.
A therapist’s unconditional positive regard is vital for change to occur. It is vital that the therapist accepts the client’s experiences regardless of their nature. In addition, the therapeutic alliance must be devoid of judgment or preconditions to allow clients to open up and share their feelings freely (Schwebel & Fine, 1992). Another vital factor for change is the demonstration of empathy by the therapist. It is essential to take note of the client’s experiences and emotional challenges without overly identifying with them. The final factor necessary for change to occur is client perception (Schwebel, & Fine, 1992). The client must be in a position to experience the therapist’s empathy and unconditional positive regard. The client’s perception of their therapist is a determinant of the degree of change that will be experienced in the therapeutic relationship.
Case Formulation Process
Initial Phase of Therapy
The goals of the initial phase of therapy are to develop trust with the clients, identify relevant family-linked cognitions and their associated behaviors, and to identify specific cognitions that characterize the clients’ family schema. The family schema is a key determinant of behavior and thought processes. It is worth noting that the steps involved in CBFT are often discrete, yet they overlap during the therapeutic process.
Step 1: Rapport Building and Introduction of New Concepts
The first step in the treatment process is building rapport while introducing new concepts (Schwebel & Fine, 1992). It is vital to introduce CBFT and explain that the intervention teaches clients new ways of addressing specific relationship issues that lead to discord. Schwebel and Fine (1992) note that the early phase of treatment involves the introduction of concepts such as the wholeness of the family system, linear and circular causality, the family schema, the constitution of the family, and vital elements of the relationship script.
Step 2: Client Assessment
The second step in the therapeutic process is client assessment. Schwebel and Fine (1992) note that one of the instruments utilized in the identification of negative or irrational cognitions is the Relationship Beliefs Inventory, which evaluates the presence of unrealistic beliefs that spouses hold about intimacy in relationships Schwebel and Fine (1992) note that in addition, the Family Beliefs inventory highlights problematic assumptions made by family members.
The identification of specific cognitions that characterize a person’s family schema may be enhanced by the adoption of informal procedures such as questioning and observation. Among the issues that may be highlighted are household rules, family strengths and weaknesses, interpersonal dynamics and dyads, and individual perceptions of family rules. Assessment progresses all through the treatment process, and the therapist must focus on specific cognitions in the chosen family’s schema (Schwebel & Fine, 1992). It is critical to introduce essential concepts to the couple at this point. The relationship script refers to a specific aspect of the family schema that guides an individual on how to behave or relate to other members of the family (Schwebel & Fine, 1992). The script outlines behavioral elements that are considered desirable and regulate interpersonal relationships. It also determines a person’s values, emotional awareness, problem-solving skills, and ability to communicate. Schwebel and Fine (1992) note that even though relationship scripts are often limiting, they provide an important sense of control and order.
The family constitution is an important element to define and introduce during the assessment stage of therapy. It refers to the unwritten rules that dictate the nature of interactions between members of a family unit (Schwebel & Fine, 1992). The constitution determines the nature of individual interactions, the modes of communication, the decision-making process, the distribution of resources, and interactions with people outside the family unit. It is vital to note that the family constitution provides the predictability required for independent and harmonious existence in a family unit. The constitution’s formation begins when the two individuals who desire to form a family first meet. Schwebel and Fine (1992) note that the focus of CBFT is to help couples identify the elements of their family constitution, which is essential in the resolution of some conflicts.
Mid Phase of Therapy
The goals of the mid-phase of therapy are to aid the clients to monitor specific cognitions and recognize the potential repercussions of holding them and teach clients how to ring an internal alarm when they think about dysfunctional cognitions. The ability to identify maladaptive thoughts is vital to the therapeutic process. Couples are also taught the potential negative impacts of specific cognitive distortions and their overall impact on the relationship.
