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CHAPTER

11Behavioral and Cognitive- Behavioral Theories: Approaches and Applications Marvarene Oliver and Yvonne Castillo Texas A&M University–Corpus Christi

Behavioral and cognitive-behavioral couple and family therapy are currently generally conceptualized under the broad domain of the cognitive-behavioral approach. Arising initially from behaviorism and later adding information from cognitive psychology and systems thinking, specific frameworks within the broad domain of cognitive-behavioral couple and family therapy (CBC/FT) vary, some- times significantly. Cognitive-behavioral theorists, scholars, and clinicians give greater or lesser emphasis to variables addressed in theory and practice, depending in part on where they fall on a continuum between a more behavioral or a more cognitive orientation. In addition, specific models vary about how much and in what way systems thinking is considered. While most behavioral and cognitive- behavioral approaches are not strictly considered systemic approaches to working with families, they do share with systems theory an emphasis on rules and communication processes, as well as attention to the reciprocal impact of each family member’s behaviors and attitudes on others. Some leading figures in CBC/ FT argue that the attention to mutual impact of family members’ thoughts, behaviors, and emotions, as well as attention to the context in which families operate, provide a systemic overlay for this approach (Baucom, Epstein, Kirby, & LaTaillade, 2010; Dattilio, 2010). Some approaches (e.g., functional family ther- apy, integrative behavioral therapy, and some forms of cognitive-behavioral therapy) strongly stress a systemic perspective that cannot easily be dismissed by critics. Wk9 Discussion Assignment Paper

However, all cognitive-behavioral approaches share an emphasis on research and clearly outlined goals, ongoing assessment, and treatment interventions. Because of this commitment to a scientific approach, as well as the relative ease

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of standardizing treatment and measuring outcomes, cognitive-behavioral approaches are the most researched treatments in the arena of couple and family counseling. There have been more studies demonstrating the efficacy of CBC/FT approaches than any other model (Datillio, 2010; Datillio & Epstein, 2005). While other therapies have demonstrated efficacy at least as strong as CBC/FT, the quantity and role of research in CBC/FT is currently unmatched in other approaches (Atkins, Dimidjian, & Christensen, 2003). Not only is CBC/FT well-researched with a sound empirical base, it is among the most-used approaches to couple and family therapy. For instance, Northey (2002), in a national survey of members of the American Association for Marriage and Family Therapy, noted that over 27% of 292 randomly selected therapists identified cognitive-behavioral family therapy (CBFT) as their primary treatment modality, and CBFT was the most frequently cited of all models mentioned.

Distinguishing among variations in CBC/FT theory and practice can be challenging for a number of reasons. Not only are there variations based on closer alignment with behavioral or cognitive elements and the relative importance of a systemic perspective, but there have also been several phases of development of CBC/FT. Each of these has spawned related threads of theory, research, and practice. Each thread provides concepts and principles that are important for the well-trained counselor to understand. In addition, both research and theory may address either couple or family approaches, or both. While couple and family treatments share similarities, they do not always translate precisely from working with couples to working with families. Research is generally clearly demarcated as being with and for couples, or with and for families. Nonetheless, general principles of behavioral and cognitive-behavioral approaches share many similarities, whether working with couples or with families. Wk9 Discussion Assignment Paper

BACKGROUND

Counselors who are interested in working from a cognitive-behavioral perspective should be knowledgeable about both behavioral and cognitive therapy and the foundational concepts on which each is based. Behavioral and cognitive-behavioral approaches have their origins in science; the scientific method was critical in the development of the behavioral approach to working with problems, and it remains critical today. The scientific method that characterized early behaviorism remains a critical component of CBC/FT.

First-Wave Approaches

Gurman (2013) conceptualized the development of cognitive and behavioral approaches to couple and family therapy as a series of waves (see Table 11.1). He includes both behavioral and cognitive-behavioral work within the behavioral couple/family therapy (BC/FT) paradigm, and called the earliest period the first wave in the evolution of behavioral therapy’s core principles and clinical thought. During the early days of BC/FT, which was closely linked to traditional

