Atlas›Domain V · Systemic, relational, group & community›Guide 067
Guide V-067

Cognitive-behavioural couple therapy

Norman B. Epstein, Donald H. Baucom1990
A 26 · L 61 · M 1330 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Enhanced Cognitive-Behavioral Couple Therapy (enhanced CBCT), as set out by Norman B. Epstein and Donald H. Baucom (2002), Enhanced Cognitive-Behavioral Therapy for Couples: A Contextual Approach (APA). It extends Baucom & Epstein's earlier Cognitive-Behavioral Marital Therapy (1990). The 2002 book's text was not available to open. Its structure comes from the publisher's page and a library table of contents. Its clinical procedures come from Baucom's APA demonstration-video page and from an open-access chapter by Dugal, Bakhos, Bélanger & Godbout (2018), which summarises the Epstein–Baucom model and cites it throughout. The current handbook chapter (Baucom, Epstein, Fischer, Kirby & LaTaillade, ch. 3 in Lebow & Snyder, Clinical Handbook of Couple Therapy, 6th ed., 2022) and a newer Guilford treatment-planning book were found but not readable. The detail in this guide therefore rests largely on secondary summary. [source: APA book page; SCU TOC; APA video page; Dugal et al. 2018; Guilford Handbook contents] [uncertain: primary manual text]

CBCT treats couple distress as coming from three linked kinds of factor, all weighted equally:

  • Behaviour: too few positive and too many negative exchanges, plus poor communication and problem-solving.
  • Cognition: selective attention, negative attributions, and unrealistic expectancies, assumptions and standards.
  • Emotion: feelings that are avoided, suppressed or expressed excessively.

The model began with Stuart's behavioural-exchange idea that satisfaction depends on the balance of positive and negative partner behaviour. Cognitions and emotions were added later. [source: Dugal et al. 2018]

The "enhanced" (contextual) version widens the focus in four ways:

  • Core themes: it looks beyond moment-to-moment exchanges to broad relationship themes, such as differences in partners' needs for intimacy.
  • Individual factors: each partner's history, motives, personality and psychopathology.
  • Interaction patterns: dyadic patterns such as boundaries, power distribution and investment in the relationship.
  • Context: the environment, including stressors, family, community, culture, life events and developmental transitions.

It also gives emotion a more central role and gives positives as much attention as negatives. [source: APA book page; APA video page]

Change happens through three routes, used together:

  1. The couple's behaviour changes, increasing positive exchanges and building communication and problem-solving skills.
  2. Partners learn to notice and test the cognitions behind their distress.
  3. Emotions are accessed, regulated and expressed in ways that build closeness.

All of this happens in the context of each person's vulnerabilities and the couple's environment. [source: Dugal et al. 2018; APA book page]

2. Framework

The published sources describe a sequence of tasks rather than fixed numbered phases. The phase labels below organise that sequence. [synthesis]

Phase A: Assessment, about 3–4 sessions [source: Dugal et al. 2018]

  • Format:
    • One or two joint sessions.
    • One individual session with each partner.
    • A joint feedback session.
  • Joint sessions: clarify each partner's goals, the relationship history, presenting concerns, the environment and sexual functioning.
  • Individual sessions: cover personal and family history, physical and mental health, substance use, trauma and work. Ask each partner directly about sexual difficulties, affairs and partner violence.
  • Methods:
    • Semi-structured interview.
    • Self-report measures covering dyadic adjustment, communication, violence, attachment and childhood trauma. Use standard licensed instruments; items are not reproduced here.
    • Direct observation of the couple trying to solve a problem.
  • Move on when:
    • You have a cognitive-behavioural formulation.
    • Safety has been screened.
    • Both partners have stated goals.
    • There are no contraindications. Severe or one-sided violence, or an active crisis, are contraindications. [source: Dugal et al. 2018]

Phase B: Feedback and treatment contract, 1 session [source: Dugal et al. 2018]

  • Goals:
    • Present the formulation, linking behaviour, cognition and emotion with the individual and environmental factors.
    • Agree on a mandate and goals.
    • Propose a treatment plan.
  • Alternative: the therapist may recommend individual therapy first.
  • Move on when: both partners accept a shared plan and the ground rules, including the no-secrets policy.

Phase C: Early treatment (de-escalation, psychoeducation, positives) [source: Dugal et al. 2018; APA book page]

  • Goals:
    • Create a safe space.
    • Teach the model.
    • Reduce escalation, using time-out and scheduled discussion times for high-conflict couples.
    • Reinforce positive behaviours already present.
  • Move on when: sessions are no longer dominated by escalation and each partner can name one positive behaviour from the other. [synthesis]

Phase D: Skills and core work [source: Dugal et al. 2018; APA book page]

  • Goals:
    • Communication training (expresser and listener skills).
    • Problem-solving and conflict resolution.
    • Cognitive interventions.
    • Emotion interventions.
    • Acceptance and tolerance work.
    • Work on core themes and macro-level patterns.
    • Address individual vulnerabilities and environmental demands as they arise.
  • Pacing: the therapist is more directive when conflict escalates and more didactic when teaching skills. [source: Dugal et al. 2018]
  • Move on when:
    • The couple can run a discussion and a problem-solving sequence with little prompting.
    • Goals agreed in Phase B show change. [synthesis]

