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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
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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
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Behavioral and Cognitive-Behavioral Family Therapies
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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
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The Juice: Significant Contributions to the Field
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Parent Training Key Principles Parent Training
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
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Rumor Has It: The People and Their Stories
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Significant Contributors
Gerald Patterson and Marion Forgatch Neil Jacobson and Andrew Christensen Norman Epstein John Gottman Frank Dattilio
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The Big Picture: Overview of Treatment
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Process for CBFTs 4 Steps To The Process Assessment
Target behaviors and thoughts for change Educate Replace and retrain
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Making Connection: The Therapeutic Relationship
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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
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The Viewing: Case Conceptualization and Assessment
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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
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Targeting Change: Goal Setting
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General Goals Behavioral and Measurable Agreeable Commitment
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
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The Doing: Interventions
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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)
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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
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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)
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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
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Encouragement and Compliments
Stay Positive Encourage positive reinforcement to increase desired behavior with children Increase compliments and expressions of appreciation to increase positive reinforcement
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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
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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
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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
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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
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Psychoeducation In-Session Education Categories
Teaching clients psychological and relational principles about their problems and how best to handle them Categories Problem-oriented Change-oriented Bibliotherapy Cinema therapy
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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
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Socratic Method and 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
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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
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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
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Mindfulness-Based Therapies
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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
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A Brief History of Mindfulness in Mental Health
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Mindfulness Origins Buddhism Mindfulness-Based Therapies
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
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Mindfulness Basics
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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
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Specific Mindfulness Approaches
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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
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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?
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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
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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
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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
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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
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Gottman Method Couples Therapy Approach
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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
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Debunking Marital Myths
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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
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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
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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
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The Big Picture: Overview of Treatment
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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
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Making Connection: The Therapeutic Relationship
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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
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The Viewing: Case Conceptualization and Assessment
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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
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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
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The Doing: Interventions
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Session Format Intervention Phase Catchup
Pre-intervention marital interaction Give an intervention The spouses make the interventions their own Got resistance? No resistance? Homework
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Signature Interventions
Love maps Soften startup Dreams within conflict Negotiating marital power
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Research and Evidence Base
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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
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Tapestry Weaving: Working with Diverse Populations
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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
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Ethnic, Racial, and Cultural Diversity (cont.)
Works with the following specific populations: Hispanic and Latinos African-Americans Chinese Americans Sexual identity diversity
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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
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Online Resources Frank Dattilio: www.dattilio.com
Gottman Method Couples Therapy: Juvenile Justice Bulletin (Functional Family Therapy): Mindfulness Awareness Research Center (UCLA): Mindfulness Based Stress Reduction Clinic (Jon Kabat-Zinn): Oregon Social Learning Center (Patterson and Forgatch Parenting Program): Substance Abuse and Mental Health Services Administration Registry of Evidenced- Based Practices:
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