262 Part 2 Theories: History, Concepts, and Techniques

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stimulus-response learning theory, there was no consideration of internal events such as thoughts or emotion because those could not be readily observed, nor was there much attention given to interpersonal processes. A major premise underlying this approach is that all behavior is learned and that people, including families, act according to how they have been reinforced or conditioned. Behavior in the family or couple is maintained by consequences, also called contingencies. Unless new behaviors result in consequences that are more desired, they will not be maintained. In addition, the focus is on maladaptive current behaviors as the target of change. From a traditional behavioral perspective, it is not necessary to look for underlying causes; behavior that is not desirable can be extinguished and replaced by more desirable behavior. Finally, many behavioral family therapists believe not everyone in the family has to be treated for change to occur. When one person comes for treatment, he or she is taught new, appropriate, and functional skills. Those who are more systemic in their thinking focus on dyadic relationships, such as parent– child or couple. Today, BC/FT relies on the same theoretical foundation as individual behavior therapy in that it utilizes principles of classical and operant conditioning. However, modeling, attention to cognitive processes and self-regu- lation, and focus on interactions between family members have been incorporated into behavioral practice. Gerald Patterson, Richard Stuart, and Robert Liberman are generally associated with this first wave of behavioral treatment of couple and family problems.

Table 11.1 Development of Cognitive and Behavioral Approaches

Theory Examples of Major Principles

First wave Behavioral family therapy (BFT) Traditional behavioral couple therapy (TBCT)

Stimulus-response learning theory Behavior is learned No consideration of internal events, underlying causes, or emotions

Skill deficits important Second wave Cognitive-behavioral couple therapy

(CBCT) Enhanced cognitive-behavioral couple therapy (ECBCT)

Cognitive variables as mediators Stimulus-organism-response theory Internal processes, context, and core themes important

Third wave Integrative behavioral couple therapy (IBCT)

Acceptance and commitment therapy (ACT)

Behavioral activation therapy Functional family therapy (FFT) Functional analytic therapy

Importance of self-regulation Recognition of limits of change-oriented interventions

Importance of context No class of behavior privileged

Developing third wave

Mindfulness training enhancement to CBCT

Integration of dialectical behavior therapy and CBCT

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Richard Stuart and Robert Weiss conducted research on couples in the 1960s. The first publication on behavioral couple therapy (BCT) was written by Stuart (1969), who has been called the founding father of behavioral marital therapy. His later text, Helping Couples Change: A Social Learning Approach to Marital Therapy (Stuart, 1980), became a classic that remains widely known and referenced. Stuart (1980) used social exchange theory and operant conditioning principles to increase the ratio of positive behaviors to negative behaviors in couples. He noted that in nondistressed relationships, partners reciprocally exchanged a higher ratio of positive behaviors than negative ones, and initially he coached partners to reward each other using tokens for enacting behaviors that were viewed as positive by each other. Behavioral couple therapists gradually replaced token economies with written contracts and good faith contracts for behavioral exchanges, and added communication and problem-solving skills training. For example, a therapist working with a couple who experiences conflict about the relative importance of work and fun might help the couple devise a contract in which one partner agrees to cleaning the bathrooms once a week. In exchange, the other partner agrees to spend two Saturday afternoons a month doing a fun activity together.

Another key figure in the first wave of BC/FT is Robert Liberman (1970), who utilized social learning principles to work with couples and families. He is often credited with adding strategies of therapist modeling and client behavioral rehearsal of new behaviors to treatment. He also used behavioral analysis of couple and family interaction patterns around presenting problems, and included in his work with couples a focus on unintentional reinforcement of undesirable behavior. In conjunction with colleagues, he reported results of a 10-session behavioral marital group therapy that involved training in communication skills; contingency contracting; increasing recognition, initiation, and acknowledgment of pleasing interactions; and redistributing time spent in recreational and social activities (Liberman, Wheeler, & Sanders, 1976).

Gerald Patterson is often credited with originating behavioral family therapy (BFT) at the Oregon Social Learning Center (OSLC). Patterson (1974) and fellow researchers at the University of Oregon noted the importance of operant con- ditioning principles in working with children, and studied parental use of reinforcers and punishers to increase a child’s desired behaviors and reduce negative ones. Patterson believed that parents and other significant adults could be change agents in the lives of children with behavioral problems, and he identified a number of specific behavioral problems and interventions for correcting them. He was instrumental in writing programmed workbooks for parents’ use in helping their children and families modify behavior. The Parent Management Training- Oregon Model, developed by colleagues at the OSLC, is now a widely accepted evidence-based model for promoting prosocial skills and preventing and reducing mild to severe conduct problems in children. In addition, Weiss, Hops, and Patterson (1973) discovered that some parents needed relationship skills in addition to parenting skills, and they applied learning-based principles and methods such as the use of behavioral exchange, contracting for positive experiences, and skills development to the treatment of distressed couples (Atkins et al., 2003; Baucom et al., 2010). Wk9 Discussion Assignment Paper

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SIDEBAR 11.1 CASE STUDY: HOW CAN JOSHUA GET BACK ON TRACK?