Phase E: Consolidation and ending [synthesis]

  • Goals:
    • Fade the therapist's coaching.
    • Review what changed and which skills produced it.
    • Plan for predictable future stressors and transitions.
    • Space out the final sessions.
  • The sources do not describe a termination protocol. [uncertain]

Session format and number

  • Format: conjoint 50–60-minute sessions, with individual sessions during assessment and as needed. [source: Dugal et al. 2018 for the conjoint/individual mix; session length is synthesis]
  • Session count: the sources give no fixed number. [uncertain] A workable default is to review progress after about 10 sessions and contract in blocks. [synthesis]
  • Typical session (in-session rehearsal plus between-session trials): [synthesis, consistent with Dugal et al. 2018]
    1. Check in, including a safety check.
    2. Review the last home trial.
    3. Agree today's focus.
    4. Teach or coach the focal skill or intervention on live material.
    5. Agree the next home trial.
    6. Ask for feedback on the session.

Supplied variants. Baucom's group has published couple-based adaptations for:

  • relationship distress combined with individual disorders such as depression and anxiety;
  • infidelity;
  • health crises.

These adaptations are covered in the inventory (4.27–4.29). [source: APA video page; Guilford Handbook contents]

Certification and fidelity. The sources mention no licensing or certification requirement for delivering CBCT. Training is through the books, handbook chapters and APA demonstration videos. [uncertain]

3. Guiding principles

  • Behaviour, cognition and emotion are interlinked and equally important. Formulate every problem across all three and choose your entry point, rather than defaulting to skills training. [source: Dugal et al. 2018; APA video page]
  • Look at three domains: the couple, each individual, and the context. Keep asking what each partner brings, such as history, needs or disorder, and what the environment is adding. [source: APA book page; APA video page]
  • Treat micro-behaviours and macro-level themes. Behind repeated small fights, look for the core theme, such as a mismatch in intimacy or autonomy needs, or power and boundary patterns. [source: APA video page; APA book page]
  • Positives count as much as negatives. Deliberately build positive behaviours, cognitions and emotions, not only reduce negatives. [source: APA book page; APA video page]
  • Communication problems may be a result of distress, not its cause. Do not assume skills deficits. Assess whether the partners communicate well with others and lose the skills only with each other. [source: APA video page]
  • Stressors matter. Assess both major events and the build-up of small demands before attributing problems to the relationship itself. [source: APA video page]
  • Collaborative, psychoeducational stance. Explain the model, agree goals jointly, and treat homework as an experiment. [source: Dugal et al. 2018]
  • Flexible directiveness. Be directive when interaction escalates, didactic when teaching, and Socratic when working with cognitions. [source: Dugal et al. 2018]
  • Balance and neutrality. Balance speaking time, avoid siding, and seek supervision if your neutrality slips. [source: Dugal et al. 2018]
  • No secrets. Information relevant to the relationship, such as an ongoing affair, cannot be held in confidence from the other partner. Say so at the start. [source: Dugal et al. 2018]
  • Safety first. Screen for violence systematically in individual sessions. Crisis management (suicidality, homicidality, severe violence) takes priority over couple work. [source: Dugal et al. 2018]
  • Use live in-session interaction as material. Intervene on cognitions and emotions as they happen in the room, not only on reported events. [source: Dugal et al. 2018]
  • Individual problems can be treated within the couple frame, or referred out when they block the couple work. [source: Dugal et al. 2018; APA book page ch. 13 title]
  • Commitment is a precondition. CBCT works poorly when the partners are not committed to change, or when each wants the therapist to declare who is right. Address this explicitly. [source: Dugal et al. 2018]

4. Intervention inventory

The primary sources organise interventions into chapters. The 2002 book has chapters on modifying behaviour, modifying cognitions, addressing emotions, couple patterns and interactions, individual psychopathology and interpersonal trauma, and environmental demands. The items below are grouped in the same way. Unless marked otherwise, procedures are paraphrased from Dugal et al. (2018), whose account cites Epstein & Baucom. Step-level detail beyond that is marked [synthesis]. [source: APA book page; SCU TOC; Dugal et al. 2018]

A. Assessment and engagement

4.1 Joint assessment interview

  • Purpose: map goals, history, concerns, context and sexual functioning, and observe how the couple interacts. Used in the first one or two sessions. [source: Dugal et al. 2018]
  • Steps:
    1. Explain the assessment format (joint sessions, individual sessions, then feedback) and the no-secrets policy.
    2. Ask each partner in turn for their goals and main concerns, balancing time.
    3. Take a relationship history: how they met, what attracted them, high points and turning points.
    4. Map the environment: work, children, extended family, health, finances and cultural differences.
    5. Ask about sexual functioning.
    6. Note behavioural, cognitive and emotional patterns as they appear in the room.
    7. Give self-report questionnaires to complete at home. [source: Dugal et al. 2018; step order is synthesis]
  • Example language (illustrative): "I'd like to hear from each of you what you hope will be different by the end of our work. I'll make sure you both get equal time."
  • Watch for:
    • Who speaks for whom.
    • Blaming attributions.
    • Emotional disengagement.
    • Positives mentioned spontaneously, which are a strengths marker. [source: APA video page]