Step 3: Personal Application of Concepts
The third step in the therapeutic process is the personal application of specific concepts. The main objective of this step of treatment is to help the clients monitor specific cognitions and recognize the potential repercussions of holding them (Schwebel & Fine, 1992). The therapist must focus on helping the couple identify specific cognitions and the impact they have on feelings and behavior. It is important to use homework to reinforce therapeutic lessons and collect vital information. For instance, helping couples define vital concepts such as selective abstraction, overgeneralization, and dichotomous thinking is necessary. The next step involves asking the couple to identify instances where individuals committed cognitive errors and the resultant distortions in experience assessments. According to Schwebel and Fine (1992), the therapist must then teach the couple the negative impacts of specific cognitive distortions and their overall impact on the relationship.
Step 4: Preliminary Cognitive Change
The penultimate step in the therapeutic process is the establishment of preliminary cognitive change. The therapist focuses on teaching clients how to ring an internal alarm when they think about dysfunctional cognitions (Schwebel & Fine, 1992). The mid-phase of therapy is often characterized by an improvement in the client’s ability to identify dysfunctional cognitions. The therapist must help the individual reframe such thoughts into more productive ones (Beck et al., 1979). Perceiving the family as a system allows individuals to realize that the expression of negative behaviors is an indicator of dissatisfaction (Gottman & Levinson, 1988). The reduction of the expression of negative behavior is likely to increase the degree of marital satisfaction between individuals (Hahlweg et al., 1982). It is vital to apply direct questioning and guided imagery to help individuals identify links between feelings, cognitions, and behavioral expressions. Schwebel and Fine (1992) note that a client’s ability to sound an internal alarm facilitates the discovery of critical elements that contribute to relationship distress.
Final Phase of Therapy
The goal of the final phase of therapy is to increase the frequency of positive family interactions and reduce the incidence of negative affect. The previously mentioned goal is achieved by giving couples specific in-session assignments. The focus in this phase is the identification of emergent issues and the proposal of effective coping techniques that can help clients make better progress in their recovery.
Step 5: Initiating Behavioral Change and Assessing its Impact
The final step of the therapeutic process is the initiation of behavior change and the assessment of its effects. It is expected that by the final step, clients have completed a significant amount of work which has translated to a decrease in their relationship issues. In addition, the therapist is expected to have a better understanding of the treatment alternatives necessary to tackle the remaining issues. Some of the interventions that may be applied in the final stage include behavioral rehearsal, role play, modeling, and communication enhancement (Schwebel & Fine, 1992). The aim of the aforesaid techniques is to increase the frequency of positive family interactions and facilitate the diffusion of negative affect. It is worth noting that promoting the practice of adaptive behaviors helps individuals feel in control of their lives, which is essential for family cohesion. The clarification of family dynamics should be accompanied by in-session assignments where the therapist helps the individuals change old thinking habits and adopt new, healthier thoughts and behaviors. It is vital to urge the clients to highlight the advantages and disadvantages of the new cognitive processes they embrace and practice. Schwebel and Fine (1992) state that the forenamed practice helps the therapist identify emergent issues and propose effective coping techniques that can help clients make better progress in their recovery.
Therapeutic Techniques
Therapeutic Techniques and Change
Technique1: Guided Behavior Change
The first therapeutic technique is designed to modify the client’s behavior. Guided behavior change includes treatment options that emphasize behavior change without the demonstration of a specific skill (Gurman et al., 2015). The therapist works with the involved parties to determine the most effective ways through which changes can be effected to ensure needs are met in addition to making the relationship function efficiently. Guided behavior change can be implemented by addressing the relationship’s overall emotional tone in a bid to increase the expression of positive behaviors while limiting the manifestation of negative mannerisms. The transition from the expression of negative behavior to positive behavior may be enhanced by the introduction of “love days” or “caring days,” where an individual practices activities designed to make their partner happy (Gurman et al., 2015, p. 37). Focally guided behavior change may be implemented when the therapist asks the couple to identify elements that lead to relationship distress.
Technique 2: Skill-based Techniques
Skills-based interventions refer to scenarios where therapists provide instructions aimed at informing couples on the techniques required to implement specific behavioral skills. Skill-based interventions are typically applied in communication training whereby individuals share their views and feelings and engage in problem-solving and decision-making conversations. The therapist must focus on the communication process rather than the details being discussed. However, Lan & Sher (2019) note that it is vital to maintain focus on the major themes that need to be addressed during the therapeutic process to ensure that each of the partner’s needs is adequately addressed.
