Kim Case

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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.

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.

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

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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).

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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.

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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career, he developed a clinical practice based on research, which helped refine his theoretical contributions to behavioral marital therapy and domestic violence. Work with graduate students also kept him focused on theory. Jacobson indicated that behaviorism is at the base of his theory, but that clinical application is more eclectic. He was intent on bridging the gap between academic research and in-the- trenches, clinical outcome research. Until his death, Jacobson was on the leading edge of the family therapy field and was involved in longitudinal research on couples, including an 8-year study with Gottman concerning male batterers (Jacobson & Gottman, 1998). One major outcome of his meticulous attention to research and refining his way of working with couples was his introduction of integrative behavioral couple therapy (IBCT, discussed later) with Andrew Chris- tensen, his long-time colleague. This orientation represented a major change from traditional behavioral couple therapy (TBCT). It includes the idea that acceptance is as important as behavior change in couple therapy and, in fact, may be more likely to facilitate change with some kinds of relationship problems than a direct focus on change. Jacobson and Christensen wrote a number of articles together and with other colleagues, and Christensen has continued research and writing about work with couples since Jacobson’s death in 1999.

Traditional Behavioral Couple Therapy

Traditional behavioral couple therapy (TBCT) was built on two major precepts: (1) that marital dissatisfaction arises when the ratio of rewards to costs is too low, which means there are inadequate behavior-maintaining contingencies, and (2) that part- ners have deficits in interpersonal skills. In clinical practice, this resulted in an emphasis on increasing positive behavior, decreasing negative behavior, and using reciprocity rather than coercion for behavior change, as well as on providing communication and problem-solving skills training. Therapy from this perspective follows a predictable format, with problem behaviors operationally defined and targeted. Behavioral interventions, such as contingency management and behavioral exchange, are used to decrease negative behaviors and increase positive ones, and skill training in communication and problem solving is provided. Overall, the tone is didactic because the therapeutic process involves much teaching and training.

Critiques of TBCT challenge traditional notions of behavioral theory. As early as the late 1970s, critics noted that BCT of that era did not take into account context (Gurman & Kniskern, 1978; Jacobson & Weiss, 1978). Gurman (2008) stated that poor communication and problem-solving skills serve a defensive function, and noted that couples who do not use such skills with each other nevertheless evidence those same skills in other relationships. Thus, the skill deficits addressed by communications and problem-solving training are not significant enough to warrant explicit instruction for many couples. Rather, the problem to be addressed in therapy is more about how to access skills partners already possess in the context of the relationship. Such arguments aside, change in how TBCT is conceptualized and practiced came largely from research within the field. This is not surprising, because behavior therapy in general strongly values empirical evidence. Research indicated, for example, that gains achieved during treatment were not sustained by a

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large portion of couples. This informationled to various hypotheses about why gains from TBCT are not sustained long term. In clinical practice, it was also evident that some couples donotbenefit from change-oriented work,especially those whoarenot compromising, collaborative, or trusting. Gurman (2013) and others (Christensen et al., 2004; Jacobson & Christensen, 1998) noted that TBCT did not include a mechanism for dealing with what Gottman (1999) called perpetual problems, which may account for nearly 70% of what couples regularly argue about. Perpetual problems often include things that involve differences in personality or relationship needsthatareexperiencedaspartofone’sessential self.Forexample,onepartnermay be an introvert and the other an extrovert, which may lead to differences in how each wants to spend leisure time or how much time each wants to spend alone.

Second-Wave Approaches

The emphasis on mediational cognitive variables constitutes the second wave in behavioral therapy (Gurman, 2013), particularly with the development of cognitive theory. As early as the 1950s, some behaviorists began to argue that the stimulus- response cycle as conceived in traditional behavioral psychology was not automatic, but rather was mediated by cognitions. The importance of the one who experienced a stimulus was recognized as a critical part of the cycle (stimulus-organism- response). At about the same time, cognitive theorists and clinicians were proposing their own ideas about how people change. Personal constructs and schemas were recognized as important in understanding how couples and family members gather information, interpret it, and predict events. Thus, therapists who believed the role of cognition was important began working with couples and families about, for example, beliefs they held about what couple or family life should ideally be. Cognitive psychology literature continues to contribute to awareness of potential sources of distortion in client cognitions about events in the family.

Changing the way family members act, as well as their dysfunctional attitudes or beliefs, is central to second-wave approaches. Although goals will vary according to presenting problems and the counselor’s particular frame of reference, there are a number of facets that characterize the approaches in this section. Among those are: (a) facilitating the family’s ability to see patterns of behavior and understand the interaction among cognitions, emotions, and behavior (Kalodner, 1995); (b) diminishing problem behaviors or interactions and increasing positive ones (Nichols & Schwartz, 2004); and (c) improving each couple or family member’s functioning in a way that improves the overall relationship (Weiss & Perry, 2002).

SIDEBAR 11.2 ASSESSMENT: A FOUNDATIONAL COMPONENT OF CBC/FT

Assessment plays a pivotal role in CBC/FT and is an integral part of the therapeutic process. In fact, it isn’t really possible to do CBC/FT without it. Assessment begins at or even before the first session and continues until the conclusion of therapy. Assessment is used to monitor progress,

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refine goals, and determine appropriate interventions. Therapists who practice from a CBC/FT model will vary to some degree in what they assess depending on their particular approach. However, some of the more common purposes of assessment from a CBC/FT perspective are to:

• Establish initial goals and refine them throughout therapy • Identify behaviors and cognitions that are problematic for the couple

or family • Understand what clients want • Understand how and why particular problems are impacting the

clients’ lives • Monitor progress • Determine interventions that address problems presented for a

particular couple or family • Set the stage for change

Cognitive-Behavioral Couple Therapy

Cognitive-behavioral couple therapy (CBCT) has its roots in BCT, cognitive therapy, and basic research in cognitive psychology (Baucom et al., 2008). Cogni- tive-behavioral couple therapy (CBCT) arose from concerns that TBCT was clinically limited because of its lack of attention to internal processes. Cognitive theory was developing as early as the 1960s, and its usefulness in clinical settings was becoming evident in the 1980s. During the 1980s, couple therapists began to attend to cognitive processes such as “attributions, expectancies, assumptions, standards, and schemas with most attention paid to the ways in which such information processing was focally important to intimate relationships” (Gurman, 2013, p. 121). Cognitive-behavioral couple therapy builds on skills-based interventions of BCT that target couple communication and behavior exchanges by directing partners’ attention to explanations they construct for each other’s behavior and to expectations and standards they hold for their own relationship and for relation- ships in general (Epstein & Baucom, 2002). Despite several decades of research, CBCT, whether considered a modality of its own or a set of adjunctive procedures to be integrated with other approaches, has only recently become a major force in the field of couple and family therapy (Datillio, 1998, 2001; Datillio & Epstein, 2003).

Cognitive Restructuring Although CBCT is considered a single entity, Gurman (2013) identified three particular emphases in theory and practice. The first, cognitive restructuring, involves core cognitive therapy methods such as identifi- cation and modification of partners’ automatic thoughts and the use of Socratic questioning to determine evidence for partner attributions about each other and about relationships. For example, some people have an unrealistic or untrue belief that if their partner loves them, then the partner will never let them down or

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