4.2 Individual assessment sessions

  • Purpose: gather individual history and screen safely for violence, affairs and sexual problems. Hold one session per partner after the joint sessions. [source: Dugal et al. 2018]
  • Steps:
    1. Restate the no-secrets limit before asking sensitive questions.
    2. Cover personal and family history, mental and physical health, substance use, trauma (especially childhood trauma) and work.
    3. Ask specifically and behaviourally about physical, psychological and sexual aggression, by either partner.
    4. Ask about affairs and sexual difficulties.
    5. Assess suicidality and homicidality using standard risk assessment.
    6. If you identify danger, move to the safety plan and referral instead of conjoint work. [source: Dugal et al. 2018; steps 1 and 6 are synthesis]
  • Example language (illustrative): "Couples sometimes push, grab or threaten each other when arguments heat up. Has anything like that happened between you, from either side?"
  • Watch for:
    • Fear of the partner.
    • One-sided control.
    • Injury.
    • Disclosed secrets that must be brought into the joint work or that make it unworkable. [source: Dugal et al. 2018]

4.3 Observed problem-solving sample

  • Purpose: see the couple's actual communication and conflict pattern directly. Used during assessment. [source: Dugal et al. 2018]
  • Steps:
    1. Ask the couple to pick a moderate, real disagreement.
    2. Ask them to discuss it for about 10 minutes while you observe without intervening. The duration is synthesis.
    3. Note specific behaviours: interrupting, criticism, withdrawal, positives and listening.
    4. Note the cognitions they voice and the emotions they show.
    5. Debrief briefly and ask whether it was typical. [source: Dugal et al. 2018 for the observation task; steps are synthesis]
  • Example language (illustrative): "Choose something that matters but isn't your biggest issue. Talk as you would at home; I'll mostly watch."
  • Watch for:
    • Escalation beyond what can be repaired. Stop and de-escalate if it occurs.
    • Whether the skills exist but are not used, which suggests the communication problem is a result of distress rather than a deficit. [source: APA video page]

4.4 Feedback session and formulation

  • Purpose: turn the assessment into a shared cognitive-behavioural formulation and a treatment plan. [source: Dugal et al. 2018]
  • Steps:
    1. Summarise each partner's goals.
    2. Describe the cycle, linking behaviour, cognitions and emotions, using the couple's own examples.
    3. Name individual vulnerabilities and environmental stressors as contributors, without blame.
    4. Name strengths.
    5. Propose goals and the interventions planned. Recommend individual therapy first if indicated.
    6. Agree the contract (frequency, homework, safety rules). [source: Dugal et al. 2018; step order is synthesis]
  • Example language (illustrative): "When Sam comes home late, Alex reads it as 'I don't matter', feels hurt and criticises. Sam hears blame and withdraws, and that confirms Alex's fear. You both lose in that loop."
  • Watch for: each partner recognising their own part rather than only the other's. If either refuses the shared frame, revisit commitment (see 5.2).

4.5 Psychoeducation on the model

  • Purpose: give partners a shared language for how behaviour, thought and feeling interact, and introduce common cognitive distortions. Used early, then repeated briefly when needed. [source: Dugal et al. 2018]
  • Steps:
    1. Draw the three-part loop (behaviour, cognition, emotion) on paper.
    2. Name the cognition types: selective attention, attributions, expectancies, assumptions and standards.
    3. Give one neutral example of each.
    4. Ask each partner for one example from their own experience, not the other's. [source: Dugal et al. 2018 for the content; steps are synthesis]
  • Example language (illustrative): "Selective attention means noticing what fits our view. If you expect to be ignored, you'll spot the times you were and miss the times you weren't."
  • Watch for: partners using the concepts as weapons ("that's your distortion"). Redirect each partner to identify their own.

B. Behavioural interventions

4.6 Time-out and anger control

  • Purpose: stop escalation. Only for couples where any aggression is minor and mutual, and both partners agree to stop it. Severe or one-sided violence contraindicates conjoint therapy. [source: Dugal et al. 2018]
  • Steps:
    1. Agree a neutral signal that either partner may use.
    2. When they notice the early warning cues of escalating anger, the partner gives the signal and leaves for an agreed period.
    3. During the break, both partners calm down using self-soothing rather than rehearsing grievances.
    4. They agree a time to resume or to bring the topic to the next scheduled discussion or session.
    5. Review each use in session. [source: Dugal et al. 2018 names time-out and anger control; steps are synthesis]
  • Example language (illustrative): "A time-out isn't walking away from you; it's walking away from the fight so we can come back to it."
  • Watch for:
    • Time-out used to avoid issues indefinitely.
    • Time-out used as punishment.
    • Aggression continuing. If it continues, stop conjoint work and move to safety planning and referral.

