Couple Therapy

Couple Behaviour Couple Therapy (CBCT)

• Aims at assisting romantic partners who report distress in their relationship.

• CBCT not only relies on behavioral interventions in the treatment of couple
difficulties, but also emphasizes the importance of working on various cognitive,
emotional and environmental factors that affect a couple’s functioning.
• CBCT therapists help couples develop their ability to observe and change their
automatic thoughts, assumptions and standards as well as identify the impact that
their ways of behaving, thinking, interpreting and feeling have on their relationship.
 Origins of CBCT (Behavioural Couple
Therapy)
• The origins of CBCT stem mainly from Stuart’s work on behavioral
exchanges between partners in 1969.
• The behavioral formulation for marital or couple distress based on social
learning theory and social exchange theory.
• Some of the common methods that are widely used by behavioral couple
therapists (BCT) are communication training , problem solving training
and contracting to increase the positive behavioral exchange.
 The Role of CBCT Therapists
• CBCT therapists hold different roles that will vary depending on the stage
of therapy and the needs of clients.
• Throughout sessions, CBCT therapists can also take a more didactic role,
for instance, when they teach communication and problem-solving skills
for couples.
• Foundations for a healthy therapeutic alliance, allocating speaking time for
each partner to express themselves, while demonstrating
neutrality and empathy.
 Assessment Methods

• Clinical interviews
• Self-report measures
• Direct behavioral observation (creating tasks or exercises)
 Phases of the Assessment Interviews

• One or two couple sessions in which both partners are present.

• One individual session with each partner.
• Feedback session by therapist for the couple.
 First Couple Session

• Therapist Introduction (qualifications, theoretical orientation)

• The therapist informs the patients that this is a couple therapy process where he/she would not be forced
to keep a secret from one partner during treatment.
• Each partner’s goals to achieve through therapy.
• Couple’s relationship history (duration of the relationship, how partners met and what attracted them to one
another).
• Describe past hardships or significant events.
• Ways they adapted to overcome them.
• Physical and social environments that are likely to contribute to the couple’s problems.
• Evaluation of the couple’s sexual functioning.
 Second Couple Session
• Individual history taking
• During these individual sessions, specific attention will be given to potential
subjects that might not have been explored during couple sessions, such as:
• Sexual difficulties
• Extradyadic affairs
• The presence of partner violence
 Third Couple Session
• Psychoeducation
• Therapist will offer feedback using a cognitive-behavioral formulation of the
couple’s functioning and the factors that affect it, namely how each partner’s
cognitions, emotions and behaviors influence one another and affect couple
interactions.
• Present his or her interpretation of the causes of the couple’s concerns and to
highlight the positive aspects that partners have expressed about their relationship.
• The therapist then sets the treatment mandates and goals in collaboration with the
couple and proposes a treatment plan.
Behavioral Techniques Commonly Used in
CBCT
1. Communication Training
2. Increasing Positive Behavior Exchange
3. Problem and Conflict Resolution
 Communication styles
• Aggressive: violate rights of others
• Passive: violate self rights
• Aggressive passive
• Manipulative: lie
• Assertive
 assertiveness
• 1)Low tone
• 2)firm body language and facial expressions
• 3) expressing feelings and thoughts
• 4)using I statement
• 5)validation and unconditional positive regard
• 6) Do not repeat past
• 7)stay on point
• (practice and set reminder)
• Use clouding if needed
Arranging regular times to
talk to improve communication
(Arranging Quality Time)
2. Increasing Positive Behavior Exchanges

• Distressed partners often do not feel especially loving toward one another,
and not surprisingly, this is reflected in the negative ways they interact (for
example, using sarcasm and doing things the other person dislikes).
1. Caring-days technique.
2. “Catch Your Partner Doing Something Nice” technique.
3. Contingency contracts.
1. Caring-Days Technique
Developed by Richard Stuart, in which partners act as if they care for each other. The therapist
instructs partners to perform small, specific, positive behaviors for each other.
Steps
1. Each partner is asked to answer the question “What could your partner do that would
show you that he or she cares for you?”
2. Compile a list of these caring behaviors.
3. The therapist instructs each partner to perform a minimum number of caring behaviors
from his or her partner’s list, even if the partner has not done so.
4. The partners keep records of the caring behaviors they perform,
Activity Scheduling
Positive coping Statements
Increasing Positive Behavior Exchanges
(Con…)
2. “Catch Your Partner Doing Something Nice” technique

• Each partner notices and acknowledges one pleasing behavior performed by

the other each day.

