Chapter 8: Cognitive-Behavioral and

slide1. Chapter 8: Cognitive-Behavioral and Mindfulness-Based Couple and Family Therapies “The key thread that binds these diverse perspectives [behavioral therapies] is a demand for continual empirical challenge. Every strategy, and every case, is subjected to empirical scrutiny that aims to define the specific therapeutic ingredients that facilitate the achievement of the specific benefits desired by the family. In other words, every family presents a new experiment with the potential to advance therapeutic frontiers.”—Falloon, 1991, p. 65 1<br>
slide2. Lay of the Land Prominent CBFT Approaches
Behavioral family therapy
Cognitive-behavioral family therapy
Integrative behavioral couples therapy
Gottman method couples therapy
Functional family therapy<br>
slide3. Behavioral and Cognitive-Behavioral Family Therapies<br>
slide4. In a Nutshell: The Least You Need to Know Cognitive-Behavioral Therapies (CBTs):
Roots in behaviorism; the premises of which are still widely used with phobias, anxiety, and parenting
Family CBTs (CBFT) integrate systemic concepts into standard cognitive-behavioral techniques
Examining how family members reinforce one another’s behaviors to maintain symptoms and relational patterns
Therapists assume directive, “teaching” relationship with clients<br>
slide5. The Juice: Significant Contributions to the Field<br>
slide6. Parent Training Key Principles
Reinforcement: positive or negative responses from environment shape future behavior
Consistency: reinforcing every time, is the key, especially in the beginning
Parent Training
Teaching compliance and socialization
Improving parental requests
Monitoring and tracking
Creating a contingent environment
Five-minute work chore<br>
slide7. Rumor Has It: The People and Their Stories<br>
slide8. Significant Contributors Gerald Patterson and Marion Forgatch
Neil Jacobson and Andrew Christensen
Norman Epstein
John Gottman
Frank Dattilio<br>
slide9. The Big Picture: Overview of Treatment<br>
slide10. Process for CBFTs 4 Steps To The Process
Assessment
Target behaviors and thoughts for change
Educate
Replace and retrain<br>
slide11. Making Connection: The Therapeutic Relationship<br>
slide12. The Therapeutic Relationship Directive Educator And Expert
Expert who directs and educates on how to better manage problems
Empathy in CBT
Used to create rapport
Contemporary Cognitive-behavioral Alliance
5 practices
Written Contracts
Spell out goals and expectations to help structure the relationship and to increase clients’ motivation<br>
slide13. The Viewing: Case Conceptualization and Assessment<br>
slide14. Defining Problems Defining Problems
Assessment of baseline functioning
Functional analysis and mutually reinforcing behaviors
A-B-C theory
Family schemas and core beliefs
Couple cognition types<br>
slide15. Targeting Change: Goal Setting<br>
slide16. General Goals Behavioral and Measurable
Agreeable
Use authoritative role to identify goals that are agreeable to all
Commitment
Obtain explicit commitment from couple or family to complete out-of-therapy assignments, often with a written contract<br>
slide17. The Doing: Interventions<br>
slide18. Classical Conditioning The procedure is technically described as conditioned and unconditioned stimuli and responses
The Natural State of Affairs:
The natural process
Food (unconditioned stimulus; UCS) Salivation (unconditioned response; UCR)
Process of pairing conditional stimulus with response
Food (UCS) + Bell (conditioned stimulus; CS)  Salivation (conditioned response: CR)
Resulting pairing
Bell (conditioned stimulus; CS)  Salivation (conditioned response: CR)<br>
slide19. Operant Conditioning Shaping: Reward Successive Small Steps
Rewarding behavior in the direction of the desired behavior using small, incremental steps, shaping behavior
Once a set of skills has been mastered, the bar is raised for which behavior will be reinforced<br>
slide20. Forms of Reinforcement and Punishment Positive reinforcement or reward
Rewards desired behaviors by adding something desirable (e.g., a treat)
Negative reinforcement
Rewards desired behaviors by removing something undesirable (e.g., relaxing curfew)
Positive punishment
Reduces undesirable behavior by adding something undesirable (e.g., assigning extra chores)
Negative punishment
Reduces undesirable behavior by removing something desirable (e.g., grounding)<br>
