Fischer Et Al-2016-Family Process PDF

Cognitive-Behavioral Couple Therapies: Review of
the Evidence for the Treatment of Relationship

Distress, Psychopathology, and Chronic Health
Conditions
MELANIE S. FISCHER*
DONALD H. BAUCOM*
MATTHEW J. COHEN*
To read this article in Spanish, please see the article’s Supporting Information on Wiley Online Library
(wileyonlinelibrary.com/journal/famp).
Cognitive-behavioral couple therapy (CBCT) is an approach to assisting couples that

has strong empirical support for alleviating relationship distress. This paper provides a
review of the empirical status of CBCT along with behavioral couple therapy (BCT), as
well as the evidence for recent applications of CBCT principles to couple-based interven-
tions for individual psychopathology and medical conditions. Several meta-analyses and
major reviews have confirmed the efficacy of BCT and CBCT across trials in the United
States, Europe, and Australia, and there is little evidence to support differential effective-
ness of various forms of couple therapy derived from behavioral principles. A much smal-
ler number of effectiveness studies have shown that successful implementation in
community settings is possible, although effect sizes tend to be somewhat lower than those
evidenced in randomized controlled trials. Adapted for individual problems, cognitive-
behavioral couple-based interventions appear to be at least as effective as individual cog-
nitive behavioral therapy (CBT) across a variety of psychological disorders, and often
more effective, especially when partners are substantially involved in treatment. In addi-
tion, couple-based interventions tend to have the unique added benefit of improving rela-
tionship functioning. Findings on couple-based interventions for medical conditions are
more varied and more complex to interpret given the greater range of target outcomes
(psychological, relational, and medical variables).
Keywords: Cognitive-Behavioral Couple Therapy; Behavioral Couple Therapy;

Couple-based Interventions; Relationship Distress
Fam Proc 55:423–442, 2016
C ognitive-behavioral couple therapy (CBCT) is an approach to assisting couples that

has strong empirical support for alleviating relationship distress and addressing indi-
vidual difficulties in a relationship context. CBCT has evolved over decades, drawing
heavily from earlier behavioral couple therapy (BCT), individual cognitive therapy, and
*Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Correspondence concerning this article should be addressed to Melanie S. Fischer, Department of
Psychology and Neuroscience, University of North Carolina at Chapel Hill, Davie Hall, CB#3270, Chapel
Hill, NC 27599-3270. E-mail: msfi@email.unc.edu.
423
Family Process, Vol. 55, No. 3, 2016 © 2016 Family Process Institute
doi: 10.1111/famp.12227
424 / FAMILY PROCESS
1
basic cognitive and social psychology research on information processing. Although early
BCT approaches focused almost exclusively on promoting behavior change (Jacobson &
Margolin, 1979; Liberman, 1970; Stuart, 1969), CBCT has expanded to include interven-
tions that directly address cognitions and emotions as well. As a result, therapists have
available a broad range of interventions based on a well-conceptualized understanding of
each couple’s needs (Epstein & Baucom, 2002). This conceptualization employs a broad
contextual perspective that takes into account (a) the well-being of both partners as indi-
viduals, (b) the couple as a unit, and (c) the couple’s environment in which they exist.
Across these three domains, behaviors, cognitions, and emotions are viewed as interre-
lated and equally important in relationship functioning (Epstein & Baucom, 2002). Con-
sistent with this framework, a healthy relationship is viewed as one that contributes to
the growth and well-being of both partners; the couple forms a well-functioning team, and
the couple responds adaptively to the demands and resources of their physical and social
environment (Baucom, Epstein, Kirby, & LaTaillade, 2015). Consequently, CBCT practi-
tioners carefully assess a variety of factors within these various domains, and relationship
distress is viewed as a unique confluence of individual, couple, and environment factors
specific to each couple.
Hence, an effective treatment plan must take this unique set of factors into account and
employ cognitive, emotional, and behavioral interventions as appropriate to address rele-
vant concerns. For example, interventions may focus on altering behaviors directly
through skill-based strategies, including communication training such as decision-making
or problem-solving skills to address problematic behaviors. Similarly, the therapist might
employ guided behavior change to target specific domains such as suggesting date nights
to increase potentially pleasurable activities without any new skills required. Cognitive
interventions to address distorted views of the relationship can be implemented through
guided discovery (which involves providing the couple with new experiences that will lead
to different perspectives on the relationship) or more typical cognitive interventions such
as Socratic questioning. Finally, a therapist might employ a range of in and out of session
interventions to (a) contain emotions when they are too high or poorly regulated or (b)
heighten emotions and their expression when the couple is distant or approaches issues
from an extreme intellectual perspective that is problematic. Treatment is not manual-
ized, but rather relies on a therapist’s ability to craft a flexible treatment plan tailored to
each couple based on a thorough case conceptualization that takes the above factors into
account.
