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Cognitive-behavioral couple therapy
Norman B Epstein and Le Zheng
This article describes how cognitive-behavioral couple therapy
(CBCT) provides a good fit for intervening with a range of
stressors that couples experience from within and outside their
relationship. It takes an ecological perspective in which a
couple is influenced by multiple systemic levels. We provide an
overview of assessment and intervention strategies used to
modify negative behavioral interaction patterns, inappropriate
or distorted cognitions, and problems with the experience and
regulation of emotions. Next, we describe how CBCT can
assist couples in coping with stressors involving (a) a partner’s
psychological disorder (e.g. depression), (b) physical health
problems (e.g. cancer), (c) external stressors (e.g. financial
strain), and (d) severe relational problems (e.g. partner
aggression).
Address
University of Maryland, College Park, USA
Corresponding author: Epstein, Norman B (nbe@umd.edu)
Current Opinion in Psychology 2016, 13:142–147
This review comes from a themed issue on Relationships and stress
Edited by Gery C Karantzas, Marita P McCabe and Jeffry A
Simpson
http://dx.doi.org/10.1016/j.copsyc.2016.09.004
2352-250/# 2016 Elsevier Ltd. All rights reserved.
Couple relationships are among the most influential
resources for enriching people’s lives and buffering neg-
ative effects that life stressors have on psychological and
physical health. Social support from a partner can reduce
negative effects of a wide range of stressors such as serious
health problems and is associated with greater psycho-
logical well-being [1–3]. Ironically, relationships also can
be sources of severe stressors that take a toll on members’
well-being, with substantial evidence that relationship
distress is a risk factor for disorders such as depression
[4]. Furthermore, couples often are exposed to dyadic
stress, involving events that affect both partners [5,6].
Such stressors can have direct influences on a couple’s
functioning, as when a child’s severe illness upsets both
parents and reduces their opportunities to express caring
for each other. Effects of dyadic stressors also can be
indirect, initially affecting one member but then spilling
into the relationship by influencing how that individual
responds to his or her partner (e.g. irritability).
Current Opinion in Psychology 2017, 13:142–147
Cognitive factors also play an important role in how stress
affects a couple. Consistent with stress and coping theory
[7] and family stress theory (e.g. [8]), the degree to which
a stressor has negative effects depends on how negatively
an individual interprets its severity/danger and appraises
his or her ability to cope effectively with it. In couple
relationships, this process is more complex, with each
person appraising a stressor and own coping resources but
also judging the other’s appraisal and being influenced by
it [5,9]. These appraisals can result in productive joint
problem solving, or they may escalate negative thinking
and conflict between the partners. The dyadic processes
can reduce partners’ emotional distress or exacerbate it.
Finally, dyadic coping involves collaboration between
partners in identifying and carrying out strategies to
remove a stressor or reduce its negative effects. If a
stressor mainly affects one member, the other may pri-
marily play a supportive role, but if it affects the couple
jointly they need to engage in collaborative problem
solving [5,6]. Their coping behaviors may benefit both
members, but in some cases they benefit one person at
the other’s expense when partners have conflicting needs
and preferred coping styles [5]. Thus, a couple’s coping
with stressors involves two partners’ cognitions, emotion-
al responses, and behavioral interactions.
Cognitive-behavioral couple therapy (CBCT)
[10,11,12,13] provides a good fit for intervening with
couples experiencing a wide variety of stressors originat-
ing within or outside their relationship. It focuses on the
interplay among partners’ cognitions, emotional
responses and behavioral interactions. CBCT applies
cognitive therapy methods for addressing partners’ cogni-
tions and emotional responses, as well as behavioral
procedures for improving couple communication, prob-
lem-solving, and exchanges of pleasing rather than dis-
tressing actions. It is a systemic model in that it tracks
interaction cycles in which partners continuously influ-
ence each other. For example, partner B may fail to
respond to Partner A’s question; A interprets partner
B’s behavior as uncaring, becomes angry, and yells at
B; B perceives A’s behavior as unjustified and walks away;
A interprets B’s walking away as disrespectful, and so on.