Technique 3: Socratic Questioning
Therapeutic interventions that address cognitions are focused on the manner in which people in committed relationships behave towards each other. The cognitive variables that define relationships include selective attention, expectations, attributions, standards, and assumptions (Gurman et al., 2015). Therapists must focus on the distorted nature through which one or both partners process information. Therefore, rather than focusing exclusively on behavior change, the therapist should aim to help the involved parties evaluate their cognitions about expressed or unexpressed behavior and analyze them reasonably. Socratic questioning is a technique where individuals are asked several questions to help them re-assess the logic of their thought processes. The reassessment of cognitive processes helps to change maladaptive thoughts. In addition, the technique helps individuals grasp the intricacies of underlying issues, and demystify specific hitherto unseen concerns. It is vital to consider contextual issues when applying Socratic questioning, especially in situations where confrontational questions are likely to lead to defensive responses.
Technique 4: Guided Discovery
The second cognitive technique is guided discovery, which involves the creation of experiences for couples in a bid to encourage critical thinking and the re-examination of perceptions regarding the relationship. Lan & Sher (2019) note that the process is likely to allow the parties involved to assess their views on specific issues that are likely to contribute to relationship distress.
Technique 5: Detailed Recall and Metaphor Use
Therapeutic techniques that focus on emotions are often applied in instances where an individual is incapable of or engages in excessive emotional expression. They include detailed recall, the use of metaphors, and healthy compartmentalization. In instances where there is limited emotional expression, the therapist must focus on helping the affected individual elevate and access their emotions. The techniques designed to facilitate emotional expression depend on the creation of a safe environment where the expression of positive and negative emotions is encouraged (Gurman et al., 2015). The individual’s partner is also encouraged to respond to the emotional expressions of their partner in a caring manner. The techniques include asking the individual to retell a specific incident in detail in an attempt to evoke a specific emotional response. The identification of dysfunctional beliefs and the emotions they elicit is a vital CBT principle applied in detailed recall and metaphor use. Gurman et al. (2015) note that couples are encouraged to use metaphors to express specific emotions in instances where direct references are challenging.
Technique 6: Healthy Compartmentalization
In scenarios where individuals have difficulties controlling their emotions, the therapist should focus on teaching individuals how to tolerate and regulate distressing emotions. Practicing healthy compartmentalization helps individuals with affect dysregulation to get upset about a specific issue and avoid projecting their emotional disturbance onto the others in the relationship (Gurman et al., 2015). It is critical to emphasize the importance of appreciating the strengths and other functional aspects of the relationship that work. Therapists must also teach their clients alternative techniques to communicate feelings and gain support from individuals other than their partners. Lan & Sher (2019) note that seeking individual therapy, creating a strong support system, and keeping a journal or finding alternative forms of emotional release, can help individuals deal with their emotional challenges and lessen the negative impacts on their relationship.
Technique 7: Cognitive Restructuring
Cognitive restructuring is a therapeutic technique that facilitates the alteration of negative thought patterns. It was developed on the premise that schemas influence thought processes that impact behavior and emotions (Dattilio, 2007). Cognitive restructuring accomplishes therapeutic goals by helping patients identify maladaptive cognitions and the cognitive distortions associated with automatic thoughts. It also helps the patients to rationally dispute automatic thoughts as well as aid in the development of rational oppositions to automatic thoughts (Dattilio, 2007). It is vital to note that cognitive restructuring can be used in tandem with Bowen’s model of family therapy, especially in instances where balancing feelings and cognitions is the goal (Dattilio, 2007). The resolution of cognitive distortions is vital when addressing family problems in therapy.
Units of Treatment/Diversity/Presenting Problems
Theory and Individual, Couples, and Family Therapy
The impact of couple, environmental and individual aspects on the functioning of a relationship are likely to vary based on the ethnicity, gender, and cultural orientation of the involved parties. It is vital to note that roles in relationships, power dynamics, and information processing modalities are dependent on an individual’s gender and cultural background. The gender differences in the above-mentioned roles may vary in the heterosexual context depending on the significance a man or a woman place on a conflict. Gurman et al. (2015) note that studies demonstrate that the female partner is more often than not likely to demand change compared to men who are often withdrawing from the situation.