Makayla and Jeremy came for family counseling with their 13-year-old son, Joshua. When Joshua entered middle school 2 years ago, his grades began dropping. Previously a good student, Joshua was now barely passing. Joshua has skipped school a number of times and was sent to a disciplinary campus for 6 weeks. He is frequently several hours late coming home from school. When his father is not home, he is verbally aggressive toward his mother whenever she directs him to do homework or chores. Jeremy has come in from work on several occasions to find his wife in tears and Joshua in his room with his door locked, playing computer games. When Jeremy is at home, Joshua sullenly responds to direction. In session, Jeremy mostly stares at the floor and says he just doesn’t want to be treated like a child. As a behavioral family counselor, where will you start?

Although they are not now associated with the first wave of behavioral therapy, at least two others should be included in any discussion of CBC/FT, although each for a different reason. John Gottman, who began his career with an interest in mathematics and earned three of his four degrees with a mathematics emphasis, became interested in psychophysiology and earned a PhD in clinical psychology in 1971. He began his work at the University of Washington in 1986 and established his Family Research Lab, familiarly known as the Love Lab. Thousands of hours of data were collected in the Family Research Lab, including audio and video recordings, use of heart monitors, and information from a chair that monitored fidgeting during different kinds of conversations. He has conducted extensive study on marital stability and divorce prediction, and is known for precision in his research. Even though he is not a cognitive-behavioral theorist, his findings have been important in research of behavioral and cognitive-behavioral approaches to couple and family therapy (e.g., Baucom, Epstein, LaTaillade, & Kirby, 2008; Datillio & Epstein, 2005; Dimidjian, Martell, & Christensen, 2008; Gurman, 2013). Gottman (1999) has identified multiple factors that contribute to relational dissatisfaction, as well as factors that seem to be critical in long-term relational success. For example, couples who are stable and happy regularly make repair attempts when things go awry in their interactions. Repair attempts are used to soften or mend what might otherwise lead to defensiveness or hurt, and are especially important during conflict. On the other hand, couples who are unstable and unhappy have low levels of positivity to negativity in their relationships and higher occurrence of criticism, defensiveness, contempt, and stonewalling. Wk9 Discussion Assignment Paper

Neil Jacobson, who started out to be a psychoanalytic and humanistic-oriented clinician, became a behavior therapist after reading the work of Albert Bandura, an influential psychologist and researcher. Jacobson was drawn to the accountability, empiricism, and methodologies associated with the theory. During his academic

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CHAPTER

14Counseling Couples Using Life Cycle and Narrative Therapy Lenses Colleen R. Logan, Aaron H. Jackson, Lee A. Teufel-Prida, and Dawn M. Wirick Walden University

CASE STUDY

Larry and Tom, an African American gay couple, are seeking counseling for a number of reasons. Larry and Tom have been together for 15 years. Larry is a successful accountant, and Tom is a soccer coach at a local high school. They have two children, Mary and Stephen. Mary is 6 years old and Stephen is 12. Larry’s mother lives with the couple and helps care for the children. Larry is very extroverted, affable, and jovial. Tom sits quietly and listens while Larry speaks. Larry reports that the two main issues for the couple are communication and intimacy. He states that he wishes Tom would talk to him more. He states he is disappointedthatheandhismomhavetodoeverythingaroundthehousewhileTom doesn’t take any initiative. He alludes that this is also the same case in the bedroom. He states that Tom never initiates and that it’s been over a year since they have been intimate. Larry goes on to say that, in general, the kids are doing well. Stephen does well at school and is very athletic. He plays football, baseball, and soccer. Mary, on the other hand, seems to struggle in school. She is frequently corrected for disruptive behavior. She also struggles with reading and math. Larry states he is not that concerned about Mary because his mother and Stephen can help her with her homework.Larryfinishes by exalting and praising his mother. “I don’t knowwhat we would do without her, truly,” says Larry, “she is such a big part of our family.”

Tom reports that he agrees that the primary concerns are sex and communi- cation. Tom feels that he does his best to anticipate Larry’s needs and participate in all that goes on at the house. Simply said, Tom feels that he doesn’t have a role or really any authority. He starts to weep as he starts to share his perspective. He shares that the first 5 years of their relationship were idyllic. They talked and

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laughed, went on vacations together, and shared many interests. And then Larry’s mother moved in and that was the beginning of the end, according to Tom. First, she ignores the fact that Tom is in an intimate relationship with her son, and she insists on referring to Tom as the “roommate.” He goes on to say that he never wanted kids, Larry and his mother did! Yes, he loves the kids, but the way he is treated by Larry’s mother and Larry, quite frankly, makes him feel like he is the hired help. Because Tom felt that he never did things “right,” he just stopped trying. Tom states that he is willing to give counseling a try, but he doesn’t really see the point and he doesn’t think the relationship will last. If it weren’t for the kids, Tom says sadly, he’d be long gone.

INTRODUCTION

After presenting some pertinent background material, the focus of this chapter is to provide a broad and yet comprehensive overview of how to work with and evaluate family systems using life cycle analysis and narrative therapy. Family systems theory arose out of von Bertalanffy’s (1968) concept of general systems theory. Systems theory has its own set of theoretical assumptions that are different from the assumptions associated with individual therapy. Chief among these assumptions is that each part of any given system is interrelated with each and every other part. In addition, these various parts are to some degree interdependent on each other. A family is defined as an organization of inter- and intrarelated parts, some of which are internal to the family, and some of which are external to the family (Gladding, 2011). Internal factors include individual interactions between and among the family members, and external factors include various institutions and entities with which the family interacts on a regular basis. Professional counselors working from a family systems perspective consider the family, however defined, in terms of the influence of both internal and external factors.

SIDEBAR 14.1 DEFINITIONS

A systems approach requires that we think about families, presenting problems,andpossiblesolutionsincontext.It isalsohelpfultoconsiderthe many different influences on any given family. These influences are both internal and external. Internal influences are factors that are within the family. Each family has its own unique history, rules, values, and character- istics. External influences come from the world around us. As systemic counselors, attention is paid to the external influences just as much as the internal things that influence the way a family operates. External influences are factors such as the surrounding community, friendship networks, extended family, politics, and cultural values. Space and time limit a thorough presentation of the many internal and external influential factors that impact family functioning. For a more in-depth understanding and analysis of these factors, see Knoff (1986) and von Bertalanffy (1968). Wk9 Discussion Assignment Paper

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In general, accurate clinical evaluation requires that counselors thoughtfully and carefully consider all aspects of the presenting problem. Counselors working with couples and families spend time observing, applying what is known (and not known), and then carefully putting together all of the related information in order to conceptualize and determine issues. Wk9 Discussion Assignment Paper

Family systems are indeed beautifully complex and difficult to understand. In many cases, it can be said that what appears to be the problem in the family is not the “real” problem that the counselor must consider (Berg & Reuss, 1997; DeJong & Berg, 2001). In other words, sometimes the family views the problem in a completely different way, and it is up to the skilled family counselor to able to see and determine the real issues. It is this set of skills that requires couples and family counselors to be purposeful and intentional when working with families and, in particular, during the evaluation process. This chapter provides guidance on the intensive and critically important process of clinical evaluation, including the unique nature of assessing couples and families, the general differences and similarities between assessing couples and families versus individuals, and general guidelines for the evaluation process.

Individual Versus Family Evaluation

One of the most challenging shifts for emerging counselors who aspire to work with couples and families is the process of moving beyond the idea of simply observing and understanding the individual versus the process of observing and under- standing the entire family system. The family as a whole is defined as the primary client, rather than the individuals, and, as such, the family as a whole is subject to evaluation from the very beginning of the counseling relationship.

The difference between individual and family evaluation is really quite clear. According to Corey (2009), the clinical evaluation process for an individ- ual is primarily guided by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 2013), now in its fifth edition. Typically, issues and symptoms are matched with diagnostic criteria, which are then attached to specific diagnoses. For example, if an individual meets all of the DSM criteria for major depressive disorder, he or she would be given that diagnosis.

Not surprisingly, the process of evaluating and indeed “diagnosing” families is not quite so simple and straightforward. According to Gladding (2011), the DSM offers very little guidance in terms of diagnostic criteria and/or specific diagnostic categories for counselors working with families. The DSM does, however, provide what are referred to as V codes, which provide a diagnostic framework for working with couples and families. These V codes are presented in Section II of DSM-5 (APA, 2013) under the topic heading of “Other Conditions That May Be a Focus of Clinical Attention.” It is of note, however, that these V codes are indicative of an issue that is “not attributable to a mental disorder” (APA, 2013) and, therefore, insurance companies and other third-party payers are reluctant to reimburse counselors for services rendered specifically for those issues. Third-party payers are typically more willing to reimburse clinicians for those diagnoses that are

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“attributable to a mental disorder.” As a result, couples and family counselors are less likely to obtain third-party payment for services.

SIDEBAR 14.2 DIAGNOSTIC CATEGORIES

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) provides helpful diagnostic direction in terms of conceptualizing family-focused diag- noses. The DSM-5 provides diagnostic categories known as V codes. A few of these are summarized here:

V61.20 (Z62.820)—Parent–child relational problem. This code may be used when the relationship between the parent(s) and children is causing problems in family functioning, treatment, and so on. Exam- ples of this include problems with parental involvement, cases of a parent being overly protective of a child, or “feelings of sadness, apathy, or anger about the other individual in the relationship” (APA, 2013).

V61.8 (Z62.29) – Upbringing away from parents. This code may be used when clinical attention is focused on issues related to a child being raised in a different setting than the home. Children who are raised in foster care and other care facilities or institutions may present with clinically significant concerns; this is applicable in those scenarios if the clinical presentation is related to the aforementioned settings.

V61.03 (Z63.5)—Disruption of family by separation or divorce. This code may be used when clinically significant concerns arise out of a situation in which the partners are in the process of separation or divorce.

These are just a few of the V codes available. For a more complete understanding, please refer to Section II of the DSM-5.

Focus of Evaluation

The diagnostic criteria for family systems have yet to be set forth in any systematic format; therefore, the diagnosis is heavily influenced by the theoretical perspective of the clinician. For example, a couples and family counselor would not diagnose a family as having obsessive compulsive disorder. The counselor would, however, use diagnostic language to describe what are observed as obsessive and compulsive behaviors within the particular family system. For example, the counselor who adheres to structural family therapy would use terms associated with structural theory to describe and understand the concerns presented during the initial evaluation. To that end, the structural family therapist might conceptualize the family’s presenting problem of obsessive and compulsive behaviors in terms of dysfunctional relationships related to poor boundaries, alignment, and abuse and/ or misuse of power. Wk9 Discussion Assignment Paper

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Family Within Context

Marriage, couples, and family counselors consider the family within the context of all other environmental, social, and cultural arenas. To that end, during the evaluation process, the counselor takes into account and considers such things as the family’s historical context, the impact of laws/legal issues, racial and ethnic domains, and interaction with educational or medical institutions. The family is always seen as an integral part of a larger system. In turn, the larger system has an impact on the family, and vice versa. Initially, an emerging couples and family counselor can become overwhelmed with all that can be and should be considered during the initial evaluation process. Rather than succumbing to the enormity of this task, students areaskedtorememberthatcouplesandfamilycounselorscananddoenlistthehelpof other professionals, such as school counselors, medical practitioners, or spiritual leaders, in an effort to help meet the treatment needs of the family.

Emphasis on Context/Culture

To assess any family without considering its unique nature in terms of the culture of the family would be inappropriate and unprofessional. For more information, review the American Counseling Association (2014) Code of Ethics, American Mental Health Counselors Association (2013) Code of Ethics, and International Association of Marriage and Family Counselors (Hendricks, Bradley, Southern, Oliver, & Birdsall, 2011) Code of Ethics. For the purposes of this chapter, culture can be defined best by Rabin (2005): “[Culture] is loosely used to denote a variety of social environmental factors related to ethnic, racial, and class factors” (p. 16). These include poverty, racism, differences in sexual behavior, immigration and resettlement, and acculturation. Cultural content (this is the definition of this concept) in the helping process refers to the specific meanings through which these social phenomena appear, including patterns of individual behavior, interpersonal reactions, and emotions. Cultural variables also include norms regarding gender roles, attitudes about sexuality, identity, and world and self views that run through an almost infinite number of guidelines for daily life behaviors.

The Family Life Cycle as a Concept

The family life cycle is both a concept and an indispensable tool for the couples and family counselor to use when conducting an evaluation of a family. As a concept, the family life cycle posits that families, over the course of their lives, progress and/or transgress through a series of life stages. These stages are described by several different models, each stage being marked by different characteristics, duties, responsibilities, and developmental trends. The underlying assumption is that in order to move on to the next stage, the family must successfully negotiate the tasks of the current stage. Carter and McGoldrick (1999) describe the family life cycle as having six distinct stages, each of which is described in Chapter 1 of this text. A summary of those stages is presented here for the convenience of the reader. For a more detailed description, see Chaper 1.

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