Behavioural couple therapy

1. Introduction

Version followed: (a) for the alcohol/drug application, O'Farrell & Fals-Stewart's Behavioral Couples Therapy (BCT) as set out in their clinician guideline for the Behavioral Health Recovery Management project and the chapter structure of their 2006 Guilford manual (the book text itself is not drawn on); (b) for traditional behavioural couple therapy (TBCT), Stuart's Caring Days (Stuart, 1980, via a university summary) plus the TBCT components of Jacobson & Margolin (1979) as reported in secondary sources. Stuart's 1969 paper and his 1980 book are not drawn on, so his full step sequence is reconstructed only partly [uncertain].

This entry covers two related behavioural couple approaches. Traditional behavioural couple therapy (social-learning marital therapy) treats relationship distress as a deficit of rewarding exchanges and of communication and problem-solving skills. Change is thought to come from deliberately increasing positive behaviour between partners (behaviour exchange, e.g. Stuart's Caring Days), then teaching communication and problem-solving skills, with written, negotiated agreements [source: Perissutti & Barraca 2013; Florida Tech on Stuart 1980; Garlie review of Jacobson & Margolin 1979]. Behavioral Couples Therapy for alcoholism and drug abuse (BCT; O'Farrell, Fals-Stewart, Harvard Families and Addiction Program / VA Boston, and Research Institute on Addictions, Buffalo) works with a married or cohabiting patient and partner. The couple first builds partner support for abstinence through a daily Recovery Contract. Once abstinence is stable, the work moves to the same TBCT-style relationship methods: more positive activities, better communication and better conflict resolution. The core idea is that relationship and substance use influence each other. A partner who rewards abstinence and a less stressful, more rewarding relationship lower relapse risk, and abstinence in turn makes relationship repair possible [source: O'Farrell & Fals-Stewart BHRM guideline].

2. Framework

BCT for alcohol and drugs [source: O'Farrell & Fals-Stewart BHRM guideline; Guilford 2006 contents]

Format: usually 12–20 weekly outpatient conjoint sessions over 3–6 months. BCT can be added to individual counselling or used as the only counselling. The 2006 manual includes a 12-session version (Appendix A [uncertain on its session-by-session content]).
Suitability: married couples, or couples cohabiting for at least a year, who live together or are reconciling. Neither partner has had psychosis in the past 90 days, and there is no high risk of injurious or lethal violence. BCT can start after detox or rehab, or with no prior treatment.
Contraindications: current psychosis in either partner; acute risk of severe violence; a restraining order that bars contact (do not see the couple together until it is lifted or modified); a partner with a current substance problem. That last rule has been relaxed: couples where both partners have an alcohol problem have been treated when both want to stop.
Phase 1, substance-focused (from the first session): the initial sessions cover assessment, commitment and starting BCT. The daily Recovery Contract begins, along with other abstinence supports (medication, meetings, screens). These continue throughout treatment.
Phase 2, relationship-focused: relationship work is added once abstinence, the contract and attendance have been stable for about a month. Its parts are positive activities (Catch Your Partner Doing Something Nice, Caring Day, Shared Rewarding Activities), then communication skills (listening, expressing feelings, communication sessions, then requests and negotiation).
Phase 3, maintenance: begins after roughly 3–6 consecutive months of abstinence. Before active treatment ends, the couple writes a Continuing Recovery Plan and a relapse prevention plan. Follow-up contacts (in person and by phone) are then spaced gradually, preferably for 3–5 years.
Session shape [synthesis from the guideline's components]: review the contract calendar and any urine screen result, and praise progress. Rehearse the trust discussion. Review relationship homework (logs, activity, communication session). Teach and practise one new skill. Assign homework.
Training and fidelity: the guideline does not name a certification or licensing scheme. It points clinicians to the manual, an O'Farrell (1993) chapter on the first session, O'Farrell & Murphy (2001) on violence, a 1994 training videotape and trainer contacts. No requirement for certification before delivering BCT was found [uncertain].