slide21. Frequency of Reinforcement and Punishment Immediacy
The more immediate the reinforcement or punishment, the quicker the learning
Consistency
The more consistent the reinforcement or punishment, the quicker the learning
Intermittent Reinforcement
Random positive reinforcement of well-established desired behaviors helps sustain them<br>
slide22. Encouragement and Compliments Stay Positive
Encourage positive reinforcement to increase desired behavior with children
Increase compliments and expressions of appreciation to increase positive reinforcement<br>
slide23. Contingency Contracting Contingencies
Promote new behaviors by creating a contingency that must be met to receive a desired reward
Privileges
Parents can use contingency contracting with children that detail how privileges will be earned and lost
Example
If child’s GPA is above 3.0, the parents agree to an 11:00 p.m. curfew on Friday and Saturday<br>
slide24. Point Charts and Token Economies Point Charts/Token Economies
Used to shape and reward positive behaviors by allowing children to build up points or tokens
Rewards should be appropriate and readily approved by the parent
In most cases, punishment is added by the child losing points/tokens for poor behavior<br>
slide25. Behavior Exchange and Quid Pro Quo Mutual Behavior Exchanges
Help partners negotiate relational rules
“If you make dinner, I will do the dishes”
Used Judiciously with Couples
Balance with more affective techniques to to avoid framing marriage as a business deal
Giving vs. Receiving
Have each partner select a behavior to “give” rather than have each “ask” for what he/she wants<br>
slide26. Communication and Problem-Solving Communication Training
Begin with the positive
Single subject
Specific, behavioral problems
Describe impact
Take responsibility
Paraphrase
Avoid mind-reading
Disallow verbal abuse<br>
slide27. Psychoeducation In-Session Education
Teaching clients psychological and relational principles about their problems and how best to handle them
Categories
Problem-oriented
Change-oriented
Bibliotherapy
Cinema therapy<br>
slide28. Challenging Irrational Beliefs Direct Confrontation
Client is explicitly told that the belief is irrational
Indirect Confrontation
Therapist uses series of questions to help client see how the belief is irrational and/or contributing to the problem<br>
slide29. Socratic Method and Guided Discovery Guided Discovery
Uses inductive reasoning
Gently encourages clients to question own beliefs
Open-ended questions that help clients to “discover” that their beliefs are illogical/dysfunctional
Therapist is neutral, allowing client’s own logic, evidence, and reason to do the convincing<br>
slide30. Thought Records Structured Journal
Clients analyze their own cognitions and behaviors on paper
Thought records generally include the following information:
Trigger situation
“Automatic” or negative thoughts
Emotional response
Evidence for
Evidence against
Cognitive distortions
Alternative thought<br>
slide31. Homework Tasks Homework
Tasks are designed to solve the client’s problem
Clients expected to do tasks
Example: To reduce couple’s conflict, therapists may assign communication tasks
In CBFT, the tasks are logical solutions to reported problems<br>
slide32. Mindfulness-Based Therapies<br>
slide33. In a Nutshell: The Least You Need to Know Mindfulness
Intentional focus on present moment experience without judgement
Acceptance
Involves accepting difficult thoughts and emotions in order to transform them
Compassion
Encourage clients to curiously and compassionately observe difficult thoughts and feelings without the intention to change them
Shift Relationship to Problem
By changing how clients relate to problems, they experience new thoughts, emotions, and behaviors in relation to the problem
Buddhism and Constructivism
Practices rooted in Buddhist psychology, essentially a constructivist philosophy<br>
slide34. A Brief History of Mindfulness in Mental Health<br>
slide35. Mindfulness Origins Buddhism
Associated with Buddhist forms of meditation
Most world religions have some form of mindfulness (e.g. centering prayer for Christian/Catholic)
Mindfulness-Based Therapies
Mindfulness Based Stress Reduction (MBSR): Original 8-week group curriculum that teaches mindful breathing, yoga postures, and mindful daily activities
Many similar programs for specific populations: depression, eating disorders, substance, couples, etc.
