International Research Journal of Interdisciplinary & Multidisciplinary

Studies (IRJIMS)
A Peer-Reviewed Monthly Research Journal
ISSN: 2394-7969 (Online), ISSN: 2394-7950 (Print)
Volume-II, Issue-XI, December 2016, Page No. 155-161
Published by: Scholar Publications, Karimganj, Assam, India, 788711
Website: http://www.irjims.com

Cognitive Behavior Marital Therapy in Distressed Couple:

A Case Report
Divyani Sharma
RCI Licensed Clinical Psychologist, Jaipur, M. Phil Clinical Psychology
Mustafa Nadeem Kirmani
Licensed Clinical Psychologist, M. Phil (Clinical Psychology, NIMHANS, Bangalore), Ph. D
(Aligarh Muslim University, Aligarh)
Mehfooz Ahmed
Licensed Clinical Psychologist M. Phil (Clinical Psychology, NIMHANS, Bangalore), Ph. D
(Jamia Millia University, New Delhi)
Abstract
Quality and enriching heterosexual relationships are often associated with happiness and
well-being. In reality, however, most relationships are also associated with conflicts. The
quality of the relationship is also indicated by how the couples resolve their conflicts
effectively and meaningfully. Cognitive behavioral intervention attempts to use behavioral
and cognitive based techniques in the marital context to decrease marital distress. These
techniques are individualized in the proper context to help the couples resolve their issues.
The current paper presents a case of a couple wherein male was the primary patient with
mixed anxiety and depression and his wife with the past history of obsessive compulsive
disorder remitted during the therapy process. They also reported communication issues.
Detail description of the therapy process has been described in the current paper. In all,
twenty sessions were conducted on weekly basis or as per the clinical judgement and
requirement of the case. Following the completion of the interventions, they reported
significant improvement in their relationship and individual symptoms.
Key Words: Cognitive behaviour marital therapy, marital distress, obsessive compulsive
disorder, mixed anxiety and depression.
Introduction: Cognitive-behavior marital therapy is based on the principles of social
learning, social exchange and cognitive behavioral interventions. In the initial phase during
the 1960s, behavioral formulation was used to reduce marital distress (Baucom, Eipstein,
Rankin, & Burnett, 1996).