Traditional behavioural couple therapy [source: Forbes 2004; Garlie review of Jacobson & Margolin 1979; Perissutti & Barraca 2013]

Format: structured conjoint sessions. Trials of TBCT (Jacobson & Margolin manual) used 20–26 sessions, with protocol adherence supervised.
Sequence: one secondary pastoral-counselling summary gives eight steps. (1) Each spouse completes a pre-counselling inventory. (2) Agree a therapy contract. (3) Hold a first joint session explaining that more positive interaction drives change. (4) Caring Days. (5) Communication training. (6) Quid pro quo contracting. (7) Mutual decision-making strategies. (8) Maintenance, with follow-up at about four-month intervals. That summary does not cite Stuart. It matches the elements attributed to Stuart elsewhere, but whether it reproduces his exact sequence was not verified [uncertain].
Jacobson & Margolin (1979): begin with an interview and behavioural assessment. Their strategies are behaviour exchange, communication training, problem-solving training, contingency contracting, cognitive restructuring and paradoxical directives, and the book includes a couples' problem-solving manual. Only the component names were available. Their procedural detail is not given here [uncertain].
Moving between stages [synthesis]: move from behaviour exchange to skills training once both partners reliably carry out caring behaviours and the session climate allows a neutral topic to be discussed. Move to problem-solving on real conflicts once speaker/listener skills hold on neutral and then mildly charged topics. Space sessions out once the couple solves problems at home without you.

3. Guiding principles

[source: O'Farrell & Fals-Stewart BHRM guideline unless marked]

Abstinence first, relationship second. Do not open relationship conflict until abstinence and the contract are stable (about a month).
The partner supports; the partner does not police. The partner's job is to reward the patient's sobriety. Past drinking and future fears stay out of home conversation.
Daily, small, observable behaviours. Change is built from daily acts that are recorded (calendar, logs), not from insight or global promises.
Reinforce everything. At every session, review records and praise progress out loud. The therapist models acknowledgement.
Skills are taught, not just discussed. Use the cycle of model, practise in session, homework, then review. Start on neutral topics and add emotional load step by step.
Positive and specific. Requests are framed as specific things the partner wants, not complaints. Feelings are owned ("I" statements), not blamed.
Relapse is an expected event to manage, not failure. Set up a crisis call agreement in advance, intervene fast, and treat each lapse as information.
Safety governs format. Screen for violence. Exclude couples at risk of severe violence. Make conflict containment an explicit early goal where violence is less severe.
Long time horizon. Plan years of follow-up. Recovery plans are written before treatment ends.
Act first; feelings follow (TBCT). Caring behaviours are done whether or not the other partner reciprocates and whether or not they feel loving yet [source: Florida Tech on Stuart 1980; Forbes 2004].
Assessment-led, tailored modules (TBCT). Assessment shapes a plan built from standard modules [source: Forbes 2004; Garlie review].
Scientist-practitioner stance (TBCT). Measure the relationship before and during therapy and evaluate what you do. Treat partners' thoughts and feelings as legitimate data. The therapeutic relationship matters [source: Garlie review of Jacobson & Margolin 1979].
Ground rules and transparency (TBCT). Sessions are joint, there are no secrets kept from either spouse, and the contract is time-limited [source: Forbes 2004].

4. Intervention inventory

Part A covers BCT for alcohol and drugs (O'Farrell & Fals-Stewart) [source: BHRM guideline; Guilford 2006 contents, ch. 2–8]. Part B covers traditional behavioural couple therapy. All example language is illustrative and written for this guide; none of it is quoted from the manuals.

A1. Initial couple sessions: engagement, assessment, commitment

Purpose / when: before any contract. Engage both partners, check suitability, and get commitment to BCT.
Steps: (1) Engage the partner, often via the patient, and invite both to a joint session. (2) Assess substance use, relationship functioning, psychosis and violence. Interview each partner separately about violence and fear [synthesis: separate interviewing is standard practice; the guideline sets exclusion criteria but its screening method is not given in detail]. (3) Check the inclusion criteria and contraindications (Section 2). (4) Explain BCT's two aims: support for abstinence, then a better relationship. (5) Get agreement to weekly joint sessions and to the Recovery Contract. Set up the crisis-call agreement (A10). Details are in O'Farrell (1993) and manual ch. 2 [uncertain].
Example language (illustrative): "We'll work on two things together. First, making it easier for you to stay sober day by day, with your partner's support. Then, once that's steady, making home a better place to be for both of you."
Watch for: fear of the partner, a partner who comes only to blame, or undisclosed drug use by the partner. Working: both commit to weekly sessions and the contract.