Mindfulness-Informed Approaches
Dialectic Behavioral Therapy
Acceptance And Commitment Therapy
Use Concepts<br>
slide36. Mindfulness Basics<br>
slide37. The Basics Mindfulness
Observe Present Moment Experience
Involves observing a single focus (the breath, sensation, etc.) in the present moment while quieting the mind’s inner chatter
Compassionately Welcome All Experience
When thoughts or sensations arise, avoid judging as good or bad, preferred or not preferred
Avoid judging self when mind wanders
Observer Position
Develops ability to experience mind in action from the position of an observe
Allows for greater conscious choice, reduces emotional reactivity<br>
slide38. Specific Mindfulness Approaches<br>
slide39. Mindfulness-Based Stress Reduction 8 Sessions in MBSR
Session 1: Introduction to Mindfulness
Session 2: Patience
Session 3: Non-Striving
Session 4: Non-Judging
Session 5: Acknowledgment
Session 6: Let it Be
Session 7: Everyday Mindfulness
Session 8: Practice Never Ends<br>
slide40. Mindfulness-Based Cognitive Therapy 8 Sessions of MBCT
Session 1: Automatic Pilot
Session 2: Dealing with Barriers
Session 3: Mindfulness of the Breath
Session 4: Staying Present
Session 5: Allowing and Letting Be
Session 6: Thoughts are Not Facts
Session 7: How Can I Best Take Care of Myself?
Session 8: Using What has been Learned to Deal with Future Moods?<br>
slide41. Dialectical Behavior Therapy Mindfulness
Used to Help clients be present with, tolerate, and accept strong emotions in order to transform them
Client’s attempts to avoid painful emotions are root of the problem
Dialectics
Manage dialectic tension, the tension between two polar opposites
Helps clients increase balance in their lives by managing inherent dialectical tensions<br>
slide42. Acceptance and Commitment Therapy ACT (Pronounced “Act”)
Construct realities through language, which shapes our thoughts, feelings, and behaviors
Attempts to control thoughts/feelings and avoid direct experience
Advocate experiencing to promote acceptance of full range of human emotions
Basic Process
A= Accept and embrace difficult thoughts and feelings
C=Choose and commit to a life direction that reflects who the client truly is
T=Take action steps towards this life direction<br>
slide43. Mindfulness in Couple and Family Therapy Couples
Cultivating mindfulness may be particularly helpful for couples
Predicted greater marital satisfaction, lower emotional stress after conflict, and better communication
Mindfulness-Based Relationship Enhancement: Group for non-distressed couples
Families
Several mindfulness-based parenting programs have been developed and researched
Mindful parenting
Mindfulness-based parenting training
Mindfulness-based childbirth and parenting<br>
slide44. Compassion Meditation Compassion Meditation
Closely related to mindfulness
Involves sending well wishes to various people
Preferred meditation when working with couples and families
Basic Format
“May [Person X] be happy, health, and at peace.”