3. Contingency contracts also are employed to promote positive behavior

exchanges and implement broader behavior changes in the relationship
Contingency Contracts
(Example)
Communication and positive
behaviour instructions (For Wife)
For Husband
 3. Problem and Conflict Resolution
In CBCT, five strategies are commonly used to help couples develop problem-solving skills.
First
• Partners must define and identify one problem on which they want to work.
Second
• The therapist helps partners understand the meaning this problem holds for them by defining each partners’ underlying
needs.
Third
• Partners are asked to suggest as many solutions they can think of, using brainstorming, which is known to increase
feelings of interest, appreciation and consideration in the relationship as well as being particularly useful in case of
serious conflict or strict patterns of interactions.
Fourth
• partners are asked to select a solution together that will allow to fulfill both partners’ wishes, although it is possible they
will not be equally satisfied.
The fifth and last step
• involves a trial period that will take place between sessions. A feedback discussion is then held during the following
session and, if partners feel unhappy during with the chosen solution, a new solution may be chosen with the therapist.
Problem Solving Cycle
Steps in Urdu
Cognitive Aspects of CBCT
 Cognitive Aspects of CBCT
• Behaioral Couple therapy was effective in helping couples resolve task-
related or instrumental aspects of relationships such as chores and
finances, but was not very effective in resolving the issues that involved ways
of demonstrating care and concern for spouse.
• Baucom (in Baucom et al., 1996) concluded that there are many instances in
which behavioral change does not lead to the important cognitive and
affective changes needed to assist couples.
• They expanded CBCT interventions that addressed emotions and cognitions
contributing to conflicts and dissatisfaction.
• This new cognitive behavioural Couple therapy (CBCT), holds the principle that
behavioral, cognitive, and affective components of marital interaction are
interrelated, and changes in one area may elicit changes in the other two. In
addition, it also admits that changes in three areas may occur independently and
thus may require different (although overlapping) sets of treatment (Baucom et al.,
1996).
• A specificity of CBCT lies in its dynamic understanding that cognitions can
influence intimate relationships through each partner’s interpretations or
appraisals of stressors and of their partner’s behaviors . Moreover, these
interpretations determine the positive and negative emotions experienced
towards the other. Then these emotions are considered to influence future
cognitions and behaviors
Interrelations of behaviors, cognitions and
emotions in CBCT
Cognitive Techniques Used in CBCT
1. Cognitive Restructuring
2. Identification and Expression of Emotions
1. Cognitive Restructuring
• Pie chart
• Evidence for and against
• Double standard
• Cost benefit analysis
2. Identification and Expression of
Emotions

• In CBCT, emotions that are minimized, avoided, repressed or excessively

expressed by partners are known to negatively impact a couple’s relational
functioning and satisfaction

• Skills specifically addressing emotion regulation as proposed in dialectical

behavior therapy have also been included in CBCT.
 Emotional Processioning Techniques (CBT)

1. Identification of Emotions
2. Healthy vs unhealthy emotions
3. Primary and Secondary Emotions
4. (Secondary: Anger, Primary: Hurt)
5. Differentiating Thoughts from Emotions
6. Written Ventilation
7. Imagery Rescripting
 Suggested Session Summary
Session 1-3
• History Taking
• Couple or individual Sessions
• Assessment
Session 4 -7
• Psychoeducation
• Communicating Training
• Increase in positive behaviour exchange
Session 8 to 12
• Cognitive Restructuring
• Work on emotions
• Sexual dysfunctions
Sexual dysfuntions
Sexual Dysfunction
 Sexual dysfunction: A disorder marked by a persistent inability to
function normally in some area of the sexual response cycle.
 Sexual dysfunctions are the disorders in which people cannot respond normally
in key areas of sexual functioning, make it difficult or impossible to enjoy sexual
intercourse. Studies suggest that as many as 30 percent of men and 45 percent
of women around the world suffer from such a dysfunction during their lives
(Lewis et al., 2010).
 The human sexual response can be described as a cycle with four
phases: desire, excitement, orgasm, and resolution
 Sexual dysfunctions affect one or more of the first three phases. Resolution
consists simply of the relaxation and reduction in arousal that follow orgasm.
 Delayed Ejaculation(Ejaculation is the discharge of semen (normally containing sperm) from the male reproductory tract as a result of an orgasm.
• A. Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity
(in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay:
• 1. Marked delay in ejaculation.
• 2. Marked infrequency or absence of ejaculation
• . B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
• C. The symptoms in Criterion A cause clinically significant distress in the individual.
• D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other
significant stressors and is not attributable to the effects of a substance/medication or another medical condition.
• Specify whether:
• Lifelong: The disturbance has been present since the individual became sexually active.
• Acquired: The disturbance began after a period of relatively normal sexual function.
• Specify whether:
• Generalized: Not limited to certain types of stimulation, situations, or partners.
• Situational: Only occurs with certain types of stimulation, situations, or partners.
• Specify current severity:
• Mild: Evidence of mild distress over the symptoms in Criterion A.
• Moderate: Evidence of moderate distress over the symptoms in Criterion A.
Erectile Disorder : An erection (clinically: penile erection or penile tumescence) is a physiological phenomenon in which the penis becomes
firm, engorged, and enlarged. Penile erection is the result of a complex interaction of psychological, neural, vascular, and endocrine factors, and is often associated
with sexual arousal or sexual attraction, although erections can also be spontaneous. The shape, angle, and direction of an erection varies considerably in humans

