Cognitive-Behavioral Marital Therapy

Donald H. Baucom, Norman Epstein

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780876305584
• eBook ISBN: 9781134850013
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The current volume by Baucom and Epstein demonstrates the product that can result when two individuals, both of whom are skilled therapists, creative theoreticians and experienced researchers, combine their efforts. No other two individuals have the depth of understanding and the breadth of knowledge needed to write a book of his magnitude on cognitive behavioral therapy of marital distress. As a result, the best of the scientist-practitioner is revealed in Cognitive-Behavioral Marital Therapy.

SECTION III

INTERVENTION

This section discusses a myriad of intervention strategies for addressing the behavioral, cognitive, and affective components of marital distress. Although any specific intervention is likely to impact all three of these domains, separate chapters are devoted to each of these areas, because most interventions are targeted to promote changes primarily in one domain. In addition, the clinician must have guidelines for when to select a given intervention strategy, when to shift from one intervention to another, and how to make such shifts. Consequently, a fourth chapter focuses on ways to integrate the various intervention strategies. Throughout these intervention chapters, it is stressed that cognitive-behavioral marital therapy is not a set of routinely applied techniques; instead, it involves a number of decisions made by the clinician based on the characteristics of the particular couple receiving intervention. Many of these decision points are discussed, and guidelines are provided for individualizing treatment for the specific couple. More so than with other theoretical approaches, behavioral and cognitive-behavioral marital therapists have emphasized evaluating the effectiveness of their treatments. Consequently, the final chapter discusses the empirical status of the field, with primary emphasis on the clinical implications of the research findings.

Chapter 8 discusses various behavioral interventions for altering communication and noncommunication behaviors. Some of these interventions call for teaching the couple new skills, whereas other strategies merely involve the couple's agreeing to behave in different ways based on their specific needs. A major focus of this chapter involves teaching the couple to resolve problems and improve their communication while problem solving. In addition, a number of issues involving the role of the therapist (e.g., controlling the session tempo, deciding when to intervene, avoiding power struggles with clients) are discussed.

Chapter 9 covers a number of intervention strategies for addressing a couple's dysfunctional perceptions, attributions, expectancies, assumptions, and standards. These interventions include ways to: (a) introduce the concepts of inappropriate and distorted cognitions; (b) build skills for identifying dysfunctional cognitions; and (c) test and modify dysfunctional cognitions. In addition, the chapter includes discussion of strategies for addressing cognitions about the partner or the relationship which are negative but appear to be reasonable or accurate. Finally, both spouses may have cognitions that appear reasonable, yet the cognitions of the two persons are incompatible with each other (e.g., reasonable but incompatible standards). The chapter provides recommendations for assisting in such instances.

Chapter 10 focuses on ways to assist couples with affective difficulties. These strategies include helping couples to: (a) label emotions and understand the bases of their emotional reactions; (b) express emotions more adaptively; and (c) alter dysfunctional levels of emotions, such as anger, depression, jealousy, and anxiety. Whereas the primary treatment targets discussed in this chapter are the spouses’ affects, the interventions are primarily behavioral and cognitive. That is, the therapist attempts to change the spouses’ affects by asking them to behave differently toward each other and think differently about their relationship. This approach is possible because the cognitive-behavioral model involves a basic assumption that behaviors, cognitions, and emotions are interrelated.

Chapter 11 describes the integration of behavioral, cognitive, and affective intervention strategies discussed in the previous chapters. This integrative approach includes guidelines for (a) developing an overall treatment plan; (b) sequencing various intervention strategies; and (c) shifting intervention strategies and revising treatment plans. The chapter emphasizes when and how to shift among strategies that focus on behavior, cognition, and affect.

Chapter 12 presents a discussion of the empirical status of the intervention approaches described throughout the book. Most of the studies to date have focused on altering couples’ behavior and overall marital adjustment. These investigations of the effectiveness of BMT have addressed a number of specific issues: (a) the effectiveness of BMT versus wait list and other control conditions; (b) the relative effectiveness of various BMT treatment components; (c) the impact of varying other BMT treatment parameters, such as single therapists versus cotherapists; (d) the magnitude of BMT effects; (e) the prediction of specific couples’ responses to BMT; and (f) the application of BMT to specific target populations. More recently, attempts to alter couples’ cognitions have been addressed, and the results of these initial studies are evaluated. Beause the integration of empirical findings and sound clinical practice is essential in order for the field to continue to progess, implications of therapy outcome studies for clinical practice are discussed.

8

Modification of Behavior

The goals of BMT are to assist couples in behaving in more positive and less negative ways by employing two major categories of intervention strategies. First, couples are given assignments to behave differently in specific ways in their day-to-day lives without receiving training in specific skills. The second category of behavioral interventions involves skills training. In many cases, couples have not learned to communicate with each other effectively, or their communication has deteriorated. Intertwined with this difficulty, many distressed couples have difficulty attempting to resolve problems, seemingly being unaware of or unable to accomplish the steps needed to reach an agreeable solution; other couples experience difficulty effecting agreed-upon behavior changes. Thus, much time is devoted to skills training in communication, problem-solving, and behavior change strategies.