Individuals
The application of CBT techniques on individuals has been embraced across the world. The modality is used to treat depression, obsessive-compulsive disorder, anxiety, suicidality, and addiction (Beck & Fleming, 2021). A broad theory of psychopathology informed the application of behavioral therapy techniques in mental and behavioral illnesses. Cognitive therapy protocols have been developed for the management of social anxiety, panic disorder, and post-traumatic disorder (Beck & Fleming, 2021). Positive results have also been experienced with eating disorders, psychosis, and other mental health challenges (Beck & Fleming, 2021). According to Söylemez (2017), negative cognitive processes increase the incidence of emotions such as aggression and anger. Managing distorted cognitions is a vital step in addressing anger-related problems.
Substance Abuse
Substance use disorder is a particularly challenging illness to address. The severity of symptoms as well as the associated physical health issues increase the condition’s complexity. CBT addresses substance use by identifying the maladaptive beliefs associated with the illnesses and devising techniques designed to change the affected individuals’ thinking (Beck & Fleming, 2021). It is vital to note that addressing the dysfunctional beliefs more often than not resulted in the resolution of substance abuse disorders.
Couples
Relationship problems often cause distress in people who are committed to each other. The application of CBT techniques on couples gained traction in the 1950s when Albert Ellis developed the rational-emotive theory to address marital problems (Söylemez 2017). He posited that relationship problems occur in instances where unreal and irrational beliefs directed to a partner are prevalent. It is vital to note that gender impacts how partners in a relationship process and organize information. According to Gurman et al. (2015), on the one hand, women are more often than not engaged in circular relationship schematic processing, which involves the consideration of both individuals’ contributions to the prevalent interaction patterns is prioritized. On the other hand, men tend to adopt an “individual schematic processing” technique where the primary objective is to highlight the linear impacts that each partner has on the relationship (Gurman et al., 2015, p. 27). It is worth noting that CBFT helps male partners improve the degree of schematic processing demonstrated in relationships, which translates to an increased degree of satisfaction among female partners in the relationship.
Families
CBT techniques are useful in addressing family-related issues that result in relationship distress. According to Schwebel and Fine (1992), the application of CBT-based techniques in family therapy is intended to increase awareness of family-based cognitions and their effects on family functioning. The clients are informed of how their thought patterns are responsible for the creation and maintenance of specific family problems. Schwebel and Fine (1992) stress that clients are taught how to identify maladaptive cognitions and how to apply rational family discussion techniques to solve problems and develop a functional family.
Cultural Awareness and Limitations
The almost exclusive focus on gender rather than sexual orientation, racial, cultural, and ethnic issues in a number of cognitive-behavioral interventions is a matter of grave concern. Divorce rates vary based on race, with specific racial groups demonstrating a higher than average rate of separation (Lan & Sher, 2019). Some of the factors in question include poverty, unemployment, violence, and continued exposure to racial discrimination. It is often the case that continued exposure to chronic stressors is linked with heightened relationship distress as well as a decline in perceived relationship quality.
Chronic stressors are detrimental in view of the fact that they increase pressure on a couple’s resources, raise their vulnerability to other elements, and worsen negative perceptions of the relationship (Sleater & Scheiner, 2020). In addition, the partners’ hopes that they will survive the prevalent tribulations are significantly reduced which results in an increase in negative interactions. For instance, a biracial couple may turn against each other in an attempt to address their frustrations with systemic racism. In some instances, couples co-opt self-blaming and racist societal views and stereotypes linked with specific relationship challenges.
There are some limitations to the application of behavioral therapy in counseling. For instance, the quality of existing extended family and social networks may impact an individual’s ability to adjust to a relationship in unpredictable ways (Gurman et al., 2015). The degree to which parental closeness impacts an individual’s ability to form relationships is dependent on numerous as yet unmeasured factors. In addition, while racial minorities with close social ties to extended family and friends are better equipped to deal with and address social stressors, CBT does not adequately explain the low incidence of relationship issues in their counterparts with poor social ties.