• A. At least one of the three following symptoms must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational
contexts or, if generalized, in all contexts):
• 1. Marked difficulty in obtaining an erection during sexual activity. 2. Marked difficulty in maintaining an erection until the completion of sexual activity. 3. Marked
decrease in erectile rigidity.
• B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
• C. The symptoms in Criterion A cause clinically significant distress in the individual.
• D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is
not attributable to the effects of a substance/medication or another medical condition.
• Specify whether:
• Lifelong: The disturbance has been present since the individual became sexually active.
• Acquired: The disturbance began after a period of relatively normal sexual function.
• Specify whether:
• Generaiized: Not limited to certain types of stimulation, situations, or partners.
• Situationai: Only occurs with certain types of stimulation, situations, or partners.
Female Orgasmic(feeling of intense pleasure)
Disorder
 Etiology
• Biological causes:
Etiology
Biological Causes
 In both men and women, a high level of the hormone prolactin, a low level of the
male sex hormone testosterone, and either a high or low level of the female sex
hormone estrogen can lead to low sex drive. Low sex drive has been linked to the
high levels of estrogen contained in some birth control pills.
 Low sexual desire may be linked to excessive activity of the neurotransmitters
serotonin and dopamine.
 Sex drive can be lowered by certain pain medications, psychotropic drugs, and
illegal drugs such as cocaine, marijuana, amphetamines, and heroin..
 Long-term physical illness can also lower a person’s sex drive.
 same hormonal imbalances that can cause male hypoactive sexual desire disorder
can also produce erectile disorder
 Psychological causes
• Depression
• Anxiety
• Stress
• Any other psychological disorder
 Socio cultural issues
• Family issues
• Unemployement
• Family stressors
• Management
• 1) Treat Comorbid Disorder
 2)Giving sex education
• A) Discussing regarding anatomy of organs
• Discuss about pregnancy, menstrual cycle, masturbation, nightfalls, stages of sexual
intercourse and human sexual response cycle.
• Educate couples about timing of sex.
• Educate couple about how to communicate with each other to express desire for
sex.
• Educate couple how to refuse sex tactfully.
• Educate couple that sexual desire levels fluctuate over life span. Encourage couple
to show each other what sort of stimulation is required for orgasm to occur.
3) Clarify sexual Myths
 4) Promoting a positive sexual attitude
• Making love does not necessarily involved sexual intercourse, orgasm and
ejaculation.
• Ask client to record daily thoughts about sexual performance or related disturbing
behaviors on Standard DTR format. (Use any Verbal Challenging Techniques on
NATs)
• Discuss with your partner the other side of love-making that does not involve
sexual intercourse (using Problem Solving)
• Repeating positive affirmations i.e. having sex is just one way of many ways of
expressing love (Pie-Charting technique
NAT Cognitive distortion Logical response
I am a loser(erectile dysfunction) Labeling I have a problem and I am working
on it, therapist says, there are good
success rates and my wife is helping
me too. We both are making our
marriage strong.
 5)Relaxation Techniques
• Progressive muscle relaxation
 Other important points
• Clarifying religious issues
• Clarifying cultural issues (hymen+bleeding)
• Importance of foreplay
• Guidance about various postures
• THANKYOU