4.7 Scheduled discussion times

  • Purpose: contain conflict in high-conflict couples by confining difficult topics to agreed times. [source: Dugal et al. 2018]
  • Steps:
    1. Agree one or two fixed, short slots a week.
    2. Agree that problem topics raised at other times are noted and saved for the slot.
    3. Use the communication guidelines (4.9–4.10) during the slot.
    4. Review in session. [source: Dugal et al. 2018 names the technique; steps are synthesis]
  • Example language (illustrative): "Let's protect the rest of your week. Write the topic down and bring it to Thursday's half-hour."
  • Watch for: the agreed slots being skipped, and the number of arguments outside the slots going down.

4.8 Increasing and reinforcing positive behaviour

  • Purpose: correct the imbalance of many negatives and few positives by noticing and reinforcing positive behaviours the partners already show. [source: Dugal et al. 2018; APA video page]
  • Steps:
    1. Ask each partner to name small things the other does, or could do, that they appreciate.
    2. Ask each partner to choose some to do more of in the coming week, at their own choice and not on demand.
    3. Ask each partner to notice and acknowledge the other's positives.
    4. Review in session, highlighting what was noticed. [source: Dugal et al. 2018 for reinforcing existing positives; steps are synthesis]
  • Example language (illustrative): "This week, each of you pick a few small things from your partner's list. Don't announce them; let's see what gets noticed."
  • Watch for:
    • Positives being discounted ("they only did it because the therapist said so"). Treat this as a cognition to work on (4.15).
  • Sign it is working: partners report noticing positives spontaneously.

C. Communication and problem-solving training

4.9 Expresser (speaker) skills

  • Purpose: teach the speaker to share their subjective experience and feelings without accusing or demanding. Start with a moderately charged topic, not the hottest issue. [source: Dugal et al. 2018]
  • Steps:
    1. Explain the speaker and listener roles and give each partner a written summary in your own words.
    2. Model a short example yourself.
    3. The speaker describes their own view and feelings in "I" statements, keeps it brief and specific, and makes no requests or accusations at this stage.
    4. The speaker pauses so the listener can reflect.
    5. Coach in the moment (4.11).
    6. Switch roles.
    7. Agree home practice on low-heat topics. [source: Dugal et al. 2018 for "I" statements, subjective experience and no requests or accusations; brevity, specificity and the sequence are synthesis]
  • Example language (illustrative): "Try starting with 'I felt… when…' and stay with your own experience. We'll get to solutions later."
  • Watch for:
    • Disguised accusations ("I feel that you never…"). Help the speaker rephrase to their own feeling and the specific event.
  • Sign it is working: the listener's reflections become accurate and less defensive.

4.10 Listener skills

  • Purpose: help the listener convey openness and understanding before giving their own view. [source: Dugal et al. 2018]
  • Steps:
    1. The listener attends without interrupting.
    2. The listener reflects or summarises the content and feelings they heard, without rebuttal, interpretation or advice.
    3. The listener checks for accuracy.
    4. The speaker corrects or confirms.
    5. Only after the roles switch does the listener give their own view. [source: Dugal et al. 2018 for reflection, summary and openness before responding; steps are synthesis]
  • Example language (illustrative): "Before you answer, tell Jo what you heard her say she felt. Then check if you got it right."
  • Watch for:
    • Parroting without empathy.
    • A "but" slipped into the reflection.
  • Sign it is working: the speaker visibly softens when they feel understood.

4.11 Therapist coaching during skills practice

  • Purpose: shape skill use live and stop bickering. [source: Dugal et al. 2018]
  • Steps:
    1. Reinforce effort and specific good moves immediately.
    2. Give brief corrective feedback.
    3. Model a better phrasing when needed.
    4. When bickering starts, stop the exchange and ask each partner what they felt and what they perceived just then.
    5. Resume in the roles. [source: Dugal et al. 2018]
  • Example language (illustrative): "Let's pause. Ben, what did you feel when Mia said that? And what did you take it to mean?"
  • Watch for:
    • Over-coaching that makes the practice feel artificial.
    • Coaching one partner more than the other. Keep the balance (section 3).

4.12 Problem-solving (five steps)

  • Purpose: reach workable decisions on concrete issues. Use it once expresser and listener skills are reasonably stable. [source: Dugal et al. 2018]
  • Steps:
    1. Define one specific problem.
    2. Each partner states the underlying needs and what the problem means to them, using the expresser and listener skills.
    3. Brainstorm many possible solutions without evaluating them yet.
    4. Choose a solution that meets both partners' wishes, accepting that neither may be fully satisfied.
    5. Try it between sessions for a set period, then review it and revise if needed. [source: Dugal et al. 2018]
  • Example language (illustrative): "Let's narrow it to Saturday mornings only. Before solutions, what does that time mean to each of you?"
  • Watch for:
    • Jumping straight to solutions.
    • Several problems bundled together.
    • A "compromise" one partner privately resents. Check each partner's genuine agreement.