Consistent with this contextual perspective, race/ethnicity, gender, sexual orientation,
ability status, SES, and other characteristics related to each partner’s identity and cul-
tural background are an integral part of the case conceptualization, taking into account
individual, couple, and environmental factors of the relationship. Unfortunately, there
still is a lack of treatment research which has explored how behavioral couple therapies
can be delivered most effectively to meet the needs of a diverse range of couples. While
more treatment research on couples who are traditionally underrepresented in clinical
1
Because behavioral approaches to intervening with couples have evolved over time and different terms
have been employed, we use the following terms in describing interventions. The term “behavioral couple
therapy” (BCT) is used to describe early versions of intervention that focused almost exclusively on behav-
ioral interventions with little direct focus on cognitions or emotions (Christensen’s group refers to this
same approach as traditional behavioral couple therapy or TBCT). The term “cognitive-behavioral couple
therapy” (CBCT) is used when discussing multifaceted approaches which incorporate behavioral, cogni-
tive, and emotional interventions based within a broad behavioral theoretical model, such as the model
proposed by Baucom and Epstein (Baucom & Epstein, 1990; Epstein & Baucom, 2002), which is also the
approach the current authors have implemented. Finally, the term “behaviorally based interventions” is
used more inclusively to refer to any behaviorally oriented couple-based intervention, including BCT and
CBCT.
www.FamilyProcess.org
FISCHER, BAUCOM, & COHEN / 425
trials clearly is needed, treatment adaptations and special considerations have been dis-
cussed more systematically (e.g., Hardy & Laszloffy, 2002), particularly for LGBT couples
(e.g., Green & Mitchell, 2015) and ethnic/racial minority couples (e.g., Falicov, 2013; Kelly,
2006; LaTaillade, 2006) in recent years. Familiarity with the specific challenges in a
diverse range of couples is integral to a case conceptualization and treatment that reflect
a thorough understanding of a specific couple’s experience without over- or underestimat-
ing the impact of a particular domain on relationship functioning. For example, while rela-
tionship distress for a same-sex couple may well be driven by factors commonly found in
different-sex couples, specific challenges related to their sexual minority status such as
lack of support by families of origin and minority stress are important to explore (Green &
Mitchell, 2015). The contextual focus of CBCT allows the clinician to identify unique
themes that may characterize conflict in diverse couple relationships and help couples
build on their particular strengths and resources (Kelly, Bhagwat, Maynigo, & Moses,
2014; LaTaillade, 2006).
The evolution of CBCT into a broad-based theoretical model with a wide range of inter-
ventions has been employed primarily for treating relationship distress. Yet the interven-
tions that have resulted from these efforts are flexible and can be viewed as ways to
promote cognitive, behavioral, and emotional change within a relational context. Conse-
quently, CBCT principles and interventions can be adapted for working with couples when
the focus of treatment is not relationship distress per se. More specifically, in recent years,
CBCT approaches have been employed to help couples in which one partner is experienc-
ing individual psychopathology or medical complications. In such instances, interventions
from CBCT are integrated with current knowledge of what is needed to help an individual
address specific forms of psychopathology or medical problems, and the couple is used as a
resource and the modality of intervention in addressing these individual concerns. In
order to differentiate these approaches from “couple therapy” for relationship distress, we
refer to these later interventions as “couple-based interventions” for treating individual
concerns (Baucom, Kirby, & Kelly, 2009; Baucom, Shoham, Mueser, Daiuto, & Stickle,
1998).
In the current paper, we present a discussion of the empirical status of CBCT with an
emphasis on its utility in alleviating relationship distress, along with mechanisms of
change that have been proposed and explored empirically. In addition, we provide an over-
view of recent applications of CBCT principles to couple-based interventions for individual
psychopathology and medical problems. Because CBCT is a theoretical approach that has
been investigated by a large number of researchers and practiced by therapists in many
countries with variations, this review will include research and interventions that are
inclusive of those efforts within a broad cognitive-behavioral perspective. Also because
BCT serves as the basis for the development of more recent evolutions of CBCT, the empir-
ical status of BCT is included under the broad umbrella of behaviorally oriented couple-
based approaches.
EFFICACY RESEARCH
Behavioral couple therapy and treatments that are based in BCT have been examined
in clinical trials for over four decades. Over time, behaviorally based treatments have
become more sophisticated and have undergone important changes, for example, in order
to address cognitions and emotions more directly as in CBCT (Epstein & Baucom, 2002).
Several meta-analyses and major reviews have been conducted to examine the efficacy of
couple therapy across trials in the United States, Europe, and Australia. Even though
these various reviews have employed differing criteria for inclusion, they reach the same
conclusion: Behaviorally based couple therapies are efficacious for the treatment of
Fam. Proc., Vol. 55, September, 2016