A2. Daily Recovery Contract: the trust discussion

Purpose / when: the core of Phase 1, from the first sessions and through to the end. It replaces daily arguments and suspicion about drinking with a short, predictable ritual of support.
Steps: (1) Each day, at a fixed agreed time, the patient states the intention not to drink or use that day. (2) The partner expresses support for that effort. (3) If the patient takes recovery medication, the partner watches and thanks them (A3). (4) The partner marks the day on the calendar (A6). (5) Both agree not to discuss past drinking or fears about future drinking at home outside sessions. Those topics are kept for sessions. (6) The couple rehearses the trust discussion in every session while you watch and coach.
Example language (illustrative): Patient: "I intend to stay sober today, and I'll call you if I'm struggling." Partner: "Thank you. I know it's hard, and I'm with you on it." Therapist: "Let's practise it here. Look at each other, keep it to those two lines, and no add-ons about last month."
Watch for: partners adding warnings or sarcasm, missed days, or a ritual done in a flat, perfunctory way. Working: the calendar is filled in, home arguments about drinking drop, and the partner reports less checking and suspicion.

A3. Partner-observed recovery medication

Purpose / when: for patients prescribed disulfiram, naltrexone or similar medication. Its aim is adherence plus reassurance for the partner.
Steps: (1) The prescriber medically clears the patient and educates both partners about the medication. (2) The medication is taken daily during the trust discussion. (3) The partner observes and verbally thanks the patient. (4) Missed doses are recorded on the calendar and reviewed in session. Dosing is the prescriber's matter and is not covered here.
Example language (illustrative): "When you watch him take it, the point isn't checking up. It's a chance to say 'thanks for doing this'."
Watch for: missed doses (an early relapse sign), and the partner using the medication as leverage. Working: consistent recorded adherence.

A4. Self-help meetings in the contract

Purpose / when: for patients willing to attend twelve-step or other mutual-help meetings. Partners may go to Al-Anon. These are fellowships, not something the therapist runs.
Steps: (1) Agree which meetings will be attended and how often. (2) Write this into the contract. (3) Record attendance on the calendar. (4) Review it in session. (5) If a partner refuses meetings, do not force them into the contract.
Example language (illustrative): "Which meetings are realistic for you this week? Let's put them on the calendar so you both can see them."
Watch for: meetings turning into a battleground. Working: steady attendance that both partners feel helps.

A5. Urine drug screens

Purpose / when: for patients with a current drug problem. Screens give objective evidence that can rebuild trust.
Steps: (1) Agree weekly screens and include them in the contract. (2) Check and discuss the result at the session. (3) Praise negative screens. (4) If a screen is positive, explain that lingering drug effects are possible, then handle it as a possible lapse (A10).
Example language (illustrative): "This week's screen is clean. That's something concrete you can both point to."
Watch for: a positive screen fuelling suspicion, especially if the patient denies use. Refer the partner to Al-Anon for support. Working: a run of negative screens and the partner's trust ratings rising [synthesis].

A6. Recovery Contract calendar and in-session review

Purpose / when: every session. It makes contract behaviour visible and lets the therapist reinforce it.
Steps: (1) The partner marks each completed contract element on a calendar (trust discussion, medication, meetings, screens). (2) Start each session by reviewing the calendar. (3) Praise each completed day specifically. (4) Explore missed days and problem-solve logistics, such as times or shifts. Forms are in manual Appendix C (not drawn on).
Example language (illustrative): "Six out of seven days done. Tell me how you managed Thursday, when you were both working late."
Watch for: blank calendars or reports filled in just before the session. Working: a completed calendar and couples taking over the review themselves.

A7. Catch Your Partner Doing Something Nice

Purpose / when: first relationship task in Phase 2. It trains each partner to notice and acknowledge caring behaviour.
Steps: (1) Each partner writes down one caring thing the other did each day. (2) At the session, each reads their log aloud to the other. (3) The therapist models how to acknowledge, with eye contact and a warm, specific thanks. (4) Assign brief daily acknowledgement exchanges at home of about 2–5 minutes.
Example language (illustrative): "Read me one from your list, but say it to her, not to me. Then tell her how it felt." "I noticed you made coffee for me on Tuesday and I liked that."
Watch for: sarcastic or backhanded entries ("for once"), or blank logs. Working: entries get more specific and partners start acknowledging each other without being prompted.