4.13 Conflict resolution sequence

  • Purpose: use problem-solving on emotionally loaded conflicts. It follows the same steps as 4.12, with more attention to emotion. [source: Dugal et al. 2018]
  • Steps:
    1. Follow the 4.12 steps.
    2. When a partner attacks or withdraws, give immediate feedback on that behaviour.
    3. Explore and challenge the cognitions and emotions driving it (4.15, 4.19).
    4. Return to the sequence. [source: Dugal et al. 2018]
  • Example language (illustrative): "You went quiet just then. What went through your mind as Lee was talking?"
  • Watch for: cycles of attack and withdrawal shortening, and quicker repair after a slip.

4.14 Replaying a past conflict

  • Purpose: improve communication and problem-solving by re-running a recent conflict in session with the new skills. [source: Dugal et al. 2018]
  • Steps:
    1. Pick a recent, contained argument.
    2. Reconstruct the sequence step by step: trigger, thoughts, feelings, actions.
    3. Identify the choice points where things went wrong.
    4. Replay the conversation using the expresser and listener skills.
    5. Debrief what was different. [source: Dugal et al. 2018 names replay; steps are synthesis]
  • Example language (illustrative): "Let's rewind to Tuesday at the door. What did each of you notice first?"
  • Watch for: the replay re-igniting the fight. Slow down and use 4.11.

D. Cognitive interventions

Targets are selective attention, unrealistic or inappropriate attributions, expectancies, assumptions and standards, and the way they drive negative emotion and behaviour. [source: Dugal et al. 2018]

4.15 Identifying cognitions live and Socratic questioning (examining evidence)

  • Purpose: catch distress-maintaining cognitions as they occur in session and test them. [source: Dugal et al. 2018]
  • Steps:
    1. When emotion spikes, pause and ask what the partner just thought.
    2. Name the type of cognition, for example an attribution such as "they did it on purpose".
    3. Ask Socratic questions: what is the evidence for it, what is the evidence against it, and what other explanations are there.
    4. Have the partner check their reading with the other partner.
    5. Note the effect on their feeling. [source: Dugal et al. 2018 for live use, Socratic questioning and examining evidence; steps are synthesis]
  • Example language (illustrative): "You said he 'obviously doesn't care'. What else could explain him forgetting? Ask him what was going on for him."
  • Watch for:
    • Challenging that feels like you are siding with the other partner. Question both partners' cognitions in the same session.
  • Sign it is working: more benign or situational attributions appear.

4.16 Weighing advantages and disadvantages of a standard

  • Purpose: examine relationship standards (beliefs about how a partner or relationship should be) without arguing about whether they are true. [source: Dugal et al. 2018]
  • Steps:
    1. State the standard clearly.
    2. List its advantages and its disadvantages for the person and the relationship.
    3. Consider whether a modified version keeps the advantages.
    4. Ask how the modified standard would look in behaviour. [source: Dugal et al. 2018 names pros and cons; steps are synthesis]
  • Example language (illustrative): "'Couples should do everything together': what does that standard give you, and what does it cost the two of you?"
  • Watch for: cultural or religious standards. Explore their meaning respectfully rather than treating them as distortions. [synthesis]

4.17 Testing worst-case predictions

  • Purpose: reduce catastrophic expectancies that block change. [source: Dugal et al. 2018]
  • Steps:
    1. Elicit the feared outcome, for example "If I tell her, she'll leave."
    2. Rate how likely it seems.
    3. Examine the evidence.
    4. Plan how the couple would cope if it did happen.
    5. Design a small behavioural test, then review it. [source: Dugal et al. 2018 names considering worst-case predictions; steps are synthesis]
  • Example language (illustrative): "What's the worst that could happen if you raise it on Thursday? And if that happened, what could you do?"
  • Watch for: genuine danger signs. A feared outcome of violence is a safety issue, not a distortion (4.2).

4.18 Perspective sharing

  • Purpose: build mutual understanding by having each partner explain how they see an event. [source: Dugal et al. 2018]
  • Steps:
    1. Each partner describes their reading of the same event, using the expresser and listener skills.
    2. You highlight where the readings differ.
    3. Each partner states the other's view to the other's satisfaction. [source: Dugal et al. 2018 names perspective sharing; steps are synthesis]
  • Example language (illustrative): "Same evening, two different films. Let's hear each version."
  • Watch for: each partner insisting their view is 'the facts'. Shift the goal from deciding who is right to understanding each other (5.2).