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 Social learning model posits that social behaviour is governed mostly by its
consequences being learned through modelling process. There are antecedent discriminative
stimuli signaling that particular reinforcement contingencies. The behavior marital
therapists attempt to understand how a particular couple extinguished certain maladaptive
behaviors which are causing marital distress and reinforce adaptive behaviors associated
with their positive functioning. Social exchange model of interpersonal relationships assert
that the quality of interpersonal functioning is a function of reward and cost the couples
incur in the process of their interaction. If the amount of efforts and cost spend is less that
the reward achieved in the relationship, it will strengthen the bond and if the amount of cost
spend is more than the reward achieved, it will weaken the mutual bond among couples.
The theory also contends that the exchange of goods between partners in a continuous
relationship is reciprocal. It means that the level of reinforcement and punishment provided
by one partner is influenced by the rewards and punishments of the other one. It is
important to remember that nature of efforts, costs and rewards differ from person to
person. Over time, this process of mutual interaction results in a relatively equitable
exchange of goods between the two partners. However, reciprocity does not necessarily
imply symmetry or equality. Balance in a marital partnership is when the exchange is
perceived as fair by both the partners. For instance, in a particular couple the wife perhaps
contribute more than the husband, but she established a sense of balance that she viewed as
gratifying. The therapist working with the couples need to make sure that the couple
function in a manner that both partners find gratifying and acceptable. Based on these
behavioral models, marital satisfaction is defined as the prevalence of positive interactions
between spouses. Initial behavioral interventions are aimed to replace negative interactions
with positive ones by increasing positive behaviors through positive communication skills
of partners, problem solving training to improve effective problem solving skills, and
contracting to increase the positive behavioral exchange.
Cognitive behavioral model believes that behaviour, cognition, and affect are
interrelated. It is, therefore, assumed that change in behaviour will automatically lead to
change in cognitions and vice versa. Baucom and Eipstein (1990) formulated marital
distress based on cognitive factors which cause and maintain marital dysfunction. These
include perception, attributions, expectancies, assumptions, and standards.
Perception is the cognitive process about what events occur. In marital relationships
there is a phenomenon called selective attention, in which partners selectively attend to and
notice, certain aspects of an interaction or an event. This tendency of selectively attending
either positive or negative aspects of the relationship while ignoring other important
behaviors can lead to distorted experiences of the partner, oneself, or the relationship occur.
One of the most complaints of partners is that their partner notices more negative behaviors
than the positive ones.
Attribution is the process of explaining the reasons of a particular set of behaviors. It has
been clinically observed that one of the most common causes of marital distress is negative
attribution by them. It often leads to negative inferences. One of the examples can be when
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a wife says “my husband did this because he wants to hurt me” when her husband makes
any mistake. This often causes cycle of blame among the couples.
Expectancies are the predictions that the couple often make about the future relationship
or individual behaviour related event. Expectancies often affect emotions and behaviors.
For example “I know my husband will never listen to me when I am upset, so why to talk to
him about this”. Such negative expectancies often leads to relationship distress.
Expectancies are integrally related to attributions because both are cognitive elements.
Assumptions that spouses hold about the characteristics of each other and intimate
relationships also contribute in marital functioning. Each person usually develops an image
of the partner (e.g. who he/she is, how he/she behaves, what he/she likes and dislikes).
Attributions are made on the basis of assumptions. Disruption of assumptions will affect
one’s attention, attributions, expectancies, emotional responses, and behavior toward the
partner.
Standards involve personal beliefs about the characteristics that an intimate relationship
and the members “should” have. Standards are different from assumptions in that
assumptions involve how things “actually” are. Standards are used to evaluate whether each
person’s behavior is acceptable and appropriate. Marital conflict and distress arise when
spouses are aware that their marital interactions do not match the ideal characteristics of
intimate relationships or their standards. Marital distress often happens when any one of the
partners have extreme standards set for their partners which may not meet in their current
relationship.
The current case uses various components of behavioral and cognitive interventions to
work with distress couple and improve their marital and individual well-being.
Case Summary:
Husband’ Name: S. K Age: 30 years
Education: Bachelor in nursing Place: Jaipur
Wife’s Name: A.S Age: 28 years
Education: M.A/B.Ed Place: Jaipur
Number of sessions: 20 sessions
Therapy conducted in the months of May and July 2013
Summary and MSE: Clients were hailing from Jaipur and belonging to a middle socio
economic status urban background. They were presented with the past history of OCD in
wife and present history of anxiety and depression in husband, nil significant family history
of any psychiatric illness. Personal history could not be elicited, however premorbidly wife
was having low frustration tolerance. They were presented with the following complaints
with insidious onset which started 1years ago and has increased over last 3-4 months. The
presenting complaints of the husband being
a) Anger
b) Irritability
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 c) Lack of interest in sex
d) Threat of adequate sexual performance
e) Feeling low
f) Repeated thoughts related to get separated.
g) Anger outburst on child
MSE revealed good eye to eye contact and irritable mood of both husband and wife. The
marital therapy was done in these contexts.
Having made the working alliance with the couple and their active role and the role of
the therapist in bringing positive therapeutic change was discussed in detail. Other issues
like confidentiality, fee structure, frequency of the session, place and duration were also
discussed.
Treatment goals: After interviewing with the clients (couple), the following goals were
decided. The goals were also prioritized in terms of both the clients’ needs. The goals of
treatment were as follows:
1. Managing Anger
2. Enhancing expressing skills
3. Decreasing general anxiety
4. Increasing communication
5. Decreasing sex anxiety
Strategies used and their rationale:
1) Cognitive restructuring: Cognitive restricting is the process in which cognitive
distortions or dysfunctional beliefs which are leading to the problems are corrected.
Through the case history it was found that they were having misbelieves about sex like
early semen release is a sign of weakness, erection should be always tight. these
dysfunctional beliefs related to sexual functioning were often the cause of fight and led
blaming each other. It was thought that the client would be making cognitive errors
hence subsequently it would cause his problems. Hence this treatment was utilized to
help the client become more realistic and rationale in his approach and to help him
correcting his cognitive errors.
2) Deep Breathing: It is a technique that teaches clients to breathe deeply using the
diaphragm, expanding the abdomen rather than the chest. Here the client is instructed to
place on abdomen while breathing slowly while having anxiety. The client is instructed
to breath so that the hands on abdomen raises up, minimizing any movement in the
upper chest. Deep breathing was chosen as one part of treatment modality as this
technique has been shown to release stress and tension, build energy and endurance,
help in pain management and also enhances mental concentration. Moreover, this
technique can be easily and unobtrusively used by clients whenever other stressful
situations emerge.

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3) Jacobson Progressive Muscular Relaxation (JPMR): JPMR was planned to decrease
the anger and anxious arousal of the husband and even wife.
Besides these, they were also trained in positive communication and problem solving
skills.
Summary of the sessions: The total of 20 sessions was conducted. The initial two sessions
focused on history taking and clarification. Actual therapy was conducted in the middle
sessions (3-17) and after completion of the middle session the termination of the therapy
was done in the session 17-20.
Initial sessions: The first two sessions focused on history taking and clarifications. The
sessions were held with the husband and wife, they were asked to write their problem areas
in which conflicts arise from most severe to least severe.
Middle Sessions: The short term and long term goals were decided. Therapeutic contract
was made. It was decided that the couple will be seen twice a week as per their convenience
and each session would usually be of one or one n half hour. They were told that it would
take 1 to 2 months to work on their issues. They were quite motivated. As planned in the
middle sessions, the therapeutic work was started. Both the clients were psychoeducated
about anger, depression and anxiety as these were their major problems and it was taken
first along with the approach toward the process of their marital issues. They were
psychoeducated about assertiveness that anger is a natural phenomenon but it should be
expressed in an assertive manner. They were also psychoeducated about how circumstances
lead to decrease their interest in sex. 6-8 sessions were focused on the beliefs related to sex
as they were asked to make a belief chart and were assigned to write about the beliefs. They
were told to make a 4 column diary about thoughts content, feeling, activity, success and
failure. And it was discussed in the sessions. In session 9-14, after exploring the problem
areas and about the situations in which conflict arises the couple was taught the problem
solving skills & express and share the emotions and feeling to each other in terms of
writing about what they like about each other and elaborate each point. They were also told
to write about what they physically like in each other and express either in session or at
home to make them feel emotionally and physically connected and to increase cohesiveness
towards each other. During these sessions, techniques of sensate focus was also done in
terms of observing their body parts initially except sensitive ones and were told not to do
intercourse initially which lead to increase the duration to hold the semen and to decrease
early ejaculation. They were told to do deep breathing whenever they feel anxious during
sex. They were also trained in JPMR to work on their excessive anxiety. During session 15-
17, they were assigned some home works in the form of metaphors like husband wife are
seen as garments for each other how? And they were told to think upon and to write about
these metaphors that what they understood. These assignments were discussed in more
detail in the therapy sessions.

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 Mutual goals and valued activities were focused till the end of the sessions to make their
life more meaningful. During the last sessions the bonding was improved between both the
husband and wife.
They learned problem solving skills and started using it when they face problems. They
continued to practice Deep breathing and JPMR in the sessions and at home. After 17
sessions, they reported overall 70% improvement in their marital life like decrement of their
anxiety, reduction in the subtle interpersonal conflicts, reduction of anger, enhancement of
marital bond.
Termination: In the last session, the review of all sessions and strategies were done. And
spouses were told to continue to be in touch with the therapist either through phone and
mails in case if it is required.
Clinical observations and therapist’s reflections:
 Initially the spouses were hesitant about their problem. Their eye to eye contact was
good. But over the course of sessions, their communication significantly improved
and looked less hesitant and more communicative.
 Rapport was developed easily. They were quite motivated and co-operative for the
sessions.
 Working with the spouses was motivating for the therapist herself as they were very
regular to the sessions.
 Their regularity in doing assignments was also highly motivating for the therapist.
 They seemed quite psychologically minded as they were able to understand the
psychological models easily and implantation was easy.
Prognosis:
Good prognostic factors:
1) Spouses’ high motivation to work on their problems.
2) Absence of any severe psychopathology.
3) Absence of any psychiatric illness in the family.
Bad prognosis factors: Specific bad prognostic factors could not be identified.
Conclusion: Cognitive behavioral marital interventions have been found to be efficious in
the current case. The 70% reported improvement by the couple in their marital functioning
and other symptoms indicate the effectiveness of cognitive behavior marital therapy in
distressed couples. There is also a strong need that couples in distress be trained about
recognizing the possible symptoms of their relapse and how to work on this. The current
case would have been improved by using pre, middle and post assessment using statistical
analysis following single case design. Statistical procedures like effect size make the results
more objective. Researchers and clinicians need to use relatively larger clinical samples
using various modes of psychological interventions for increasing generalization of the
results.
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Ethical considerations:
1. The anonymity of the case was maintained for the publication work.
2. The prior written permission was taken from the client for getting the work
published with the maintaining of his anonymity.
3. It was clearly shown to the client that the therapist has been trained for doing the
therapy.
4. The rationale and possible harm and limitations of the clinical work were discussed
before the therapy.
5. The role of the active involvement of the client and the therapist for therapeutic
success was discussed in detail before therapy work.
Acknowledgement: The authors acknowledge SMS Psychiatric center, Jaipur, the referring
psychiatrist and Amity University Rajasthan for providing the base for working with the
current clinical case.

References:
1. Baucom, D. H, & Eipstein, N. (1990). Cognitive behavioral marital therapy. New
York: Brunner/Mazel, Publishers.
2. Baucom, D.H., Eipstein, N. Rankin, L.A., & Burnett, C.K. (1996). Understanding
and treating marital distress from a cognitive behavioral orientation. In Dobson, K.S.
& Craig, K.D. (editors). Advances in cognitive behavioral therapy. Thousand Oaks:
Sage Publications.

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