Therapeutic Alliance
The nature of the therapeutic alliance in the treatment of couples using cognitive-behavioral interventions is vital for success. It comprises a variety of conversational devices that facilitate the seamless flow of information during interactions, which is essential for the resolution of concerns highlighted during therapy (Horvath, 2018). The therapeutic alliance is a delicate affair for a number of reasons. For instance, both parties involved in a relationship conflict may desire an alliance with the therapist in which each blames the other for the relationship’s challenges. It is vital that the therapist reacts in a manner that shows both partners that the seriousness of the raised issues is a matter of urgency. In addition, it is crucial to avoid siding with either of the involved parties in the conflict (Horvath, 2018). Therapists must apply empathic reflective listening techniques with each of the involved parties, after which a concise summary of the issues with an emphasis on the connected concerns must be presented. This technique helps establish a position of neutrality, which demonstrates the desire to help both individuals resolve the relationship issues that cause conflict. According to Horvath (2018), it is also vital to prioritize the use of didactic terms when defining relationship problems to help emphasize neutrality.
Client concern regarding the safety of conjoint sessions is a vital matter to consider in the establishment of a therapeutic alliance. Therapists must assess clients for the potential expression of physical violence and make informed decisions as to whether having both parties participate in the same session is wise. It is also worth considering the fact that some individuals may prefer to avoid verbal attacks from their partners and may, therefore, need the therapist to establish firm rules and boundaries to address the client’s concerns (Horvath, 2018). It is also important to intervene in instances where the expression of aversive behavior is imminent or when the agreed-upon guidelines are violated. For instance, a partner who receives attention after offering criticism may be reluctant to adhere to the therapist’s recommendation for constructive communication for fear of losing their partner’s attention. In this instance, the therapist must work to address the concerns by suggesting novel reinforcement techniques and to continue to create guidelines for constructive partner interactions during sessions. Horvath (2018) states that the therapist’s ability to create a successful therapeutic alliance is a fundamental factor in creating the necessary change.
Self of the Therapist
The success of the therapeutic intervention is dependent, to a large extent, on the therapist’s style, personality, and style of work. A therapist must be cognizant of their real self in order to use it effectively in a therapeutic relationship (Sleater & Scheiner, 2020). The self is an essential element of the therapeutic process in view of the fact that it forms the basis of the human relationship that underlies successful interventions. According to Aponte (2021), the therapist rather than the therapeutic model is the key determinant of success. Therefore, therapists must consciously use their personal selves in their interactions with clients. It is vital to note that the expanded therapeutic alliance that characterizes CBFT results in the creation of immensely complex relationships (Aponte, 2021). Countertransference, which refers to the therapist’s projection of personal issues during interactions is an essential matter to consider. In addition, therapists must be aware of totalistic countertransference, which depicts scenarios in which a therapist reacts emotionally to a patient’s issues (Aponte, 2021). The use of the self in such contexts is, therefore, an immensely delicate affair.
There are specific factors that therapists must consider when using the self to positively impact therapeutic outcomes. The first is connection, which refers to a therapist’s ability to create and cultivate a therapeutic link with each client (Brenner, 2020). Through self-disclosure, therapists may share pertinent personal information, share information unintentionally, or have a strong emotional reaction to an issue raised by a client. It is vital to strike a balance between the behavioral requirements of a therapeutic setting and those of a social setting Brenner, (2020) notes that being emotionally blank is off-putting, as is excessive familiarity.
The second important factor to consider is awareness, which refers to the identification of the unique features of each therapeutic encounter. It is critical to grasp the intricacies of a therapeutic interaction and consider the unique perspectives presented by each of the parties under the therapist’s care (Brenner, 2020). The use of the self in the therapeutic context is grounded on vulnerability, meaning that the client understands that the therapist is part of the process. It is necessary to be authentically involved while observing the required professional boundaries. CBFT requires that the therapist gets emotionally involved with clients while observing the rules regulating boundaries. The use of the self requires a mastery of the fundamentals of attachment theory. It is essential to understand a client’s attachment style and how the therapist’s attachment influences the therapeutic relationship (Brenner, 2020). It is critical to be aware of bodily experiences such as anxiety when engaging with clients.