relationship distress, and the findings are similar when these interventions are employed
across countries. The evidence largely points to equal efficacy among various forms of cou-
ple therapy derived from behavioral principles. In addition, applications to specific issues
including infidelity, intimate partner violence, and separation/divorce have been investi-
gated as well. Discussing these applications to specific relationship concerns is beyond the
scope of the current article, but reviews and treatment descriptions are available else-
where (Epstein, Werlinich, & LaTaillade, 2015; Gordon, Khaddouma, Baucom, & Snyder,
2015; Lebow, 2015).
Several meta-analyses also have examined the effects of couple therapy across theoreti-
cal approaches. Shadish and Baldwin (2003) conducted a review of various meta-analyses
of couple therapies and found that couple therapy was clearly efficacious compared to no
treatment with a mean effect size of 0.84 across theoretical approaches. With regard to
BCT and CBCT, they concluded that there was little evidence for differential efficacy of
the various theoretical approaches. Several other meta-analyses and reviews by other
author groups reached similar conclusions regarding the overall and relative effects of a
variety of couple therapies including BCT and CBCT (Baucom et al., 1998; Dunn & Sch-
webel, 1995; Hahlweg & Markman, 1988; Snyder, Castellani, & Whisman, 2006). Shadish
and Baldwin (2005) conducted a meta-analysis focused on 30 studies of BCT, including a
number of studies that were not part of the 2003 review. The authors concluded that the
smaller mean effect size of 0.59 found in this later review was likely attributable to unpub-
lished dissertations with smaller effects that were not included in previous reviews. How-
ever, this later meta-analysis included a range of treatment formats beyond what would
typically be considered behavioral “couple therapy.” For example, some of the interven-
tions were fairly limited, such as a problem-solving skills training without other BCT com-
ponents. Thus, an effect size of 0.84 seems like a reasonable approximation of average
effect sizes for peer reviewed randomized controlled trials of couple therapy, including
BCT/CBCT.
A number of smaller studies have explored a variety of issues regarding the efficacy of
behavioral couple therapies and specific impact on a variety of domains. For example,
studies have consistently shown that behavioral couple therapies effectively reduce nega-
tive communication behaviors but less change is observed in increasing positive communi-
cation (Baucom & Adams, 1987). A number of smaller studies have also attempted to
identify the “active ingredients” in BCT in a number of augmentation or dismantling stud-
ies and have generally found that interventions including communication skills and prob-
lem-solving training, behavioral exchanges/contracting, or a combination are equally
effective (Baucom, 1982; Emmelkamp, van der Helm, MacGillavry, & van Zanten, 1984;
Ewart, 1978; Jacobson, 1984). Other studies regarding the optimal delivery of BCT have
concluded that one couple therapist is equally as effective as a co-therapy team (Mehlman,
Baucom, & Anderson, 1983), and treating one couple at a time is preferable to employing
BCT to couples in a group format (Hahlweg, Schindler, Revenstorf, & Brengelmann,
1984).
Across these and other studies, it has become clear that a given component of BCT typi-
cally produces change in the targeted domains (e.g., communication skills); however, the
overall amount of change in relationship satisfaction among behaviorally based couple
therapies tends to be equal. It is possible that overall efficacy may be greater when the tar-
geted domains in a given treatment match the domain in which a couple requires the most
change, although this question has not been examined systematically in empirical
research.
Since the aforementioned major meta-analyses, there has been only one randomized
controlled trial of behaviorally based couple therapies: Christensen and colleagues com-
pared the efficacy of traditional behavioral couple therapy (BCT or as they refer to it,
TBCT; a version of couple therapy with almost exclusive focus on behavioral change with
little emphasis on cognitions or emotions, unlike more modern treatments such as CBCT)
and integrative behavioral couple therapy (IBCT) in the largest randomized controlled
trial of couple therapy to date (Christensen et al., 2004). Despite differences in how
quickly change occurred and the mechanisms of change, both treatments resulted in simi-
lar improvements in relationship satisfaction with an overall effect size of d = 0.86 at post-
treatment (Christensen et al., 2004), almost identical to effect sizes obtained in earlier
meta-analyses. Among couples receiving TBCT, 44% were classified as recovered in terms
of their relationship satisfaction at end-treatment. An additional 15% of couples reliably
improved but did not reach the nondistressed range (Christensen et al., 2004). Also, levels
of relationship satisfaction remained similar across the two treatments at the 2- and 5-
year follow-ups (Christensen, Atkins, Baucom, & Yi, 2010; Christensen, Atkins, Yi, Bau-
com, & George, 2006). Five years after treatment completion, relationship satisfaction
among couples in both treatment conditions was notably improved compared to pretreat-
ment, with an effect size for TBCT of 0.92. Within TBCT, 37% were still considered recov-
ered at the 2-year follow-up and an additional 23% of couples reliably improved compared
to their baseline relationship satisfaction (Christensen et al., 2006). At the 5-year follow-
up, 33% of couples were categorized as recovered and an additional 13% as reliably
improved (Christensen et al., 2010). Thus, results of the largest trial of behaviorally ori-
ented treatments to date demonstrate the equivalence of TBCT and IBCT in alleviating
relationship distress. Quite promising, the overall effects of treatment are maintained at
5-year follow-up. As discussed below, to strengthen these efficacious inventions further, it
is important to elucidate the mechanisms of change for CBCT (as well as other forms of
couple therapy) and identify which couples respond to various interventions within this
multicomponent approach. Finally, almost all of these intervention studies were con-
ducted in controlled university settings, and the effectiveness of all forms of couple ther-
apy must be evaluated in more typical, real-world settings.
EFFECTIVENESS RESEARCH
Despite numerous efficacy trials of behaviorally based couple therapies in controlled
settings, effectiveness studies in real-world settings have been largely unexplored, with
only four effectiveness studies conducted over the last several decades. Of note, three of
the four studies employed an eclectic mix of couple therapy approaches that were not nec-
essarily evidence-based or behavioral/cognitive-behavioral in nature. However, given the
dearth of effectiveness research, these studies provide the closest estimation of effects in
community settings that are available. Two studies were conducted in Germany (Hahlweg
& Klann, 1997; Klann, Hahlweg, Baucom, & Kroeger, 2011). Within these studies, primar-
ily masters-level counselors provided couple therapy of their own choice for a variable
number of sessions. In both studies, the findings indicated that significant improvements
were achieved in communication and in global relationship satisfaction, and within-group
effect sizes ranged from 0.22 to 0.52. Both studies also offered encouraging results in alter-
ing depressive levels across partners (d = 0.46 in the first study; d = 0.72 in the second
study). These results suggest that couple therapy is effective in reducing relationship dis-
tress as well as individual depressive symptomology in both partners. Similarly, a Norwe-
gian research team conducted an effectiveness study of couple therapy within a family
counseling agency (Anker, Duncan, & Sparks, 2009). In this study, therapists used a vari-
ety of couple therapy approaches of their own choosing (cognitive-behavioral, humanistic,
etc.), which resulted in positive effects on individual functioning (d = 1.14) as well as rela-
tionship satisfaction (d = 0.52). Finally, a study with military veterans mirrored the
results of the three other studies (Doss et al., 2012). In this case, therapists used