E. Emotion interventions

Emotions that are avoided, suppressed or expressed excessively harm intimacy. Enhanced CBCT gives emotion a more central role than earlier CBT versions. [source: Dugal et al. 2018; APA video page]

4.19 Accessing and heightening minimised emotion

  • Purpose: help emotionally restricted or disengaged partners reach and voice the feelings beneath their behaviour. Address emotions as they arise in session. [source: Dugal et al. 2018; APA video page]
  • Steps:
    1. Notice a non-verbal shift, such as a change in tone, a look away or tears.
    2. Slow the pace.
    3. Ask for a detailed description of the moment and the bodily sensation.
    4. Reflect the feeling tentatively.
    5. Offer a metaphor or image if words are hard to find.
    6. Invite the partner to share the feeling with the other partner, who uses listener skills. [source: Dugal et al. 2018 for detailed description, reflection and metaphor; steps are synthesis]
  • Example language (illustrative): "When you say 'it's fine', your voice drops. If that feeling had a shape, what would it be like?"
  • Watch for:
    • Flooding. Shift to regulation (4.21).
    • Partners who resist vulnerability. The APA demonstration shows Baucom working with exactly this kind of couple. [source: APA video page]

4.20 Normalising emotions

  • Purpose: reduce shame and reactivity about both positive and negative feelings. [source: Dugal et al. 2018]
  • Steps:
    1. Name the feeling as understandable in context.
    2. Separate the feeling from the behaviour chosen in response to it.
    3. Invite the partner to acknowledge it. [source: Dugal et al. 2018 for normalising; steps are synthesis]
  • Example language (illustrative): "Anger makes sense when you feel left out. The question is what you do with it."
  • Watch for: normalising being heard as justifying aggression. Keep the line between the feeling and the act clear.

4.21 Emotion-regulation skills (DBT-derived)

  • Purpose: for high-conflict or emotionally dysregulated couples, reduce reactivity so that the other interventions become usable. [source: Dugal et al. 2018; Kirby & Baucom 2007 cited there] [uncertain: exact protocol]
  • Steps:
    1. Teach partners to notice and name arousal early.
    2. Teach self-soothing and distress-tolerance strategies.
    3. Agree when each partner will use a skill rather than continue the argument.
    4. Combine the skills with time-out (4.6) and scheduled discussions (4.7).
    5. Review use in session. [synthesis, guided by Dugal et al. 2018]
  • Example language (illustrative): "On a 0–10 scale, where's your anger now? At 7 we take a break and use your calming plan."
  • Watch for: skills used to shut the other partner down, and whether escalation episodes become shorter.

F. Acceptance and tolerance

Dugal et al. present these as part of current CBCT. The empathic joining and unified detachment techniques originate in integrative behavioural couple therapy (IBCT; Jacobson & Christensen). [source: Dugal et al. 2018] [uncertain: how far Epstein & Baucom 2002 incorporates them was not verified]

4.22 Empathic joining

  • Purpose: transform a conflict into closeness by having partners express the vulnerable feelings beneath their complaints. [source: Dugal et al. 2018]
  • Steps:
    1. Identify a recurrent complaint.
    2. Help the complaining partner move from the accusation to the hurt, fear or need beneath it.
    3. Have the other partner reflect it.
    4. Highlight the softer exchange. [source: Dugal et al. 2018 for vulnerable expression; steps are synthesis]
  • Example language (illustrative): "Underneath 'you're always on your phone', is there something like 'I miss you'?"
  • Watch for: the other partner using the vulnerability against the speaker later. Protect it in session.

4.23 Unified detachment

  • Purpose: describe the problem pattern as an external, shared "it" that both partners observe together, rather than as one partner's fault. [source: Dugal et al. 2018]
  • Steps:
    1. Describe the cycle neutrally.
    2. Give it a name with the couple.
    3. Analyse a recent episode together as observers.
    4. Ask how "it" gets them. [source: Dugal et al. 2018; steps are synthesis]
  • Example language (illustrative): "So 'the chase' showed up again on Sunday. How did it pull you both in this time?"
  • Watch for: the name being used to mock. Externalising should not erase individual responsibility for harmful acts.

4.24 Tolerance through reframing a trait

  • Purpose: increase tolerance of a partner's trait that will not change, by pointing to its benefits. [source: Dugal et al. 2018]
  • Steps:
    1. Identify the trait.
    2. Explore when the same trait has helped the couple, or originally attracted the partner.
    3. Help partners hold both its costs and its benefits. [source: Dugal et al. 2018; steps are synthesis]
  • Example language (illustrative): "The caution that frustrates you about money is also what got you both through the redundancy."
  • Watch for: reframing being used for behaviour that should not be tolerated, such as abuse or addiction.

4.25 Mindfulness and touch exercises

  • Purpose: build non-judgemental awareness of self and partner. [source: Dugal et al. 2018]
  • Steps:
    1. Introduce a brief guided awareness practice in session.
    2. Assign short daily practice.
    3. Where both partners want it, assign non-demanding touch exercises between the partners at home. These are partner-to-partner, never therapist touch, with explicit consent and either partner able to stop. [source: Dugal et al. 2018 names meditation and touch; steps and safeguards are synthesis]
  • Example language (illustrative): "For two minutes, just notice your breath and any urge to react, without acting on it."
  • Watch for:
    • Trauma histories, where touch exercises need care and consent and may need deferring.
    • Sexual pressure. Refer to sex-therapy methods for sexual concerns.