Initially CBCT was designed to improve relationships by
reducing aversive behavioral interactions, increasing pleas-
ing behavior, reducing distorted or inappropriate cogni-
tions contributing to conflict and dissatisfaction, and
improving partners’ abilities to regulate negative emotions
such as anger [10]. Regarding behavior patterns, practi-
tioners apply knowledge from studies that identified de-
structive sequences such as one partner making demands
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and the other withdrawing, or both partners escalating
verbal or physical aggression (e.g. [14,15]). In addition,
CBCT has focused on developing couples’ skills for com-
munication (in expressive and empathic listening roles)
and problem solving. Studies (e.g. [16]) continue to dem-
onstrate its effectiveness in creating such positive behavior
changes as well as improved relationship satisfaction.
CBCT has focused on five types of cognitions involved in
relationship distress [12], including three that tend to
occur as ‘automatic thoughts’ in individuals’ stream-of-
consciousness thinking. Selective attention involves notic-
ing particular aspects of events in one’s relationship and
overlooking others. Attributions are inferences about fac-
tors that have influenced one’s own or a partner’s behavior
(e.g. that a partner’s failure to respond to a question was
due to his not caring). Expectancies are predictions about
the probability that particular events will occur (e.g. that
trying to engage one’s partner in a discussion will lead the
partner to withdraw). Two other forms of relational cog-
nitions involve relatively stable schemas or longstanding
constructs or beliefs that individuals have developed
during their lives. Assumptions are beliefs about natural
characteristics of people and relationships (e.g. an as-
sumption held by a man whose parents divorced when
he was a child that marriages are inherently unstable). In
contrast, standards involve beliefs about characteristics
that people and relationships ‘should’ have (e.g. that a
partner who cares should be able to sense your feelings
without your needing to express them directly).
Because members of couples commonly fail to evaluate
the validity of their cognitions about their partner and
relationship, the thoughts function as individuals’ views
of reality, influencing their emotional and behavioral
responses to each other [12]. CBCT clinicians monitor
couple interactions during sessions and guide partners in
identifying and evaluating their cognitions as they occur.
Once a distorted or extreme cognition has been identi-
fied, the therapist can coach the partners in using a variety
of cognitive therapy procedures to modify it. For exam-
ple, when an individual makes a negative attribution
about the cause of a partner’s behavior, the therapist
can coach the person in considering alternative reasons
for the partner’s actions.
CBCT also addresses emotions, both positive ones (e.g.
love, joy) associated with intimate bonds and negative
ones (e.g. anger, sadness, anxiety) that detract from
individual and relational well-being. Behavioral interven-
tions, such as increasing a couple’s shared pleasant activi-
ties and verbal expressions of caring, are used to enhance
positive emotions, whereas a variety of emotion regula-
tion strategies such as muscle relaxation training, positive
self-instruction for staying calm during conflicts, and
challenging of anxiety and anger-eliciting thoughts are
used to reduce negative affect.
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Cognitive-behavioral couple therapy Epstein and Zheng 143
Epstein and Baucom’s enhanced CBCT [12] takes an
ecological, contextual perspective in which a couple is
influenced by multiple systemic levels. These commonly
range from individual partners’ needs and traits to con-
flicts between partners, to interactions with immediate
and extended family members and friends, to job
demands, to more distal environmental stresses such as
community violence. The model includes a stress and
coping component, in which relationship quality depends
on partners’ abilities to cope with life demands from any
systemic levels that they experience (e.g. a partner’s
depression, job stresses). We now describe how CBCT
is used with variety of stressors.
CBCT for stressors involving a partner’s
psychological disorder
Many couples experience stressors associated with symp-
toms of a member’s psychological disorder, and increas-
ingly CBCT protocols have been developed to treat
disorders in a dyadic context. The following are examples
of such CBCT interventions.
There is substantial evidence of a bi-directional associa-
tion between depression and couple relationship distress
[4]. Relationship distress is a risk factor for development
of depression, and in turn depression is a stressor on a
relationship. Consequently, couple interventions were
designed to decrease negative behavioral interactions
and enhance partners’ mutual emotional support
[17,18]. Conjoint therapy also can provide psychoeduca-
tion for both partners regarding risk factors for depression
and regarding interventions that can reduce depression, as
well as behavioral interventions to improve relationship
quality. Outcome studies found that for individuals who
experienced both depression and relationship problems,
couple therapy reduced both, whereas individual cogni-
tive therapy did not improve the relationship distress
[19,20].