approaches that were primarily behavioral, and, on average, couples experienced improve-
ment in the context of relationship satisfaction (d = 0.44 for men; d = 0.47 in women).
Effect sizes also varied depending on initial levels of relationship distress, with couples
who entered treatment with higher levels of relationship distress demonstrating signifi-
cantly larger gains than couples who reported lower initial levels of relationship distress.
Broadly, the results of these four studies suggest that while effectiveness studies in
community settings are still in the early stages, couples therapy appears to be an effective
approach to improving relationship and individual functioning outside of controlled, uni-
versity contexts. However, the effect sizes overall appear to be somewhat lower than those
evidenced in randomized controlled trials conducted with significant supervision and
control regarding selection criteria. Importantly, most of these studies did not focus on
behaviorally based couple therapies specifically, and larger effects may result from
evidence-based treatments in community settings.
MECHANISMS OF CHANGE
Attempts to isolate the mechanisms of change in CBCT have been mixed. In early stud-
ies with small sample sizes that were somewhat underpowered to detect mechanisms of
change, both Iverson and Baucom (1990) and Halford, Sanders, and Behrens (1993) found
that, contrary to predictions, changes in communication skills during CBCT did not pre-
dict relationship adjustment at the end of treatment. However, a more recent investiga-
tion with a larger sample, more frequent assessments, and more sophisticated data
analytic strategies provides insight into possible mechanisms of change of behaviorally
based couple therapies. Doss, Thum, Sevier, Atkins, and Christensen (2005) explored
mechanisms of change in Christensen’s comparative outcome study of TBCT and IBCT
(Christensen et al., 2004). The investigators concluded that TBCT promoted a significant
amount of reported targeted behavior change during the first half of therapy, and these
changes predicted increases in relationship adjustment halfway through therapy. During
the second half of therapy, these targeted behavior changes decreased, with corresponding
decreases in relationship adjustment during that time. Acceptance of the partner’s behav-
ior was important in predicting improvements in relationship functioning across the
entire treatment. Importantly, contrary to earlier investigations, increases in self-
reported positive communication and decreases in self-reported negative communication
both predicted changes in relationship adjustment in the expected directions. Taken
together, these findings indicate that targeted changes in BCT are important to successful
treatment. That is, helping couples communicate more effectively is important in promot-
ing improvements in relationship functioning; also as anticipated, the degree of targeted
behavior change that partners demonstrate during treatment predicts changes in rela-
tionship adjustment. An important finding that raises concern is that initial behavioral
changes during treatment appeared to tail off as treatment continued, suggesting that the
couples’ initial motivation might wane as treatment persists and, thus, should be targeted
in treatment. Also, internal cognitive–affective changes such as acceptance are important
in improving relationship adjustment and may be more effectively addressed in CBCT
(and other modern behaviorally based evolutions of couple therapy such as IBCT) com-
pared to purely behavioral interventions. As Doss et al. (2005) note, these findings merit
replication, and the findings regarding communication and behavior changes were based
solely on self-report. Thus, direct behavioral assessment of these domains is essential.
Even so, these findings are consistent with the theoretical underpinnings and therapeutic
applications of behaviorally based couple therapies.
In addition to mechanisms of change that are important across couples, relationship
distress can result from a wide variety of factors (Epstein & Baucom, 2002), which would
suggest that different mechanisms of change might be important for different couples.
That is, different couples may need different types of intervention (e.g., targeting cogni-
tions, behaviors, or emotional factors), or there might well be moderators of treatment out-
come. Unfortunately, there have been no intervention studies that have been conducted
with an emphasis on matching specific interventions to particular couples, although some
efforts have been made to identify post hoc which couples may benefit most from a particu-
lar intervention. For example, O’Leary and Turkewitz (1981) found that young couples
benefited more from BCT than communication training, whereas older couples benefited
more from the communication training intervention. However, couples were randomized
to the conditions, and the post hoc findings are not sufficient to determine whether treat-
ment outcomes could be optimized by matching couples to different treatments.
Also, there may be broader nonspecific change or common factors in interventions that
cut across different theoretical orientations, including CBCT. For example, Benson,
McGinn, and Christensen (2012) provide a framework for considering five common princi-
ples across different models of couple therapies in their discussion of a unified protocol for
couple-based interventions for relationship distress. In attempting to decrease relation-
ship distress, therapists attempt to (a) alter the couple’s view of their difficulties to be
more dyadic rather than individually based, (b) decrease maladaptive emotion-driven
behavior, (c) draw out vulnerable emotion-based behaviors that might be adaptive for
partners to share, (d) increase constructive communication patterns, and (e) emphasize
the couple’s strengths. Davis, Lebow, and Sprenkle (2012) review common factors in cou-
ple therapy with a focus on the empirical evidence and identify similar processes specific
to couple therapies, in addition to other factors likely shared with individual treatments
(such as expectancies and therapeutic alliance). However, most empirical evidence is
either based in individual therapy or qualitative studies rather than quantitative studies
examining causal links between common factors and couple therapy outcome.
Integrating these various empirical findings and considerations regarding common fac-
tors points out the complexity of understanding the nature of therapeutic change. There
might well be interventions focal to CBCT that promote adaptive change for most couples;
even within CBCT, some couples might respond well to certain interventions, whereas
other couples need different CBCT foci in treatment. Furthermore, there might be com-
mon factors that span effective treatments across theoretical approaches. While consider-
ing all these factors, we must remain realistic about what we can achieve with a given
couple. Even if partners interact with each other adaptively, they may not wish to spend
the rest of their lives with each other. A challenge awaiting the field is to develop criteria
for determining whether ending a committed relationship should be viewed as a treatment
failure or a healthy decision to move forward in a different direction.
APPLICATIONS OF CBCT TO INDIVIDUAL PROBLEMS