Person X =
Neutral other (acquaintance)
Intimate other
Enemy or difficult relationship
Self
Everyone<br>
slide45. Gottman Method Couples Therapy Approach<br>
slide46. In a Nutshell: The Least You Need to Know Gottman’s Model
Developed from observational and longitudinal research on communication differences between couples who stayed together and ones who divorced
The therapist coaches couples to develop interaction patterns that distinguish successful marriages
Grounded entirely in research results rather than theory; not evidence-based but evidence-informed<br>
slide47. Debunking Marital Myths<br>
slide48. Myth 1: Communication Training Helps Communication Training Helps Couples Stay Together : FALSE
All married couples engage in defensiveness, criticism, and stonewalling
Contempt, is seen mostly in marriages heading for divorce
Couples who stay together maintain a ratio of 5:1 positive-to-negative interactions during conflict
20:1 during non-conflict conversations
Improving communication not as important as increasing the ratio of positive to negative interactions<br>
slide49. Myth 2: Anger Is a Dangerous Emotion Anger is Bad: FALSE
Expressing anger does not predict divorce
Contempt (feeling superior to one’s partner) and defensiveness do
Anger associated with lower marital satisfaction in the short term, increased marital satisfaction long term<br>
slide50. Myth 3: Quid Pro Quo Error This for That: NOT ALL THAT
Quid pro quo actually characterizes unhappy marriages
Contingency contracting is not appropriate when treating couples<br>
slide51. The Big Picture: Overview of Treatment<br>
slide52. The Process Assessment
Highly detailed system with numerous written and oral assessment tools
Intervention
Extensive psychoeducation about what works and what does not
Should include:
A positive affect experience
Primarily dyadic experience
Emotional learning
Easy
Non-idealistic<br>
slide53. Making Connection: The Therapeutic Relationship<br>
slide54. Therapist as Coach Relationship Coach
Empowers couples to take ownership of their relationship
Therapist does not soothe but coaches couple to soothe themselves and each other<br>
slide55. The Viewing: Case Conceptualization and Assessment<br>
slide56. Case Conceptualization and Assessment Assessing divorce potential
The four horsemen of the apocalypse
5:1 ratio
Negative affect reciprocity
Repair attempts
Accepting influence
Harsh startup
Distance and isolation cascade
Typologies of happy marriages
The sound relationship house<br>
slide57. The Four Horsemen of the Apocalypse Criticism
A statement that implies something is globally wrong with the partner
Defensiveness
Used to ward off attack
Contempt
Seeing oneself as superior to one’s partner
Single best predictor of divorce
Stonewalling
Listener withdraws from interaction physically or mentally<br>
slide58. The Doing: Interventions<br>
slide59. Session Format Intervention Phase
Catchup
Pre-intervention marital interaction
Give an intervention
The spouses make the interventions their own
Got resistance?
No resistance?
Homework<br>
slide60. Signature Interventions Love maps
Soften startup
Dreams within conflict
Negotiating marital power<br>
slide61. Research and Evidence Base<br>
slide62. Research and the Evidence Base CBFT therapies are some of the best-researched approaches in family therapy
CBFT theorists have modified approach based on research outcomes to incorporate more affective and relational components
Neil Jacobson reformulated his couples therapy to include more affective aspects; integrative behavioral couples therapy
CBT critiqued on basis that it’s claims to superiority rest on the volume of research rather than any substantive advantage<br>
slide63. Tapestry Weaving: Working with Diverse Populations<br>
slide64. Ethnic, Racial, and Cultural Diversity Carefully apply this approach with diverse populations to avoid conflicts in values and relational styles
Men and certain culture groups, such as Latinos, Asians, and Native Americans, often prefer active, directive therapy
Hierarchical difference may cause a rebellious reaction or an overly compliant and withholding response
CBT’s help clients conform to dominant cultural values<br>
slide65. Ethnic, Racial, and Cultural Diversity (cont.) Works with the following specific populations:
Hispanic and Latinos
African-Americans
Chinese Americans
Sexual identity diversity<br>
slide66. In Conclusion Cognitive Behavioral Family Therapy
Examines how family members reinforce each other’s behaviors, symptoms and relational patters
Main focus on Parental Training
Therapist takes a directive/expert role
Mindfulness-Based Therapies
Change the way client’s relate or view their problem; push toward acceptance
Gottman Method Couples Therapy Approach
Goal is to increase ratio of positive interaction to negative interaction in relationship; 5:1
The therapist takes a directive/coach role<br>
slide67. Online Resources Frank Dattilio: www.dattilio.com
Gottman Method Couples Therapy: www.gottman.com
Juvenile Justice Bulletin (Functional Family Therapy): www.ncjrs.org/pdffiles1/ojjdp/184743.pdf
Mindfulness Awareness Research Center (UCLA): www.marc.ucla.edu
Mindfulness Based Stress Reduction Clinic (Jon Kabat-Zinn): www.umassmed.edu/cfm/mbsr/
Oregon Social Learning Center (Patterson and Forgatch Parenting Program): www.oslc.org
Substance Abuse and Mental Health Services Administration Registry of Evidenced- Based Practices: www.nrepp.samhsa.gov<br>