G. Couple patterns, individual and environmental factors

4.26 Working with core themes and macro-level patterns

  • Purpose: address the broad themes and patterns that generate many small conflicts. Examples are differences in intimacy and autonomy needs, demand–withdraw cycles, boundaries, power distribution and investment in the relationship. [source: APA video page; APA book page; 2002 book ch. on couple patterns, title only]
  • Steps:
    1. Collect several specific conflicts.
    2. Ask what they have in common and propose a theme.
    3. Link the theme to each partner's needs and history (4.27).
    4. Choose targets at the level of the pattern, for example agreed time together and apart.
    5. Use behavioural, cognitive and emotion interventions on the theme rather than on each incident. [synthesis, guided by the APA pages]
  • Example language (illustrative): "The dishes, the weekend, the phone: they all seem to be about how close each of you needs to be."
  • Watch for: a theme recognised by both partners, after which incident-level fights drop. [synthesis]

4.27 Addressing individual psychopathology, unresolved issues and interpersonal trauma within couple therapy

  • Purpose: work with one partner's depression, anxiety or other disorder, their history or trauma, inside the couple frame where suitable. Refer for individual therapy when it blocks couple work. [source: Dugal et al. 2018; APA book page; APA video page]
  • Steps:
    1. Assess the disorder and how it interacts with the relationship.
    2. Psychoeducate both partners about the disorder.
    3. Help the partner without the disorder support rather than accommodate or criticise.
    4. Link past injuries or trauma to present triggers so partners can respond to each other's vulnerabilities.
    5. Coordinate with any individual therapist. [synthesis, guided by Dugal et al. 2018; disorder-specific couple protocols not drawn on] [uncertain]
  • Example language (illustrative): "When Ana's depression is bad, your attempts to cheer her up can feel like pressure. Let's find what actually helps."
  • Watch for:
    • Suicidality. Use standard risk assessment and safety planning.
    • Substance use.
    • The partner being cast as the only 'patient'.

4.28 Interventions for environmental demands (including health crises)

  • Purpose: help the couple cope together with external stressors, both major events and the build-up of minor ones. Examples are work, children, extended family, health, finances, culture, and developmental transitions such as children reaching adolescence. [source: APA video page; APA book page]
  • Steps:
    1. List current demands and the resources available.
    2. Separate what can be changed from what must be adapted to.
    3. Use problem-solving (4.12) for the changeable demands.
    4. Use support and acceptance work (4.22–4.24) for the unchangeable ones.
    5. Connect the couple with external resources. [synthesis, guided by the APA pages]
  • Example language (illustrative): "Before we decide this is a 'you two' problem, let's look at what's landed on you this year."
  • Watch for: stress-driven negative attributions, such as reading exhaustion as indifference. Link this to the cognitive interventions (4.15).

4.29 Infidelity: treating the affair as interpersonal trauma

  • Purpose: help the couple recover after an affair. Use Baucom, Snyder and Gordon's forgiveness-based approach, whose detailed protocol is not drawn on here [uncertain]. [source: Dugal et al. 2018; Guilford Handbook contents, Gordon, Mitchell, Baucom & Snyder chapter title] [uncertain]
  • Steps:
    1. Manage the crisis of disclosure, including safety, containment and agreements about contact with the affair partner.
    2. Explore the factors in the couple, each individual and the context that made the relationship vulnerable.
    3. Move towards forgiveness and a decision about the future, without forcing reconciliation. [source: Dugal et al. 2018]
  • Example language (illustrative): "Right now the goal isn't to decide your future; it's to get through these weeks without making it worse."
  • Watch for:
    • An affair that is ongoing. The no-secrets policy applies.
    • Trauma-like symptoms in the hurt partner.
    • Pressure to forgive too early.

5. Handling problems

The sources address violence, crisis, affairs, secrets, neutrality and lack of commitment. Everything else here is marked [synthesis].

5.1 Partner aggression

Source guidance [source: Dugal et al. 2018]:

  • Assess aggression systematically in the individual sessions.
  • Severe or one-sided violence usually contraindicates couple therapy. Crisis and safety procedures come first.
  • Minor, mutual aggression may be addressed conjointly only if both partners commit to stopping it, using time-out and anger control (4.6).

Practical additions [synthesis]:

  • Ask again at intervals.
  • Never confront a perpetrator with a victim's private disclosure in a joint session without a safety plan.
  • If aggression recurs, pause conjoint work and refer to specialist services.
  • Epstein, LaTaillade & Werlinich's handbook chapter on partner aggression exists but is not drawn on here. [uncertain]

5.2 Low commitment, or each partner wanting a verdict

Source guidance: CBCT works poorly when partners are not committed to change, or when each wants the therapist to say who is right. [source: Dugal et al. 2018]

What to do [synthesis]:

  1. Name the pattern openly.
  2. Restate the shared goal: understanding each other and changing the cycle, not deciding who is right.
  3. Ask each partner what they are willing to change. Use 4.23 to externalise the cycle.
  4. If one partner is ambivalent about staying, contract a few sessions focused on clarifying that decision before skills work.

Example (illustrative): "If I rule for one of you, the relationship loses. My job is to help you both win against the pattern."