Over the past two decades, CBCT interventions have been adapted to address a wide
range of individual psychological and medical problems. The driving force for the develop-
ment of these interventions has been the recognition that individual functioning and rela-
tionship quality influence each other, and working with the couple holds the promise of
added efficacy beyond individual interventions by (a) drawing on the support of the part-
ner, and (b) directly addressing the interpersonal context within which the individual
problem occurs.
These applications can be referred to as couple-based interventions, where the primary
goal is to address the individual disorder (e.g., depression, substance use, cancer, cardio-
vascular disease) by working with the couple, rather than targeting relationship distress.
Maladaptive couple interaction patterns that negatively impact the target disorder often

are still addressed (e.g., high levels of criticism, symptom accommodation), and improved
relationship functioning is a common secondary outcome for many of these treatments.
Couple-based interventions for individual psychopathology and medical problems can be
grouped broadly into three approaches of incorporating a partner into treatment (Baucom
et al., 1998): (a) Partner-assisted interventions draw on the support and involvement of
the partner as a “coach” and do not attempt to change the relationship itself. For example,
partners may be taught how to assist depressed patients with behavioral activation, or
partners may assist a patient with diabetes in implementing dietary changes. (b) Disor-
der-specific interventions broaden the focus of intervention to aspects of the couple’s rela-
tionship that are relevant to the maintenance and treatment of the disorder. For example,
if a partner has taken over roles and responsibilities such as grocery shopping due to a
patient’s fears of leaving the house, disorder-specific interventions would aim to adapt
these behaviors to reduce symptom accommodation and increase the patient’s informal
exposure to feared situations as part of daily life. (c) Couple therapy is the broadest type of
intervention and targets general relationship difficulties when they are present, because
relationship distress serves as a chronic stressor that will negatively impact the patient’s
psychopathology or medical problem. It is important to note that couple therapy is the only
one of the three types of interventions where relationship distress is assumed to be pre-
sent; partner-assisted and couple-based interventions primarily draw on partners as a
resource and employ strategies to target the ways in which even happy, well-intended
partners can inadvertently contribute to the maintenance of a disorder (e.g., through
symptom accommodation) or distress related to a medical illness.
Although these categories apply both to psychopathology and medical illnesses, cou-
ple-based interventions across these two contexts differ in important ways. As we dis-
cuss below, applications to both areas have been quite successful. However, the efficacy
of couple-based interventions for psychopathology appears to be more consistent,
whereas findings are more varied in the health area. We consider the following two
observations about differences between couple-based interventions for psychopathology
and for medical conditions as critical to understanding the state of the field in terms of
CBCT applications to individual problems: First, the nature of the target outcomes dif-
fers in important ways: In couple-based interventions for psychopathology, the psycho-
logical symptoms are always the primary target (e.g., alleviating depression or
posttraumatic stress disorder [PTSD] symptoms). Within couple-based interventions for
medical illnesses, the targets are more variable. Some interventions target physical
symptom reduction directly and use medical symptoms as primary outcomes (e.g., reduc-
ing levels of pain for arthritis). Other couple-based interventions target health behavior
change (e.g., increased exercise for cardiac patients) in order to improve long-term medi-
cal outcomes which cannot be captured in the typical length of most clinical trials; yet,
other couple interventions target psychological factors resulting from the medical disor-
der as the outcome (e.g., alleviating depression and anxiety following a cancer diagno-
sis). In addition, although a given psychological problem can vary in terms of severity
(e.g., mild vs. moderate depression), there are more distinct stages for some medical ill-
nesses which have implications for intervention (e.g., addressing Stage 1 vs. Stage 4 can-
cer with a couple can be quite different). Finally, for some conditions, medical
treatments occur in various steps, and therefore the timing of couple-based interventions
for medical concerns likely is important as well (e.g., offering intervention soon after
diagnosis vs. after chemotherapy is completed). Thus, “success” is defined very differ-
ently across various couple-based interventions for health concerns, and the severity of
the disorder and timing of intervention likely affect outcome. All of these factors make it
more difficult to reach broad conclusions about the efficacy of these interventions for
medical problems.
Second, psychopathology appears to be a more influential factor in couple interactions:
A given type of psychopathology appears to pull for specific interaction patterns with close
others that impact the course of the disorder. For example, extensive symptom accommo-
dation has been observed in family members and partners of patients with anxiety disor-
ders, PTSD, or obsessive–compulsive disorder (OCD) in order to help the person avoid the
anxiety (providing reassurance, assisting with avoidance) (Boeding et al., 2013; Fredman
et al., 2015). On the other hand, individuals with anorexia nervosa (AN) often keep their
disorder a secret or minimize its seriousness, frequently keeping their partner at a dis-
tance more generally (Fischer, Kirby, Raney, Baucom, & Bulik, 2015). Such distinctive
interaction patterns mean that there are clear targets for disorder-specific interventions
for a given psychological disorder (e.g., stopping symptom accommodation for anxiety dis-
orders and increasing openness between partners for AN). On the contrary, specific medi-
cal illnesses do not have as strong a pull for unique interpersonal patterns, with some
notable exceptions such as accommodation for arthritis-related pain behaviors and protec-
tive buffering to shield cancer patients from partners’ own worries. Instead, the behaviors
and experiences of couples with a given medical problem appear to vary widely, which
raises the question whether all couples who face a particular diagnosis need a psychosocial
intervention, and how to identify subgroups that do.
In the following overview, we present evidence regarding the efficacy of behaviorally
oriented, couple-based interventions for psychopathology and medical problems. Consis-
tent with the above considerations, the focus of interventions for psychopathology has
been somewhat more straightforward than for medical problems, accompanied by what
appears to be a more consistent pattern of findings to date.
Couple-Based Interventions for Individual Psychopathology

Mood disorders
Depression and substance abuse have been the most commonly studied psychiatric dis-
orders within the context of relationship functioning. Both cross-sectionally and longitudi-
nally, relationship distress and depressive symptoms are closely associated and predictive
of each other (see Whisman & Baucom, 2012, for a review), and relationship distress at
the end of treatment is a risk factor for future relapses (Whisman, 2001; Whisman & Bau-
com, 2012). Thus, treatments for depression that address both depressive symptoms and
relationship functioning are of particular value when treating individuals in distressed
relationships.
Behavioral couple therapies have repeatedly been shown to be effective in the treat-
ment of depression, even when the treatment focused on relationship distress rather than
depression in a couple context more specifically (Baucom et al., 1998). In a meta-analytic
review, Barbato and D’Avanzo (2008) found couple therapy to be as effective as individual
therapy in reducing depression, and couple therapy significantly improved relationship
distress, thereby addressing an important risk factor for relapse of depression. Although
this meta-analysis also included investigations based on other theoretical orientations
(e.g., emotion-focused couple therapy), the results of the five studies using behaviorally
based models were consistent with the overall conclusions. More recently, BCT interven-
tion principles have been adapted to address depression in a more targeted way, for exam-
ple, by including partner-assisted behavioral activation or disorder-specific interventions,
also improving both depression and relationship satisfaction (Bodenmann et al., 2008;
Cohen, O’Leary, & Foran, 2010). Although there is evidence that depressed individuals in
distressed relationships are most likely to experience the greatest added benefit of a cou-
ple-based versus individual treatment (Beach & Whisman, 2012), other moderating fac-
tors are yet to be determined. A recent study of a behavioral family-based therapy (FBT)

for bipolar disorder (62% of relatives in the study were spouses) highlights the importance
of examining such moderators (Fredman, Baucom, Boeding, & Miklowitz, 2015). Patients
with family members who exhibited high rates of inappropriate emotional overinvolve-
ment benefited more from FBT compared to an individual intervention, whereas there
was no difference between the two interventions at low levels of inappropriate emotional
involvement. That is, when maladaptive family interaction patterns were present, a fam-
ily-based intervention was the treatment of choice.
In summary, behaviorally based couple therapies have generally been found to be at
least as effective as individual treatments for depression but more effective in also treat-
ing relationship distress simultaneously. Even stronger effects may be achievable when
partner-assisted and disorder-specific interventions informed by individual evidence-
based treatments are incorporated.
Substance Use Disorders