INCREASING POSITIVE AND DECREASING NEGATIVE NONCOMMUNICATION BEHAVIOR

One of the major goals of BMT is to help couples behave toward each other in more positive ways and less negative ways. This goal underlies all of the BMT treatment procedures to be discussed, but some interventions are aimed explicitly at increasing positive and decreasing negative day-to-day marital behavior, based simply on various instructions to do so. These strategies seem particularly helpful when spouses report or the therapist observes that they make little effort to please the other person. Similarly, when spouses frequently feel irritated with their partners’ day-to-day behaviors, then decreasing negatives becomes important. These techniques are not intended for major areas of conflict in which the couple will need to negotiate behavior changes. In essence, clinicians working with distressed couples become aware that many distressed spouses make little effort to be nice to their partners. The message from the clinician is that “If you want to be happier in your marriage, try being nice to each other.” Whereas this may seem naïve for many of the complex issues confronting the couple, these techniques do not constitute the entire treatment. They are devoted to helping the couple start thinking about making efforts to please the other person and changing the atmosphere of the relationship by altering small, frequent behaviors.

One strategy involves having each spouse complete the Spouse Observation Checklist (SOC) nightly, describing the partner's behavior for the past 24 hours. As discussed in Chapter 5, each spouse uses the SOC to describe which of 408 marital behaviors his or her partner exhibited and then rates each behavior as positive, neutral, or negative. At the beginning of therapy, the clinician should get a baseline of behaviors. Therefore, each spouse can be instructed to complete the form nightly, perhaps for a week, and not to share this information with the partner. These completed forms are returned to the clinician, who calculates the mean number of positive, neutral, or negative behaviors occurring daily. This information is shared with the couple, and the partners are asked to increase positive behavior and decrease negative behavior by some percentage during the following week. How much to ask the couple to change must be based on the individual couple, their initial level of various behaviors, amount of time spent together daily, level of motivation for change, and so forth. The degree of change requested should be set to maximize the likelihood that the couple will experience success with this assignment. Arbitrarily deciding that all couples should double their positives or cut negatives in half will doom some couples to failure.

A second strategy used to increase positive behaviors is referred to as “love days” (Weiss et al., 1973; Wills et al., 1974) or “caring days” (Stuart, 1980). Although there are numerous variants of this procedure, we ask partners to alternate days and do something nice for the other person on that day. This positive behavior need not involve some major effort or major expense; such major positive acts are unlikely to be maintained over time. Therefore, couples are encouraged to engage in positive behaviors which they could realistically continue within their marriage on an intermittent basis. Because one frequent complaint of spouses is that they often feel taken for granted, each person also is encouraged to be alert to positive behaviors shown by the partner. Appreciation should be made obvious, by either a verbal “thank you,” some demonstration of affection, or some reciprocal act. Thus, love days can serve as an opportunity to build positive reciprocity into the relationship.

The spouses are encouraged to perform acts of caring which will focus on the preferences of the particular couple and individuals involved and which will bring pleasure. For example, spouses who feel distant from each other and who spend little time together would be encouraged to select acts that would provide for more togetherness. Conversely, if one of the couple's difficulties is that they do almost everything together during nonwork hours and one or both is feeling smothered, then an appropriate act of kindness would be one that would promote individuality. Thus the husband might wash the dishes for his wife so she can retire to the bedroom alone to read. Whereas the specific behaviors are to be decided upon by the couple, the therapist can be helpful in pointing out general guidelines, such as spending more or less time together.

Although the idea of caring days is appealing, it is not universally successful when applied. Occasionally, both spouses cooperate for the first few days, but one spouse then fails to continue with the activities. In response, the partner likewise either stops participating or continues but feels angry and/or hopeless. There are numerous reasons why a person may not comply with this assignment. First, the individual may cling to the belief that he or she should not have to make special efforts, because the relationship should be “naturally” satisfying to both partners. Under such circumstances, the therapist needs to help the client alter this attitude. The therapist's goal is to help the client see the need for special effort, especially given the state of the relationship. Hopefully each person has characteristic behaviors which bring pleasure to the partner, but rarely is that alone enough to sustain a gratifying relationship. Most people seem to want a partner who is thoughtful, and thoughtful means thinking about how to behave in order to bring happiness to others. Thus, planned positive behaviors are reinterpreted to the client as ways of showing that one cares and is willing to make an effort to improve the relationship.