It is critical to take care of the self if it is to be successfully applied in the therapeutic processes. Wellness and self-care are imperative to the success of therapy. The therapist must consciously implement measures designed to limit burnout, moral injury, and depression (Brenner, 2020). It is necessary to engage in healthy behaviors that limit one’s susceptibility to excessive fatigue. Therapists must seek help as needed and strive to maintain an appropriate degree of work-life balance.
Empirical Support
Contemporary practice dissuades the application of cognitive interventions without considering behavior. In addition, behavioral approaches must take into account affective and cognitive dimensions when addressing client needs. Cognitive-Behavioral Family Therapy (CBFT) is the most practiced form of couple treatment given the high number of empirical studies conducted to assess its effectiveness. It is also widely practiced because of its integrative potential and flexibility (Dattilio & Epstein, 2005). A large number of randomized controlled studies have demonstrated the efficacy of CBFT as a therapeutic intervention (Iniesta-Sepúlveda et al., 2017). The findings from the highlighted studies are generalizable across different population groups in varying contexts.
Most of the individuals who undergo treatment maintain the gains for a reasonable period. It is estimated that the benefits last for approximately a year (Gurman et al., 2015). However, long-term studies demonstrate that many couples experience devastating relapses. Contrary to the long-term study predictions, a 2-year study conducted by Christensen et al. (2006) demonstrated that approximately 60% of couples improved significantly compared to their pretreatment conditions (Gurman et al., 2015). The study revealed that the couples experienced an initial decline soon after therapy before recording significant improvements in the long run. Long-term studies indicated that cognitive-behavioral therapeutic interventions significantly reduced the separation and divorce rates among couples.
It should be noted that the empirical status of CBFT is noteworthy seeing as numerous randomized controlled trials across various geographical and cultural contexts have demonstrated its efficacy. Therapists with differing levels of experience attest to the fact that CBFT consistently improves relationship functioning and alleviates distress. Most of the couples who undergo the treatment maintain the gains in the long term. Dattilio and Epstein (2005) note that the result is a significantly reduced divorce rate and an increased degree of relationship functionality.
Conclusion
CBFT is an effective and efficient method of addressing numerous relationship challenges. The theories that underlie the intervention are the social exchange theory and the social learning theory. It is vital to apply a broad contextual perspective when addressing relationship issues. Therefore, the individuals involved, their environment, and social factors must be reviewed when formulating solutions to the presented problems. The assessment procedure is vital because it sets the tone for the therapeutic relationship. It is vital to build rapport, conduct a detailed assessment, encourage the application of specific concepts, establish preliminary cognitive change, and initiate cognitive changes (Schwebel & Fine, 1992). The application of therapeutic techniques designed to address behavior, cognition, and emotions is necessary for the resolution of relationship distress. It is worth noting that the success of the therapeutic intervention is dependent, to a large extent, on the therapist’s style, personality, and style of work. A therapist’s ability to establish an effective therapeutic alliance is a key determinant of success. It is evident that CBFT’s main objective is to help individuals change irrational beliefs and maladaptive behaviors to guarantee the development of functional relationships.
References
Alshobramy, H. (2019). The effectiveness of Bandura’s social learning theory in learning English: Speaking skill among secondary school EFL students. International Journal of Vocational and Technical Education Research, 5(5), 11–23. Web.
Aponte, H. J. (2021). The soul of therapy: The therapist’s use of self in the therapeutic relationship. Contemporary Family Therapy, 0123456789.
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery G. (1979). Cognitive therapy of depression Guilford.
Beck, J. S., & Fleming, S. (2021). A brief history of Aaron T. Beck, MD, and cognitive behavior therapy. Clinical Psychology in Europe, 3(2), 1–7.
Bedrosian, R. C. (1983). Cognitive therapy in the family system. In A. Freeman (Ed.), Cognitive therapy with couples and groups (pp. 95–106). New York: Guilford Press.