A strong association between relationship distress and alcohol use disorders (AUDs) is
well established (Whisman, 2007). Behavioral couple therapies for alcohol use disorders
(McCrady & Epstein, 2009; O’Farrell & Fals-Steward, 2006) are well-researched interven-
tions that target couple interaction patterns to promote abstinence and sobriety by
decreasing negative communication patterns and increasing positive interactions around
sober behaviors. Adaptations for other drug use disorders have evolved as well, but much
less empirical research is available (e.g., Epstein, McCrady, Morgan, & Cook, 2007). BCT
for AUDs has consistently been shown to be efficacious both in terms of improvement of
alcohol consumption and relationship functioning (O’Farrell, Cutter, Choquette, Floyd, &
Bayog, 1992; O’Farrell, Cutter, & Floyd, 1985; Walitzer & Dermen, 2004) and superior to
individual treatments always on some alcohol and relationship outcomes and equal on
others within each study (Bowers & Alredha, 1990; McCrady, Epstein, Cook, Jensen, &
Hildebrandt, 2009; McCrady, Stout, Noel, & Abrams, 1991; McCrady et al., 1986; Vedel,
Emmelkamp, & Schippers, 2008). More recent adaptations have confirmed treatment effi-
cacy in couples, where a female rather than a male partner has the AUD (McCrady et al.,
2009; Schumm, O’Farrell, Kahler, Murphy, & Muchowski, 2014) or where both partners
have a current AUD (Schumm, O’Farrell, & Andreas, 2012). Most recently, an important
integration of BCT for AUDs and CBCT for PTSD—two highly comorbid conditions—
showed promising initial results (Schumm, Monson, O’Farrell, Gustin, & Chard, 2015). To
conclude, BCT for alcohol and substance use disorders has consistently been at least as
effective and often more effective than individual treatments both in terms of substance-
related outcomes and relationship adjustment.
Anxiety disorders, PTSD, and OCD
Couple-based interventions for anxiety disorders, PTSD, and OCD have varied in terms
of the degree of partner involvement, typically including some variation of partner-
assisted exposures and disorder-specific interventions. In their 1998 review, Baucom et al.
concluded that couple-based interventions where partners simply served in a support role
during exposure exercises tended to be equally as effective as individual interventions for
OCD and agoraphobia, while some initial evidence suggested that disorder-specific inter-
ventions targeting couple communication and/or interaction patterns were associated with
stronger effects compared to individual treatments (Daiuto, Baucom, Epstein, & Dutton,
1998). Since then, two couple-based interventions for OCD and PTSD have been developed
that include a more extensive focus on couple interaction patterns that inadvertently
maintain symptoms (i.e., disorder-specific and couple therapy interventions). These more
comprehensive approaches resulted in notable OCD or PTSD symptom improvement in
the patient, as well as improved relationship satisfaction for both partners (Abramowitz
et al., 2013; Monson et al., 2012; Schumm, Fredman, Monson, & Chard, 2013; Schumm
et al., 2015). However, there are currently no controlled trials that directly compare these
couple-based interventions with individual treatments, although benchmark comparisons
with other published trials suggest stronger effects for the couple-based treatment for
OCD (Abramowitz et al., 2013). Both in the OCD and PTSD trials, partner symptom
accommodation moderated treatment effects (Boeding et al., 2013; Fredman et al., 2015);
thus, future research should examine whether treatment should specifically target cou-
ples where symptom accommodation is high.
Other disorders and emerging treatments
The above positive findings have served as a basis for the development of couple-based
interventions for other disorders with initial encouraging results. For example, Kirby and
Baucom (2007) developed a couple-based intervention to treat significant emotion dysreg-
ulation. This integration of dialectical behavior therapy (DBT) with CBCT demonstrated
favorable outcomes for both individual and couple functioning in an initial open trial. Cou-
ple-based interventions for eating disorders also have been a recent area of investigation.
An open trial of a couple-based intervention for anorexia nervosa (integrating all three
forms of couple-based interventions) has shown very promising results both in terms of
symptom improvement and relationship satisfaction (Bulik, Baucom, Kirby, & Pisetsky,
2011, 2012; Fischer et al., 2015), and an RCT comparing this intervention to individual
CBT for anorexia nervosa is currently under way. In addition, interventions for binge eat-
ing disorder and bulimia nervosa currently are being developed and evaluated (Kirby,
Runfola, Fischer, Baucom, & Bulik, 2015).
Conclusions and future directions
Overall, cognitive-behavioral couple-based interventions generally have been found to
be at least as effective as individual CBT across a variety of psychological disorders, and
at times more effective, especially when partners were substantially involved in treat-
ment. In addition, compared to individual treatments, couple-based interventions tend to
have the unique added benefit of improving relationship functioning for both the patient
and the partner. However, only general behavioral couple therapy (targeting relationship
distress) for depression and couple-based interventions for substance abuse have been
studied extensively, with recent studies supporting more specific couple-based interven-
tions for depression, PTSD, OCD, and eating disorders. In addition, effects on the individ-
ual psychological functioning of the partner who is not the index patient have not typically
been considered, with some exceptions that show positive effects particularly for dis-
tressed partners (Belus, Baucom, & Abramowitz, 2014; Cohen et al., 2010; Shnaider,
Pukay-Martin, Fredman, Macdonald, & Monson, 2014).
One of the most important issues to address in future research is to identify which
patients will experience the greatest added benefit from a couple-based intervention com-
pared to individual therapy. This issue is important not only from a research perspective
but clinicians must also address this practical question on an ongoing basis—what treat-
ment to recommend to patients with a partner. Although much additional inquiry is neces-
sary before clear guidelines are developed regarding treatment recommendations, thus far
it appears that (a) relationship distress and (b) couple interaction patterns that contribute
to the maintenance of the disorder (e.g., high levels of emotional overinvolvement or part-
ner accommodation) might call for the inclusion of partners in treatment. From a broad
perspective, it appears that couple interventions originally developed to alleviate relation-
ship distress can be adapted successfully to focus on individual psychological difficulties in
an interpersonal context.