5.3 Crisis (suicidality, homicidality, a newly disclosed affair)

Source guidance: ensure safety first, then decide whether to continue couple therapy or refer to individual therapy. Treat an affair as interpersonal trauma (4.29). [source: Dugal et al. 2018]

What to do:

  • Follow standard risk assessment and safety planning.
  • For lethal means, discuss storage and removal only.
  • Involve the partner in safety plans only if this is safe. [synthesis]

5.4 A secret disclosed in an individual session

Source guidance: relationship-relevant secrets cannot be kept from the other partner. [source: Dugal et al. 2018]

What to do [synthesis]:

  1. State the policy before the individual sessions.
  2. If a disclosure occurs, give the partner a short, defined period to disclose it themselves, with your help.
  3. If they decline, explain that you cannot continue conjoint work as if nothing were known.

The exception is safety: never force disclosure of a victim's fear of violence. Prioritise safety planning instead.

5.5 In-session escalation or emotional overwhelm

Source guidance: become more directive when conflict escalates. [source: Dugal et al. 2018]

What to do [synthesis]:

  1. Stop the exchange.
  2. Have partners speak to you rather than to each other.
  3. Slow the pace and use regulation skills (4.21).
  4. Narrow the topic and resume in speaker and listener roles.
  5. If overwhelm persists, end with a containment plan and use scheduled discussions (4.7) at home.

5.6 Emotionally disengaged or vulnerability-avoidant couples

Source guidance: some couples present as disengaged rather than angry. Baucom's APA demonstration shows him working with partners who resist vulnerability. [source: APA video page]

What to do [synthesis]:

  • Use 4.19, starting with low-risk feelings.
  • Reinforce positives (4.8).
  • Check for depression (4.27) and for a deeper core theme, such as fear of rejection (4.26).

5.7 Homework not done

[synthesis]

  1. Review every assignment. Not reviewing teaches partners that homework does not matter.
  2. Explore the obstacles without blame: practical problems, misunderstanding, cognitions such as "why should I go first?", or fear.
  3. Shrink the task.
  4. Rehearse it in session.
  5. Link it explicitly to the partner's stated goals.

If one partner repeatedly does not take part, return to 5.2.

5.8 Ruptures: a partner feels you are taking sides

Source guidance: keep balance and neutrality, and seek supervision if neutrality is compromised. [source: Dugal et al. 2018]

What to do [synthesis]:

  1. Name the possible rupture.
  2. Invite the aggrieved partner's view and validate it.
  3. Acknowledge your part.
  4. Rebalance immediately, for example by turning to the other partner's cognitions.
  5. Track the balance of airtime and challenge across sessions.

Example (illustrative): "I've been pushing you harder today. Is that how it felt?"

5.9 Skills are there but are not used at home

Source guidance: communication problems can be a result of distress rather than a deficit. [source: APA video page]

What to do [synthesis]:

  • Spend less time drilling skills.
  • Target the cognitions and emotions that switch the skills off (4.15, 4.19).
  • Look at the macro theme (4.26).
  • Look at the stressors (4.28).

5.10 One partner's disorder dominates

Source guidance: individual problems can be treated within the couple frame, or individual therapy recommended first. [source: Dugal et al. 2018]

What to do [synthesis]:

  • Decide jointly whether the couple sessions are the main treatment or an adjunct.
  • Coordinate with the individual clinician.
  • Avoid one partner becoming "the problem".

5.11 Cultural and intercultural differences

Source guidance: cultural differences, for example in language, religion or parenting, are part of the environmental assessment. [source: Dugal et al. 2018; APA book page]

What to do [synthesis]:

  • Explore what standards mean in each partner's culture before targeting them (4.16).
  • Use interpreters rather than relying on one partner to translate.
  • Check your own cultural assumptions.

5.12 Stuck: no change at review

[synthesis]

  1. Re-formulate. Ask whether you have missed something: an individual disorder, an undisclosed affair, aggression, a stressor, ambivalence about staying, or a core theme.
  2. Ask the couple what has and has not helped.
  3. Consider switching the entry point, for example from skills to emotion or acceptance work.
  4. Consider a consultation, or referral to another couple approach.

Sources

Sources:

Found but not readable [uncertain]:

Further reading (not drawn on):

  • Baucom, D. H., & Epstein, N. (1990). Cognitive-Behavioral Marital Therapy. Brunner/Mazel (reissued by Routledge).
  • Epstein, N. B., & Baucom, D. H. (2002). Enhanced Cognitive-Behavioral Therapy for Couples: A Contextual Approach. American Psychological Association.
  • Baucom, D. H., Epstein, N. B., Fischer, M. S., Kirby, J. S., & LaTaillade, J. J. (2022). Cognitive-behavioral couple therapy. In J. L. Lebow & D. K. Snyder (Eds.), Clinical Handbook of Couple Therapy (6th ed.). Guilford.
  • Epstein, N. B., LaTaillade, J. J., & Werlinich, C. A. (2022). Couple therapy for partner aggression. In the same handbook.
  • Gordon, K. C., Mitchell, E. A., Baucom, D. H., & Snyder, D. K. (2022). Couple therapy for infidelity. In the same handbook.
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