Bedrosian, R. C., & Bozicas, G. D. (1993). Treating family of origin problems: A cognitive approach. New York: Guilford Press.
Bodenmann, G., Kessler, M., Kuhn, R., Hocker, L., & Randall, A. K. (2020). Cognitive-behavioral and emotion-focused couple therapy: Similarities and differences.Clinical Psychology in Europe, 2(3), 1–12.
Bormanaki, H. B., & Khoshhal, Y. (2017). The role of equilibration in Piaget’s theory of cognitive development and its implication for receptive skills: A theoretical study.Journal of Language Teaching and Research, 8(5), 996–1005.
Brenner, G. H. (2020). How therapists use the self during therapy. Psychology Today. Web.
Dattilio, F.M. (2001). Cognitive-behavior family therapy: Contemporary myths and misconceptions.Contemporary Family Therapy 23, 3–18.
Dattilio, F. M. (2007). The restructuring of family schemas: A cognitive–behavior perspective.Journal of Marital and Family Therapy, 31(1), 15-30.
Dattilio, F. M., & Epstein, N. B. (2005). Introduction to the special section: The role of cognitive-behavioral interventions in couple and family therapy. Journal of Marital and Family Therapy, 31(1), 7-13.
Davlembayeva, D., & Alamanos, E. (2021). Social exchange theory. Theory Hub.
Gotlman, J. & Levinson, R. (1988). The social psychophysiology of marriage. In P. Noller and M. Fitzpatrick (Eds.), Perspectives on marital interaction (pp. 182-200). Multilingual Matters.
Gurman, A. S., Lebow, J. L., & Snyder, Douglas, K. (Eds.). (2015). Clinical handbook of couple therapy (5th ed.). The Guilford Press.
Hahlweg, K., Revenstorf, D. & Schindler, L. (1982). Treatment of marital distress: Comparing formats and modalities. Advances in behavior Research Therapy, 4(2), 57-74.
Hayes, A. M., & Andrews, L. A. (2020). A complex systems approach to the study of change in psychotherapy. BMC Medicine, 18(1), 1–13.
Horsburgh, J., & Ippolito, K. (2018). A skill to be worked at: Using social learning theory to explore the process of learning from role models in clinical settings.BMC Medical Education, 18(1), 1–8.
Horvath, A. O. (2018). Research on the alliance: Knowledge in search of a theory. Psychotherapy Research, 28(4), 499–516.
Iniesta-Sepúlveda, M., Rosa-Alcázar, A. I., Sánchez-Meca, J., Parada-Navas, J. L., & Rosa-Alcázar, A. (2017). Cognitive-behavioral high parental involvement treatments for pediatric obsessive-compulsive disorder: A meta-analysis.Journal of Anxiety Disorders, 49, 53–64.
Leahy, R. L. (2015). Contemporary cognitive therapy: Theory, research and practice. Gilford Publications.
Lan, J., & Sher, T. G. (2019). Cognitive-behavioral family therapy. Encyclopedia of Couple and Family Therapy, 31571157, 1–9.
Moors, F., & Zech, E. (2017). The effects of psychotherapist’s and clients’ interpersonal behaviors during a first simulated session: A lab study investigating client satisfaction.Frontiers in Psychology, 8(1868), 1–14.
Rozental, A., Kottorp, A., Forsström, D., Månsson, K., Boettcher, J., Andersson, G., Furmark, T., & Carlbring, P. (2019). The negative effects questionnaire: Psychometric properties of an instrument for assessing negative effects in psychological treatments.Behavioural and Cognitive Psychotherapy, 47(5), 559–572.
Ruggiero, G. M., Spada, M. M., Caselli, G., & Sassaroli, S. (2018). A Historical and theoretical review of cognitive behavioral therapies: From structural self ‑ knowledge to functional processes. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 36(4), 378–403.
Schwebel, A. I., & Fine, M. A. (1992). Cognitive behavioral family therapy.American Journal of Family Therapy, 3(1), 73–91.
Sleater, A. M., & Scheiner, J. (2020). Impact of the therapist’s “use of self.”The European Journal of Counselling Psychology, 8(1), 118–143.