Applications to Physical Health Problems

CBCT intervention principles also have been adapted successfully for couples in which
one partner suffers from a medical illness, again with the primary goal of improving out-
comes in the patient with the medical problem. Compared to couple-based interventions
for psychopathology, interventions for medical problems tend to be shorter in duration.
Partner-assisted and disorder-specific interventions are based on medical and behavioral
medicine knowledge of what is needed to treat or manage specific health conditions, while
couple therapy principles are based in research that has consistently shown that a positive
committed relationship can result in physical health benefits, while relationship conflict
can have deleterious effects on health (see Kiecolt-Glaser & Newton, 2001, for a review).
Below are discussions of adaptations of BCT/CBCT interventions, as well as other couple-
based treatments that are not labeled as cognitive or behavioral but apply fundamental
principles of CBCT.
Cancer
Interventions targeting cancer are among the most prevalent couple-based interven-
tions for medical problems. A cancer diagnosis and its physical and psychological sequelae
tend to result in elevated levels of psychological distress for both patients and partners
(Bowman, Rose, & Deimling, 2006). As such, there have been increased efforts to examine
the efficacy of couple-based interventions for couples facing cancer, which typically
emphasize either (a) coping skills, (b) social support, or (c) both.
Coping skills focused interventions are intended to help patients manage their symp-
toms and side effects of cancer treatment, with their partners serving within the “coach”
or partner-assisted role. Thus, partners are shown how to help the patients understand
and employ coping skills, which may include relaxation, cognitive restructuring, or other
methods of reducing psychological distress. Broadly, these interventions have been shown
to improve the experience of both patients and their partners, e.g., reducing caregiver
strain (Campbell et al., 2007; Porter et al., 2011), as well as a host of other individual and
interpersonal outcomes (Kuijer, Buunk, De Jong, Ybema, & Sanderman, 2004; Scott, Hal-
ford, & Ward, 2004).
Social support interventions are designed to help the couple approach the illness
together as a team, typically by teaching communication and problem-solving skills to
assist with providing appropriate emotional and instrumental support (Baucom et al.,
2009). For example, Porter et al. (2009) developed a social support intervention for gas-
trointestinal cancer, which resulted in improved relationship quality for couples, particu-
larly for couples who initially reported high levels of holding back when discussing cancer-
specific concerns (Porter et al., 2009). To date, couple-based interventions for cancer have
primarily targeted breast cancer (Baucom et al., 2005, 2009; Heinrichs et al., 2012; Manne
et al., 2005; Scott et al., 2004), prostate cancer (Campbell et al., 2007; Northouse et al.,
2007), and gastrointestinal cancer (Porter et al., 2009). As previously discussed, great
variability across studies in terms of targeting a range of psychosocial versus medical out-
comes makes general conclusions about the efficacy of couple-based interventions difficult,
and mixed findings are somewhat difficult to interpret. In a recent review, Shields, Finley,
Chawla, and Meadors (2012) reported on five interventions with positive psychological
outcomes, ranging from improved communication and relationship satisfaction to reduc-
tions in psychological distress in both partners. However, they also highlighted four stud-
ies that did not find differences between couple-based and individual interventions for
cancer, as individuals in both groups experienced equal reductions in psychological dis-
tress and improved relationship outcomes (Shields et al., 2012). Thus, even though cou-
ple-based interventions have been shown to have positive effects on individual and couple
functioning, it is not clear whether, and for which couples, there are unique added benefits
compared to an individual intervention, highlighting the need for further study in this
area.
Arthritis
The literature on couple-based interventions for arthritis shows promising findings,
again with variable intervention targets. Broadly, couple-based interventions for arthritis,
which focus on cognitive and behavioral pain management strategies as well as relation-
ship skills training (e.g., communication training), tend to yield improvement in communi-
cation for arthritis patients and their partners, but improvements in pain and physical
functioning are not as consistent (Martire, Schulz, Keefe, Rudy, & Starz, 2007, 2008; van
Lankveld, van Helmond, Naring, de Rooij, & van den Hoogen, 2004). In the two studies
that compared a couple-based intervention to an individual intervention, patients in both
conditions made equal improvements in psychological, relational, and physical outcomes
(Martire et al., 2007; van Lankveld et al., 2004). However, when these couple-based inter-
ventions were combined with exercise training, patients made greater gains in self-effi-
cacy, as compared to exercise training standard care (Keefe et al., 2004). The combined
couple-based intervention also yielded improvements in physical fitness and strength
above and beyond the improvements made in the coping skills group alone. Similarly,
those in the combined group reported an ability to cope with pain above and beyond those
in the exercise training group (Keefe et al., 2004). Taken together, these findings suggest
that the inclusion of the partner tends to yield most benefit when the intervention has
both physical and psychological elements.
Chronic pain
Given the impact of psychosocial factors on chronic pain (West, Usher, Foster, & Ste-
wart, 2012), researchers have given increased attention to couple-based interventions for
pain, primarily in the context of arthritis and cancer. The investigations are highlighted
separately here, because the findings may have implications for other types of chronic
pain as well.
Two studies of chronic pain in osteoarthritis (Keefe et al., 1996, 1999, 2004) focused on
couple communication around pain and the resulting distress, facilitating processes for
showing support as well as providing opportunity for the partner to process the difficulty
of being in a caretaking role. Findings from these studies showed that patients in the cou-
ple-based intervention experienced significantly reduced levels of pain as compared to the
studies’ control groups. Similarly, Keefe et al. (2003) created a couple-based intervention
for end-of-life pain management, which helped partners to feel a greater sense of self-effi-
cacy for helping as well as reduced levels of caregiver strain as compared to a usual care
control group. In conclusion, although findings have been somewhat mixed, across ill-
nesses these studies offer evidence of an alternative way to approach pain management, a
growing and important area of exploration.
Cardiovascular disease
Individuals with cardiovascular disease (an umbrella term that encompasses heart dis-
ease, high blood pressure, and other related conditions) are strong candidates for a couple-
based intervention given that the recommended lifestyle changes for the management of
the disease (e.g., dietary changes, exercise) often occur in a family context and impact
partners as well. In their review, Martire, Schulz, Helgeson, Small, and Saghafi (2010)
reported that couple-based interventions for cardiac surgery patients produced greater
improvements in self-efficacy in one of four areas relating to physical activity compared to
individual therapy; however, patients in the couple-based intervention also reported less

tolerance for emotional distress as compared to those in individual therapy (Martire et al.,
2010). More recent studies similarly support the possibility that couple-based interven-
tions for this population have been largely successful in producing greater behavioral,
rather than psychological, change. For example, postmyocardial infarction patients receiv-
ing a couple-based intervention returned to work sooner than the control group and expe-
rienced improved adherence to their recovery plans (Broadbent, Ellis, Thomas, Gamble, &
Petrie, 2009). Similarly, patients with cardiac disease who received a couple-based inter-
vention exhibited increased physical activity as well as improved medication adherence
compared to patients who received the individual control intervention (Sher et al., 2014).
The couple-based intervention uniquely improved relationship satisfaction as well.
In summary, couple-based interventions for cardiovascular disease have been shown to
consistently effect lifestyle change in the face of a condition that requires such change,
whereas short-term effects on psychological outcomes have been more varied.
Type-2 diabetes
In spite of the growing incidence of diabetes and the extensive lifestyle changes that are
often required for its management, there have been few couple-based interventions for
diabetes. In two randomized trials (Trief et al., 2011; Wing, Marcus, Epstein, & Jawad,
1991), the couple-based interventions focused on health behavior change (e.g., dietary
change) as well as communication skills. In both studies, patients experienced meaningful
improvements in health behaviors and physical outcomes (e.g., dietary changes and
weight loss), but the couple-based interventions did not offer an advantage over individual
interventions on these outcomes. On the surface, while these results may suggest that
individual and couple-based approaches for diabetes are equivalent, neither study mea-
sured individual psychological outcomes (e.g., depressive symptoms), which have been
shown to impact the course of the disease (de Groot, Anderson, Freedland, Clouse, & Lust-
man, 2001). As such, future study is needed to explore the benefits of dyadic interventions
in this context.
HIV
Couple-based interventions in the context of HIV have traditionally targeted HIV trans-
mission and risk behaviors in the interest of preventing spread of the disease (see Burton,
Darbes, & Operario, 2010; El-Bassel & Wechsberg, 2012, for reviews). Both the Burton
and El-Bassel reviews highlight that there are many interventions that target testing and
counseling about safe sex practices termed Couple Voluntary Counseling and HIV Testing
(CVCT) interventions) but that there are a dearth of behavioral interventions that target
serodiscordant couples (where one partner is HIV positive and one partner is HIV nega-
tive). To address this gap in the literature, recent studies have examined the efficacy of
couple-based interventions for partners in serodiscordant relationships. Interventions tar-
geting this population typically use psychoeducation and communication training in order
to optimize partner support, alleviate impact of the disease, and reduce risk of transmis-
sion in two different ways. One approach is to improve antiviral medication adherence
through a couple-based treatment, which has been shown to be more effective than treat-
ment as usual through their medical provider (Remien et al., 2005). Additionally, another
approach aims to improve coping strategies by building social support and stress manage-
ment techniques in both partners (Fife, Scott, Fineberg, & Zwickl, 2008). Improving cop-
ing strategies not only helps patients and their partners to manage the illness more
effectively and collaboratively but also has been shown to improve psychological outcomes
in patients (Fife et al., 2008). More broadly, a 2013 meta-analysis examined 29 couple-
based interventions for HIV prevention and determined there was a reduction in unpro-
tected sex within the context of romantic relationships (LaCroix, Pellowski, Lennon, &
Johnson, 2013). Taken together, these couple-based interventions offer a promising area
of study in the context of HIV prevention and treatment.
Conclusions
The literature on couples and physical health interventions is complex and multifaceted
because of the wide range of health conditions and indicated treatments, as well as great
variability in the focus on (a) psychosocial versus physical outcomes and (b) individual ver-
sus relationship outcomes. Overall, these interventions appear to be at least as effective
as individual interventions on the measured outcomes, with apparent added benefits of a
couple-based intervention typically in the realm of relationship functioning rather than
individual outcomes. However, outside of the cancer realm, no other interventions for
medical conditions have been comprehensively examined in an interpersonal context. In
addition, some differences in outcomes may not become evident until years after the inter-
vention, for example, when interventions focus on health behavior changes that might
impact the disorder at a later time. An important avenue of future research will be to
examine which couples benefit most from couple-based interventions, and which patients
benefit optimally or equivalently to individual treatment.
SUMMARY AND CONCLUSIONS

Over decades of research in the United States, Europe, and Australia, CBCT and
related behavioral couple therapies have been shown to be efficacious in the treatment of
relationship distress. The small number of effectiveness studies suggest that these treat-
ments are successful in community settings as well, although effect sizes tend to be some-
what lower than in randomized controlled trials. Investigations of mechanisms of change
have often not been successful in isolating change processes, but more recent attempts
with larger samples and more sophisticated approaches have provided support for pro-
posed change mechanisms including communication skills and targeted behavior change.
A major direction in the field in more recent years has been to adapt intervention princi-
ples of CBCT to address individual psychopathology and medical conditions in a relation-
ship context, with the hypothesis that harnessing the support of partners, directly
targeting the social environment including maladaptive interaction patterns such as
symptom accommodation by partners, and alleviating relationship distress as a chronic
stressor would result in added benefits compared to typical individual treatments. Over-
all, these efforts have been most consistently successful in the treatment of psychopathol-
ogy and more varied in the context of medical conditions where treatment targets vary
greatly across studies (i.e., medical, psychological, and relationship outcomes).
Thus, where does the field go from here? The CBCT theoretical model is clear; a range
of interventions have been developed and evaluated, and the intervention results over the
past 40 years demonstrate that a cognitive-behavioral couple approach can assist couples
in making adaptive changes in a wide range of contexts. This recognition is important.
After all, many couples will experience relationship difficulties or one or both partners will
have to contend with psychological or medical problems at some point in their shared lives.
Given that we now have tools to assist couples in a wide range of conditions, the next
major step is to learn how to implement these interventions in a more targeted way. As
noted above, we still must investigate whether these interventions apply to a diverse
range of couples and when couple versus individual intervention is the treatment of choice
for which conditions. That is, the remaining questions center not so much on whether to
consider couple-based interventions based on behavioral principles, but rather how and
when to employ them most effectively to assist couples addressing a range of complex
problems across the couple’s lifespan.

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Cognitive-Behavioral Couple Therapies: Review of

the Evidence for the Treatment of Relationship

Cognitive-behavioral couple therapy (CBCT) is an approach to assisting couples that

Keywords: Cognitive-Behavioral Couple Therapy; Behavioral Couple Therapy;

Fam Proc 55:423–442, 2016

C ognitive-behavioral couple therapy (CBCT) is an approach to assisting couples that

Fam. Proc., Vol. 55, September, 2016

Fam. Proc., Vol. 55, September, 2016

APPLICATIONS OF CBCT TO INDIVIDUAL PROBLEMS

Fam. Proc., Vol. 55, September, 2016

Couple-Based Interventions for Individual Psychopathology

Fam. Proc., Vol. 55, September, 2016

Substance Use Disorders

Fam. Proc., Vol. 55, September, 2016

Applications to Physical Health Problems

Fam. Proc., Vol. 55, September, 2016

SUMMARY AND CONCLUSIONS

Fam. Proc., Vol. 55, September, 2016

Fam. Proc., Vol. 55, September, 2016

Fam. Proc., Vol. 55, September, 2016

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