A8. Caring Day (BCT version)

Purpose / when: after Catch Your Partner is under way. It shifts partners from waiting for the other to change to taking the initiative themselves.
Steps: (1) Each partner plans a day in the coming week to give the other special caring acts. (2) They do so without waiting for the other to go first. (3) Review it in session: what was done and how it was received.
Example language (illustrative): "Pick one day this week and surprise him with a few things you know he likes. Don't wait to see if he goes first."
Watch for: keeping score. Working: both carry it out and report feeling cared for.

A9. Shared Rewarding Activities

Purpose / when: Phase 2. Rebuilds pleasant time together and replaces drinking-linked leisure.
Steps: (1) Each partner separately lists activities the two could do together, at home or outside, alone as a couple or with family or friends. (2) In session, the therapist models planning an activity: date, time, cost, childcare, a fallback. This heads off common pitfalls. (3) The couple plans one activity for the week. (4) Problems are not discussed during the activity. (5) Review it next session.
Example language (illustrative): "Let's plan it in detail now: which evening, who books, what if it rains. And while you're out, no talking about problems. That's for here."
Watch for: activities near alcohol, plans that are too ambitious, or rows during the outing. Working: activities happen and are enjoyed, and the couple plans the next one themselves.

A10. Crisis intervention for lapse or relapse

Purpose / when: from the first session (agreement) and any time use occurs or seems imminent.
Steps: (1) At the start, agree that either partner will call the therapist if use happens or seems close. (2) On a call, see the couple as soon as possible. (3) Defuse hostile or hopeless reactions, and say plainly that uneven progress is normal. (4) Decide together what will restore stability: restarting medication, reinstating the contract, going to meetings together, or entering detox. (5) Identify the trigger and generate alternative coping responses. (6) Treat the episode as a learning experience.
Example language (illustrative): "Thank you both for calling. A slip doesn't wipe out the last two months. Let's work out what set it off and what gets you back on track this week."
Watch for: the partner's anger or despair, the patient's shame and withdrawal, and safety at home after a lapse [synthesis]. Working: the contract restarts within days and the trigger plan is used.

A11. Communication skills I: listening

Purpose / when: after positive activities are established. This is the first skill.
Steps: (1) Teach by modelling, in-session practice, homework and review. (2) The listener repeats the speaker's words and feelings and checks they understood correctly, before giving their own view. (3) Start with neutral topics.
Example language (illustrative): "Before you answer, tell her what you heard and what you think she feels, then ask 'did I get that right?'"
Watch for: rebuttals disguised as paraphrase. Working: speakers confirm they have been understood.

A12. Communication skills II: expressing feelings directly

Purpose / when: alongside or after listening.
Steps: (1) Teach "I" statements: say the feeling and what triggered it, and take responsibility for the feeling. (2) Rehearse in session. (3) Coach blaming "you" statements into "I" statements.
Example language (illustrative): "Try: 'I felt worried when you were late and didn't call', instead of 'you never think about me'."
Watch for: "I feel that you…" used as a disguised accusation. Working: fewer blaming statements at home and in session.

A13. Communication sessions

Purpose / when: to carry the skills over into home life.
Steps: (1) Schedule a planned, private, distraction-free talk with turn-taking using the listener and speaker skills. (2) Start with 2–5 minutes daily. (3) Build to 10–15 minutes, three or four times a week. (4) Raise topic difficulty week by week, from neutral to emotionally charged topics, only after the skills have been practised.
Example language (illustrative): "This week, ten minutes, Tuesday and Thursday after the kids are in bed, TV off. Pick something low-stakes, like weekend plans."
Watch for: sessions that escalate, which means the topic is too hard too soon. Working: sessions happen as planned and are rated calm.

A14. Positive specific requests and negotiation

Purpose / when: after communication skills are in place. Used for resolving conflicts, changes and problems (manual ch. 7).
Steps: (1) Each partner lists at least five positive, specific requests: what they want, stated as an action, not a complaint. (2) In session, they negotiate agreements in which each partner does one requested thing for the coming week. (3) Review whether it was kept. (4) Apply the same method to deeper conflicts. Ch. 7 also covers problem-solving, which is not given in detail [uncertain].
Example language (illustrative): "Turn 'stop ignoring me' into a request: what exactly would you like her to do, and when?"
Watch for: vague or negative requests, or one-sided bargains. Working: agreements are kept and the couple begins to negotiate unprompted.