Individuals who experience post-traumatic stress disorder
(PTSD) due to events such as warfare and sexual assault
commonly exhibit chronic symptoms that are stressors for
themselves and their significant others. These symptoms
include behaviors (e.g. restricted communication, aggres-
sion, avoidance of situations that remind the individual of
the trauma), cognitions (e.g. self-blame for the traumatic
event, exaggerated expectancies of danger), and emotions
(e.g. anxiety, anger, emotional numbing, depression).
Monson and Fredman [21] developed a cognitive-behav-
ioral conjoint therapy for PTSD that addresses the dis-
order’s negative effects on couple relationships and
harnesses the dyadic bond as a resource for treating
symptoms. It uses interventions that address partners’
cognitions regarding the stressor of PTSD, including
psychoeducation that covers causes and symptoms of
PTSD, mutual influences between an individual’s symp-
toms and the couple’s behavioral patterns (including
Current Opinion in Psychology 2017, 13:142–147
144 Relationships and stress
avoidance), and current knowledge about effective treat-
ments. These interventions help increase partners’ expec-
tancies that they can overcome the problem. In addition,
behavioral interventions focus on improving the couple’s
resources of positive interactions, communication, and
problem-solving skills. Other interventions focus on emo-
tion regulation and reducing emotional numbing and
avoidance. Cognitive restructuring is used to reduce
beliefs (e.g. ‘Bad things happen to bad people.’) that
maintain PTSD symptoms and relationship distress. Ini-
tial studies demonstrated positive effects of the program
[22], and further research found that it led to improve-
ments in all PTSD symptom clusters, trauma-related
beliefs, and guilt cognitions, compared to a waitlist condi-
tion [23]. Shnaider et al. [24] also found that partners of
individuals with PTSD who themselves entered the cou-
ple therapy with clinical levels of psychological distress
experienced significant improvement in their symptoms at
a post-treatment assessment. Furthermore, Luedtke et al.
[25] examined the potential for integrating mindfulness
interventions into the standard cognitive-behavioral con-
joint therapy protocol. They conducted a case study of a
male combat veteran and his wife who were referred
regarding his PTSD and both partners’ relationship dis-
tress. The results showed improvements in PTSD symp-
toms and both partner’s relationship satisfaction.
The symptoms of obsessive-compulsive disorder (OCD)
commonly involve cognitions (e.g. recurrent intrusive
thoughts), emotions (e.g. anxiety), and behaviors (e.g.
compulsive rituals such as checking). These symptoms
not only interfere with the individual’s personal function-
ing; they also can be significant stressors in the person’s
close relationships. In turn, conflict between partners can
exacerbate the individual’s OCD symptoms. Conse-
quently, Abramowitz et al. [26] developed and evaluated
a couple-based approach to exposure and response pre-
vention procedures for OCD that emphasizes CBCT
principles. It includes psychoeducation for both partners
about OCD symptoms and how they are maintained (e.g.
through rituals that create a false sense of security),
partner-assisted exposure and response prevention
(ERP) exercises in which the couple confront feared
situations together, and coaching the couple to reduce
OCD-specific accommodation behaviors and build effec-
tive communication and problem-solving skills. The
treatment addresses partners’ cognitions and anxious
moods through psychoeducation and cognitive restructur-
ing of beliefs associated with obsessive thinking and
ritualistic behavior, as well as behaviors through part-
ner-assisted ERP. Abramowitz et al. [26] found that a
large reduction in OCD symptoms was achieved, and the
attenuation of symptoms was maintained at 6-month and
12-month follow-ups.
Substance abuse is another problem that creates persis-
tent stressors both for the individual and his or her close
Current Opinion in Psychology 2017, 13:142–147
relationships. The symptoms that contribute to stress
include cognitions (e.g. denial of substance use as a
problem), emotional responses (e.g. unregulated anger),
and behavior (e.g. aggressiveness, social withdrawal, fail-
ure to carry out family roles) [27]. Responses from a non-
using partner can unintentionally maintain or ‘enable’
substance use (e.g. when a partner tells the boss of a
spouse with a hangover that the spouse has the flu).