Second, a spouse may be unwilling to engage in acts of kindness if he or she is angry toward the partner. Thus a couple may be enjoying caring days until they have an argument in the middle of the week and then cease to carry out their acts of caring. It is not atypical for couples to have disagreements and arguments; the concern is with the extent to which the couple allows an argument to infiltrate other areas of their lives for a long time period. By means of various communication skills, couples are taught how to respond to negative affect in a way that will not disrupt their lives on an ongoing basis.

Whereas the above reasons for lack of compliance with caring days involve certain attitudes which interfere with the person's seeking to make efforts to please the partner, other persons are motivated to change but have difficulty thinking of what to do to please the partner. Although this can be interpreted as an excuse for not really trying, some spouses are so distant from each other and it has been so long since either person has made an effort to please the other that they simply cannot think of how to make the other person happy during the day. Therefore, spouses at times return to a therapy session saying, “I tried, but I just could think of only one or two things to do during the week. I don't know what to do to make her happy any more. My mind just went blank.” Such individuals typically have spent little time recently being attentive to their partners. They might not require an attitudinal shift but do need a shift in attention toward thinking about ways to satisfy their partners. Other related treatment strategies have been devised to assist in accomplishing this goal.

The “cookie jar technique” is a strategy for helping an individual who cannot think of small positive acts to perform for the spouse (Weiss & Birchler, 1978). If the wife cannot think of ways to please her husband, he can write down on separate pieces of paper a number of small acts that would bring him pleasure. Then he places these pieces of paper in a jar or container. Whenever the wife cannot think of things to do to please her husband, she can go to the jar and remove a slip of paper. Spouses are encouraged to spend some time trying to decide on activities before going to the cookie jar, so that each individual will become accustomed to focusing cognitively on what to do to please the partner.

Another treatment strategy similar in structure and purpose to the cookie jar technique is the wholistic contract (Stuart, 1980). As used in this volume, the term contract refers to an agreement with an explicit set of contingencies for completion and noncompletion of an agreement. In this sense, the wholistic contract is not a contract because there are no contingencies included. In the wholistic contract, each person makes a list of perhaps 10 to 20 activities in which the partner could engage to bring pleasure to the person. The partner agrees to engage in a specified number of these at some point during the next week. However, the partner does not state which specific activities he or she will enter into or exactly when during the week these acts will occur. These guidelines are intended to provide suggestions for how to please the other person, but they also include choices as to which specific acts will occur and the timing for those behaviors. This sense of choice and freedom is important to some people who engage in the acts, so that they do not feel they were forced into activities against their will. This sense of volition also can be beneficial to the person receiving the act of caring, because it increases the sense that the partner acted voluntarily and wanted to bring pleasure, thus increasing its significance at times. As will be discussed later in this chapter, one of the concerns that has been raised about behavioral contracts is that their legalistic nature can serve to alter the meaning of the behavior included in the contract.

The above techniques focus on one individual behaving in certain ways to bring pleasure to his or her partner. However, there are frequent occasions when it is important to alter the couple's behavior, for example, when they report that they engage in few pleasurable activities together. For some couples, having children ends their life as a viable dyad because most free time is focused on either the children's needs or family activities. Whereas the family unit is not to be minimized, it is important for most couples to maintain some sense of being a couple as well. For other couples, little time is spent with the spouse in pleasurable activities, either as part of the family or as part of the couple. These latter couples typically have become distant from each other, and each has built an independent world for him- or herself.

When the couple spends little time together enjoying themselves, increasing the number of pleasurable or leisure activities together is appropriate. As a result, early in therapy couples often are asked to engage in more pleasurable activities together. Typically, couples agree with the importance of such activities for the welfare of their relationship. However, this does not mean that they immediately increase the number of enjoyable events which they share. For many couples, there is an awkwardness as they struggle and acknowledge that they have difficulty thinking of what to do together. Under such circumstances, the therapist might suggest that the couple think back to things they once did together and enjoyed. Also, activities that one person currently enjoys can be altered to include the partner. Frequently when one person has a hobby or area of knowledge, that person is quite willing to share information and teach the partner about that area. Table 8-1 includes a list of joint activities that couples have reported they enjoy together. Such a list can be given to couples to spur their thinking if they are having difficulty arriving at joint activities.

TABLE 8-1
Joint Activities for Couples

Taking a walk	Going to a concert
Going to a movie or play	Attending a lecture
Going out for dinner	Going to a ballgame
Bicycling	Having a picnic
Playing golf or tennis	Hiking
Playing board games or cards	Preparing a special meal
Going bowling	Taking photographs
Working on a joint hobby	Going dancing
Taking a class	Jogging
Going to a park	Sitting outside
Having a cookout	Staying overnight at a hotel
Camping out	Listening to music
Playing musical instruments	Going sa...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Foreword
• Preface
• SECTION I THEORETICAL AND EMPIRICAL FOUNDATIONS
• SECTION II ASSESSMENT
• SECTION III INTERVENTION
• Appendix: Marital Assessment Scales
• References
• Name Index
• Subject Index