A15. Continuing Recovery Plan

Purpose / when: written before active treatment ends (Phase 3).
Steps: (1) Review which parts helped. (2) Write down which behaviours continue and how often: the contract or trust discussion, meetings, shared activities, communication sessions. (3) Both partners keep a copy.
Example language (illustrative): "Which of these do you want to keep going after we stop meeting weekly, and how often?"
Watch for: dropping everything at once. Working: the plan is followed at the first follow-up contacts.

A16. Relapse prevention plan

Purpose / when: Phase 3.
Steps: (1) Identify high-risk situations and early warning signs. (2) Rehearse coping strategies. (3) Write a plan for how the couple will respond if a relapse happens, with the emphasis on stepping in early.
Example language (illustrative): "What would be the first sign, for either of you, that things are slipping? Who does what then?"
Watch for: plans that rely only on the patient. Working: both partners can name warning signs and first steps.

A17. Long-term follow-up

Purpose / when: after active treatment, preferably for 3–5 years.
Steps: (1) Plan in-person and phone contacts at gradually longer intervals. (2) The therapist schedules contacts, sends reminders and makes the agreed calls. (3) Use the contacts to review the plans and to catch early relapse.
Example language (illustrative): "I'll call in a month, then at three months, just to check how the plan is holding."
Watch for: couples going quiet, which may signal relapse [synthesis]. Working: contacts are kept and problems are raised early.

A18. Conflict containment where violence is less severe

Purpose / when: for couples with a history of less severe violence who are not excluded.
Steps: make conflict containment an explicit early goal and take specific safety steps. The procedure is described in O'Farrell & Murphy (2001) and manual ch. 10, neither opened [uncertain]. The following is [synthesis] from standard practice: a safety plan, agreed time-out rules, keeping charged topics for sessions, and checking each partner privately about violence at every session.
Watch for: any escalation. If it occurs, stop conjoint work and move to individual safety-focused care [synthesis].

Part B: traditional behavioural couple therapy (Stuart; Jacobson & Margolin). Procedural detail here is thinner than in Part A, because the primary books are not drawn on. Steps marked [synthesis] are general behavioural practice and are not attributed to Stuart or to Jacobson & Margolin.

B1. Behavioural assessment and pre-counselling inventory

Purpose / when: before treatment. It defines target behaviours, each partner's commitment, and the treatment plan.
Steps: (1) Hold a conjoint interview and individual interviews. (2) Use self-report questionnaires; a pre-counselling inventory completed by each spouse also gauges commitment to the marriage. A Couple's Pre-Counseling Inventory, revised 1987, exists; its link to Stuart is from a search listing only [uncertain]. Do not reproduce its items. (3) Use behavioural observation of a discussion where possible. (4) Have spouses self-monitor at home. (5) Build a tailored plan from standard modules [source: Forbes 2004; Garlie review of Jacobson & Margolin 1979].
Example language (illustrative): "Over the next week, each of you note the times your partner did something that pleased you, and the times something upset you. Just what happened, no commentary."
Watch for: very low commitment, violence, or one partner already decided on separation [synthesis]. Working: concrete, agreed targets.

B2. Therapy contract and ground rules

Purpose / when: at the start.
Steps: agree time-limited goals, joint sessions, a no-secrets rule, and that changes need mutual agreement [source: Forbes 2004].
Example language (illustrative): "I won't hold secrets for either of you. Anything you tell me alone, I may help you bring here."
Watch for: requests for individual alliances. Working: both sign up to the rules.

B3. Inducing positive expectancy (first joint session)

Purpose / when: first joint session.
Steps: explain that increasing positive interaction is what drives change, and set realistic hope [source: Forbes 2004, which lists inducing positive expectancies, structuring, instigation, teaching and emotional nurturing as therapist skills].
Example language (illustrative): "Distress grows when the good exchanges dry up. We'll start by putting some back, deliberately, before we tackle the hard topics."