O’Farrell and colleagues [27,28] developed an empirically
supported program that integrates behavioral aspects of
CBCT and interventions focused on a partner’s substance
use. Its goals are to increase positive interactions, resolve
conflicts, and promote a desire for change. The proce-
dures include instructions from therapists regarding con-
structive couple interactions, with couple practice during
sessions. In addition, homework is assigned and reviewed
regularly, focused on increasing exchanges of pleasing or
caring behavior, increasing shared rewarding activities,
and improving partners’ communication and problem-
solving skills. The couple-based interventions are used
concurrently with strategies for the substance user to
promote recovery (e.g. standard abstinence treatment,
support groups, pharmacological treatment). The treat-
ment targets both partners’ cognitions about the disorder
(and patterns that maintain it) and increases their sense of
efficacy in reducing the problem through behavioral
changes. A meta-analysis by Powers et al. [29] of random-
ized controlled outcome studies for couples with a mem-
ber diagnosed with a substance use disorder indicated
that such couple therapy was more effective than indi-
vidual therapy in reducing both substance use and rela-
tionship distress. Further support for the couple approach
was found by Schumm et al. [30], who compared the
effects of behavioral couple therapy plus a 12-step ori-
ented individual therapy with those from only the indi-
vidual therapy, in a sample of alcohol-dependent women
and their male partners without a substance use disorder.
The combined treatment resulted in a significantly higher
percentage of abstinent days, fewer substance-related
problems, and improvements in both partners’ relation-
ship satisfaction, compared to individual treatment (with
both treatments significantly reducing intimate partner
violence).
CBCT for stressors involving a partner’s
physical health problems
Other stressors that couples face regarding characteristics
of an individual partner involve physical health problems.
As with psychological disorders, symptoms and treat-
ments for a disease or disability tax the individual and
couple’s coping resources. CBCT offers a variety of
helpful interventions that target the ways that partners
think about the stressors and the resources that they can
use to manage them. In a review of empirical literature,
Baucom et al. [31] noted that most couple-based treat-
ments for medical problems have tended to be CBCT-
based.
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For example, Baucom et al.’s [32] intervention for women
being treated for breast cancer and their male partners
uses CBCT procedures. The procedures include psy-
choeducation about psychological and physical effects
that cancer treatments commonly have on partners’ sex-
ual functioning, training in expressive and listening com-
munication skills that are applied to cancer-related topics
such as fear of mortality, and problem-solving skills for
making decisions regarding treatments. The program
fosters mutual emotional support and effective deci-
sion-making to reduce negative effects of the stresses
associated with cancer.
Reese et al. [33] conducted a randomized trial comparing
the effects of a telephone-based intimacy enhancement
intervention with those from a waitlist condition among
colorectal cancer patients and their partners. The
intervention included components from behavioral
couple therapy and cognitive-behavioral sex therapy
(sensate focus exercises; sexual communication train-
ing; identification and challenging of negative sexually
related cognitions; skills for solving problems regarding
a deficit in intimacy activities). The treatment group
produced improved sexual function for female
and male patients, but no improvement for sexual
distress, intimacy, or sexual communication, whereas
all measures revealed improvement among the patients’
partners.
Sher and colleagues [34,35] developed a couple-based
intervention emphasizing CBCT procedures (psychoe-
ducation, expressive and problem-solving communica-
tion skills training) for patients with cardiac disease. It
focuses on assisting partners in coping with stresses
associated with the diagnosis and engaging in risk-reduc-
ing health behaviors regarding exercise/activity level,
nutrition, and medication management. The treatment
harnesses resources of partners’ mutual emotional sup-
port and dyadic coping. Sher et al. [35] found that the
intervention was more effective than individual treat-
ment in improving exercise and activity level, although
both treatments had minimal effect on weight loss and
nutrition.
CBCT for external stressors
Couples need to cope with a variety of stressors within
their interpersonal and physical environments, some of
which are normative and relatively predictable and
others that are more unusual [12]. Partners’ appraisals
of a stressor, their expectancies regarding their ability
to deal with it effectively, and the resources that
they have available to cope with it determine the
amount of emotional distress they experience and
how well they work together. CBCT provides inter-
ventions for modifying unrealistic negative appraisals
and for improving and mobilizing couples’ behavioral
coping skills.
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Cognitive-behavioral couple therapy Epstein and Zheng 145
For example, couples commonly experience financial
strain, the subjective negative appraisal and associated
emotional distress associated with objective financial
conditions such as job loss or debt [36]. Financial strain
is stronger when partners believe that they do not have
sufficient financial resources to meet demands. Studies
have found that financial strain detracts from partners’
relationship satisfaction, especially when they communi-
cate negatively with each other about the problem (e.g.
expressing verbal hostility, engaging in a demand-with-
draw pattern) [36]. In addition, there is evidence that
cognitions such as catastrophic thinking about financial
disaster can contribute to financial strain and negative
communication between partners. Because money man-
agement, financial strain and couple relationship dynam-
ics often are intertwined, there is an emerging trend
toward professional services that integrate financial
counseling and couple therapy, including CBCT methods
[36,37].
CBCT for stressors involving severe relational
problems
Therapists traditionally avoided treating couples con-
jointly who reported any partner aggression, based on
the belief that this places a victim of violence at risk for
injury or death. However, research has differentiated
forms of partner aggression. Severe physical violence or
battering typically is perpetrated by one member of a
couple (most often a male) against the other member
(most often a female) for the purpose of control. In
contrast ‘common couple violence’ commonly is bilateral
and consists of psychological aggression and mild to
moderate physical aggression [38]. Empirical evidence
has accumulated that couples who engage in the milder
form of partner aggression can be treated safely and
effectively with conjoint couple therapy, and the most
commonly used therapy model for partner aggression is
CBCT. Empirically supported CBCT commonly
includes psychoeducation about forms of partner aggres-
sion and their negative effects on partners and their
relationship, anger management training, interventions
to modify cognitions that justify or elicit aggression (e.g. a
belief that aggression is an appropriate way to punish
one’s partner for unacceptable behavior), training in
expressive and listening communication skills, and train-
ing in problem-solving skills (Epstein et al. [38]).
Infidelity is another major stressor experienced by many
couples, which often elicits trauma symptoms in betrayed
individuals. Baucom, Snyder and Gordon’s predominantly
CBCT-based program [39] helps partners cope with the
trauma symptoms, understand the factors that led to a
betrayal, communicate in constructive ways about each
other’s thoughts and feelings, develop strategies for re-
ducing risk factors for further infidelity if they choose to
stay together, and make rational decisions about the future
of their relationship. Preliminary research by Baucom et al.
Current Opinion in Psychology 2017, 13:142–147
146 Relationships and stress
[40] indicated that the program improved relationship
satisfaction of betrayed partners but had mixed effects
on satisfaction of perpetrators.
Finally, CBCT increasingly has been used to treat sexual
dysfunctions, which are significant stressors in many
couples’ relationships. Most of the literature applying
CBCT to sexual dysfunction has involved promising
anecdotal reports of effects in clinical practice (e.g.
[41]), with limited empirical studies. Corsini-Munt
et al. [42] conducted a pilot study of CBCT for women
diagnosed with provoked vestibulodynia and their part-
ners. Among the eight of nine couples who completed the
treatment, there were significant improvements in the
women’s self-reported pain during intercourse, as well as
sexual function and satisfaction of both partners. Both
members of couples also reported improvements in pain-
related cognitions, as well as depression and anxiety
symptoms, and their therapists reported high couple
participation in therapy and client satisfaction with treat-
ment. Controlled clinical trials still are rare and are
needed. Boddi et al. [43] conducted a promising example
of such a clinical trial, comparing a combined vardenafil
orodispersible and cognitive-behavioral sex therapy with
the medication alone in treating a sample of men with
erectile dysfunction and their female partners. The sex
therapy included psychoeducation about the sexual dis-
order, the impact of anxiety, and sexual functioning;
training in communication and sexual skills; sensate focus
exercises; and reframing negative cognitions about sexual
function. The investigators found that both treatments
improved erectile function but that only the combined
treatment involving cognitive-behavioral interventions
improved both partners’ sexual satisfaction and females’
sexual function (desire, arousal, etc.).
Conclusions
Although CBCT is a couple-based theoretical model, the
interdependent nature of relationships allows it to have
great value for treating individual problems such as psy-
chological disorders, health problems, and sexual dys-
function, as well as dyadic problems such as
relationship conflict and external stressors such as finan-
cial problems. It can be integrated well with individually-
focused treatments. CBCT assists partners in attaining
realistic appraisals of stressors and their capabilities for
coping with them, communicating in constructive ways
rather than behaving aggressively or withdrawing, using
systematic problem solving to make use of their resources
(or to develop new resources) for implementing change,
and emphasizing dyadic coping that strengthens their
relationship. A hallmark of CBCT is its versatility in
addressing a range of intra-personal and interpersonal
stressors in people’s lives.
Conflict of interest statement
Nothing declared.
Current Opinion in Psychology 2017, 13:142–147
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Papers of particular interest, published within the period of review,
have been highlighted as:
 of special interest
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This review article describes the empirical base and principles for design-
ing and implementing couple-based interventions for various medical
problems that include psychoeducation about the disorder, skills for
communicating about the disorder, skills for making decisions about
treatment, strategies for changing relationship patterns to accommodate
effects of a disorder, and procedures for reducing general sources of
relationship stress that can affect the patient’s functioning.
32. Baucom DH, Porter LS, Kirby JS, Gremore TM, Wiesenthal N,
Aldridge W, Fredman SJ, Stanton SE, Scott JL, Halford WK,
Keefe FJ: A couple-based intervention for female breast
cancer. Psychooncology 2009, 8:276-283.
33. Reese JB, Porter LS, Regan KR, Keefe FJ, Azad NS, Diaz LA,
Herman JM, Haythornwaite JA: A randomized pilot trial of a
telephone-based couples intervention for physical intimacy
and sexual concerns in colorectal cancer. Psychooncology
2014, 23:1005-1013.
34. Sher TG, Baucom DH: Mending a broken heart: a couples
approach to cardiac risk reduction. Appl Prev Psychol 2001,
10:125-133.
35. Sher TG, Braun L, Domas A, Bellg A, Baucom DH, Houle TT: The
Partners for Life Program: a couples approach to cardiac risk
reduction. Fam Process 2014, 53:131-149.
36. Falconier MK, Epstein NB: Couples undergoing financial strain:
 what we know and we can do. Fam Relat 2011, 60:303-317.
This article reviews empirical findings about negative effects of financial
strain on couples’ relationships, effectiveness of individual and dyadic
coping strategies, and assessment and treatment guidelines that apply
stress theories and evidence-based cognitive-behavioral couple therapy.
37. Gale J, Goetz J, Bermudez M: Relational financial therapy. Fam
Ther Mag 2009, 8:25-29.
38. Epstein NB, Werlinich CA, LaTaillade JJ: Couple therapy for
 partner aggression. In Clinical Handbook of Couple Therapy, 5th
ed.. Edited by Gurman AS, Lebow JL, Snyder DK.New York, NY:
Guilford Press; 2015:389-411.
This book chapter reviews literature on forms of partner aggression and
their negative effects on individual and relationship well-being, and
describes empirically supported conjoint couple interventions, including
CBCT, for psychological aggression and mild to moderate physical
aggression.
39. Baucom DH, Snyder DK, Gordon K: Helping Couples Get Past the
Affair: A Clinician’s Guide. New York, NY: Guilford; 2009.
40. Baucom DH, Gordon KC, Snyder DK, Atkins DC, Christensen A:
Treating affair couples: clinical considerations and initial
findings. J Cogn Psychother 2006, 20:375-392.
41. Metz ME, McCarthy BW: Enduring Desire. New York, NY:
Routledge; 2011.
42. Corsini-Munt S, Bergeron S, Rosen NO, Mayrand M-H, Delisle I:
Feasibility and preliminary effectiveness of a novel cognitive-
behavioral couple therapy for provoked vestibulodynia: a pilot
study. J Sex Med 2014, 11:2515-2527.
43. Boddi V, Castellini G, Casale H, Rastrelli G, Boni L, Corona G,
 Maggi M: An integrated approach with vardenafil
orodispersible tablet and cognitive behavioral sex therapy for
treatment of erectile dysfunction: a randomized controlled
pilot study. Andrology 2015, 3:909-918.
In a randomized trial comparing a combined vardenafil orodispersible and
cognitive-behavioral sex therapy intervention with medication alone in
treatment of men with erectile dysfunction and their female partners, it
was found that both treatments improved erectile function but only the
combined treatment improved both partners’ sexual satisfaction and
females’ sexual function.
Current Opinion in Psychology 2017, 13:142–147