B4. Caring Days (Stuart)

Purpose / when: early behaviour exchange, before skill training. Restores positive exchanges and shows each partner that change is possible.
Steps [source: Florida Tech summary of Stuart 1980; Forbes 2004]: (1) Each partner lists small, specific, positive behaviours that would make them feel cared for. Items should be doable daily and unrelated to a recent conflict. (2) Together the couple agrees a shared list; the summary gives 18 items. (3) For about two weeks, each partner does a set number of items daily from the list; the summary gives 5. They do this whether or not the other reciprocates. (4) Each charts the acts given and received. (5) Review the charts in session. Forbes gives a broader range of 4–20 daily caring behaviours [uncertain which figure is Stuart's own].
Example language (illustrative): "Write the small things, like a text at lunch or asking about the meeting, not 'be nicer'. Then do your five a day regardless of what the other does."
Watch for: items tied to the main conflict, or waiting for the other to start. Working: charts are kept and both report feeling cared for, even if it felt mechanical at first.

B5. Behaviour exchange (general)

Purpose / when: early TBCT. Raises the frequency of positive behaviour [source: Perissutti & Barraca 2013; Garlie review].
Steps [synthesis beyond the component name]: (1) Each partner identifies behaviours of their own that would please the other. (2) Each commits to increasing a few of them. (3) Monitor and review the results.
Watch for: early gains that delay work on core issues, a known limitation [source: Perissutti & Barraca 2013].

B6. Quid pro quo contracting

Purpose / when: after Caring Days. Used to trade desired changes.
Steps: negotiate a written trade in which one partner's specific positive behaviour is matched by an equivalent behaviour from the other [source: Forbes 2004].
Example language (illustrative): "So: you'll handle the school run Tuesdays and Thursdays, and you'll take Saturday mornings with the kids. Shall we write that down?"
Watch for: stalemate if one partner defaults ("you didn't, so I won't"). Working: both sides are kept.

B7. Good-faith contracting

Purpose / when: an alternative where tit-for-tat stalls.
Steps: each spouse commits to specific actions independently of the other's behaviour [source: Forbes 2004].
Watch for: one partner carrying the load. Working: commitments are kept despite lapses by the other.

B8. Communication training

Purpose / when: after behaviour exchange, or alongside it.
Steps: teach (1) "I" messages, (2) staying with present problems, (3) describing behaviour rather than labelling the person, and (4) positive feedback. Use instruction, modelling, rehearsal and feedback in session, then homework [source: Forbes 2004; Garlie review].
Example language (illustrative): "Instead of 'you're selfish', say what he did: 'you booked the trip without asking me'."
Watch for: reverting to blame under stress. Working: in-session discussions stay descriptive.

B9. Problem-solving training

Purpose / when: after communication skills.
Steps: (1) Specify the problem in behavioural terms. (2) Negotiate a resolution. (3) Contract the agreed way of carrying it out [source: Forbes 2004]. Jacobson & Margolin include a couples' problem-solving manual [uncertain on its specific rules]. [synthesis]: tackle one problem at a time, start with a positive, and keep problem definition separate from solution generation.
Example language (illustrative): "Define it as one specific situation first. We won't talk solutions until you both agree on the definition."
Watch for: sidetracking into history. Working: written agreements that get implemented.

B10. Mutual decision-making

Purpose / when: late in therapy [source: Forbes 2004].
Steps: teach the couple to agree who decides what and how joint decisions are reached. The detail is not in the sources [uncertain].

B11. Interrupting rule violations and training self-regulation

Purpose / when: throughout, whenever partners break agreed rules (blame, interruptions).
Steps: (1) Interrupt the violation. (2) Discuss why you interrupted. (3) Train the couple to catch it themselves [source: Forbes 2004].
Example language (illustrative): "Let me stop you there. That was a label, not a description. Can you say it again as what she did?"

B12. Cognitive restructuring and paradoxical directives

Listed among Jacobson & Margolin's (1979) strategies, but their procedures are not given [uncertain]. Do not use them under the TBCT name without consulting the book.

B13. Maintenance and termination

Steps: (1) Gradually lengthen the gaps between sessions. (2) Give a written and a spoken evaluation of gains and remaining goals. (3) End on the timeline agreed at the start. (4) Hold follow-up contacts, about every four months [source: Forbes 2004].
Working: gains hold over the spaced sessions.

5. Handling problems

From the sources [source: O'Farrell & Fals-Stewart BHRM guideline; Guilford 2006 contents ch. 9–10]

Logistical problems, anger or distrust disrupt the contract: work through them with the couple in session. Reschedule the trust discussion to a time that actually works, and shorten it if needed. Explore the anger that is blocking it.
Positive urine screen and rising suspicion: explain that lingering drug effects are possible. Treat the result as a possible lapse and use crisis steps (A10). Refer the non-using partner to Al-Anon for their own support.
Refusal of self-help meetings: do not force meetings into the contract. Keep the rest of the contract going.
Relapse: use the pre-agreed crisis call, see the couple quickly, defuse blame and despair, normalise uneven progress, choose stabilising steps, identify the trigger and plan coping. Frame it as learning.
Deep, entrenched conflict: move from complaints to positive specific requests and weekly negotiated agreements (A14). Keep the gradient from neutral to charged topics.
Violence: exclude couples at high risk of injurious or lethal violence, and do not see couples together while a no-contact order is in force. With less severe violence, make conflict containment an explicit early goal and take specific safety steps (manual ch. 10; O'Farrell & Murphy 2001 [uncertain on exact steps]).
Dual-problem couples (both partners use): historically excluded unless one partner had 90 days of abstinence. BCT is now used if both partners want to stop, or decide to early in treatment. A Recovery Contract can then cover both partners [synthesis on the both-partner contract].
Separated couples: manual ch. 9 addresses them [uncertain]. [synthesis]: if the couple is reconciling, run the trust discussion by phone at a fixed time, and do not push moving back in as a treatment goal.
Psychosis: not suitable while either partner is psychotic. Refer and treat first, and reconsider once there has been no psychosis for 90 days.
TBCT early gains masking core issues: behaviour-exchange gains may come quickly yet delay work on long-standing problems. Move on to communication and problem-solving training rather than resting on early improvement [source: Perissutti & Barraca 2013].
TBCT rule violations in session: interrupt, explain why and train self-regulation (B11) [source: Forbes 2004].

Therapist's own synthesis (not in the sources) [synthesis]

The partner turns into a monitor or prosecutor (checking breath, searching, adding lectures to the trust discussion): name the cost ("checking keeps you both on edge"), restate the partner's role as supporter, and give suspicions a fixed slot in session instead of at home. Offer Al-Anon or individual support for the partner's fear.
The patient feels infantilised by observed medication or the calendar: reframe the contract as a gift of reassurance the patient gives the partner, which earns back trust. Let the patient fill in their own part of the calendar too, and set a review date for scaling the contract down.
Homework non-adherence (logs, activities, communication sessions): never skip the review. Ask what got in the way, shrink the task (one log entry, a 2-minute talk), schedule it to a specific day and time in session, and praise partial completion. If non-adherence persists, look at ambivalence about the relationship.
Stuck in blame, "catch your partner" lists empty or sarcastic: go back to the guided version in session. Have each partner find one thing from the past week while you prompt, and model the acknowledgement. Check for depression in either partner.
Overwhelm or escalation in session: stop the exchange. Switch to the therapist talking to each partner in turn, lower the topic difficulty, and use an agreed time-out. Resume skills practice on a neutral topic before the session ends. Check safety before the couple leaves.
Rupture with the therapist, usually one partner feeling you have sided with the other: name it, ask for that partner's view, balance airtime and praise, and restate that you are working for the relationship and for recovery, not for one side. Use brief separate check-ins if needed, within the no-secrets rule agreed at the start.
Secrets disclosed individually (an affair, hidden use, fear): apply the rule agreed at intake. Help the person decide how to bring it to the joint session, or, where fear of violence is involved, put safety first and continue individually rather than conjointly.
Suicide risk in either partner after a relapse or crisis: assess risk with standard practice, plan for safety, and agree with the partner on lethal-means safety (storage and removal). Consider whether conjoint sessions should pause.
Partner wants to end the relationship: do not use BCT to hold the couple together. Shift to discernment or separation-focused work, and keep the patient's individual recovery supports in place.
Children affected by conflict or drinking: the manual's enhancements chapter (ch. 11) may cover parenting add-ons [uncertain]. Meanwhile, include child-focused shared activities and refer for family or child services as needed.

Sources

Sources: