Chapter 8 Cognitive-Behavioral and Mindfulness-Based Couple .docx

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
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved.
For classroom use only.
Lay of the Land
Types of therapies
Behavioral family therapy: Focuses on parent training.
Cognitive-behavioral family therapy: Integrate cognitive
elements into therapy with couples and families.
Integrative behavioral couples therapy: Enhanced version of
behavioral couples therapy; humanistic component added in an
attempt to improve long-term outcomes.
Gottman method couples therapy: Scientifically-based approach
to couples therapy based on Gottman’s 30 years of research on
key differences between happy/unhappy marriages.
Functional family therapy: Treatment for working with troubled
teens and their families.

Diane R. Gehart
Behavioral and Cognitive-Behavioral Family Therapies
Diane R. Gehart
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.
Until 1980s, most family CBT were primarily behavioral:
behavioral family therapy and behavioral couples therapy.
Recently, approaches that more directly incorporate cognitive
components have developed: cognitive-behavioral family
therapy and Gottman method couples therapy approach.
Family CBTs 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.
Diane R. Gehart
The Juice: Significant Contributions to the Field

Diane R. Gehart
Parent Training
Influence on parenting
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
Diane R. Gehart
Rumor Has It: The People and Their Stories
Diane R. Gehart
Significant Contributors
Gerald Patterson and Marion Forgatch
Neil Jacobson and Andrew Christensen
Norman Epstein
John Gottman

Frank Dattilio
Diane R. Gehart
The Big Picture: Overview of Treatment
Diane R. Gehart
Process for CBFTs
4 steps
Assessment: Obtain detailed behavioral and/or cognitive
assessment of baseline functioning.
Target behaviors and thoughts for change: Identify specific
behaviors and thoughts for intervention.
Educate: Educate clients on irrational thoughts and
dysfunctional patterns.
Replace and retrain: Interventions designed to replace
dysfunctional behaviors/thoughts with more productive ones.
Diane R. Gehart
Making Connection: The Therapeutic Relationship

Diane R. Gehart
Directive Educator and Expert
Primary role
To serve as an expert who directs and educates client and family
on how to better manage problems.
Then and now
Traditional CBFT therapists maintained distance from clients,
diagnosing and prescribing interventions without achieving
emotional connection.
Quality of therapeutic relationship being a strong predictor of
positive outcomes.
Therapists are increasing use of empathy and warmth to create
connection/clients.
Diane R. Gehart
Empathy in Cognitive-Behavioral Counseling
Use of Empathy
Cognitive-behavioral therapists use empathy for entirely
different reasons than humanistic therapists.
CBT uses empathy to create rapport, which then allows for
“real” interventions that will lead to change.
Idea is to make clients feel more comfortable with the process.
Doesn’t “integrate” experiential concepts, they are adapting it.
Diane R. Gehart

Contemporary Cognitive-Behavioral Alliance
Five practices for fostering counseling alliance
Actively collaborate with patient: Decisions about counseling
should be jointly made with client.
Demonstrate empathy, caring, and understanding: Expressing
empathy help clients trust the therapist.
Adapt one’s counseling style: Interventions, self disclosure, and
directiveness adjusted for each client.
Alleviate distress: Helping clients solve problems and
improving moods enhances counseling relationship.
Elicit feedback at the end of the session: By asking clients “how
did it go?” at the end of each session, therapists can intervene
early in cases of alliance rupture.
Diane R. Gehart
Written Contracts
Relationship on paper
Frequently use written contracts spelling out goals and
expectations to help structure the relationship and to increase
clients’ motivation and dedication.
Putting goals and agreements in writing and having clients sign
that they agree can be a very motivating experience that creates
commitment to the process.
Diane R. Gehart

The Viewing: Case Conceptualization and Assessment
Diane R. Gehart
Defining Problems
Problem analysis
Process of taking vague descriptions and developing them into a
clear description of behavioral interactions and emotional
consequences.
Focuses on present-day behaviors, emotions, and cognitions.
CBFT therapists listen for the behaviors, emotions, and
thoughts that make situations a problem.
Focus of treatment is on reducing undesirable thoughts,
feelings, and behaviors and increasing more desirable ones.
Diane R. Gehart
Assessment of Baseline Functioning
Monitoring and tracking
Therapists conduct a baseline assessment of functioning, which
provides a starting point for measuring change.
Ask clients to log the frequency, duration, and severity of
specific behavioral symptoms.
Identify antecedent events that may have triggered symptoms.
Baseline assessment provides more detailed and accurate
information than client recall alone.

Diane R. Gehart
Functional Analysis and Mutually Reinforcing Behaviors
Functional analysis
Identifies the precise contexts, antecedents, and consequences
of the problem behavior.
Mutually reinforcing behaviors
Examine how patterns are maintaining the symptom.
Example: If a parent inconsistently reinforces a child’s
problematic behavior, the behavior is likely to continue.
Diane R. Gehart
Functional Analysis Questions for Families
Examples
How does this specific problem handicap this person (and/or the
family) in everyday life?
What would happen if the problem were reduced in frequency?
What would this person (and his or her family) gain if the
problem were resolved?
Who (or what) reinforces the problem with attention, sympathy,
and support?
Under what circumstances is the specific problem reduced in
intensity?
Diane R. Gehart

Functional Analysis Questions for Couples
Strengths and skills of the relationship
What are the major strengths of the relationship?
What is each spouse’s capacity to reinforce the other?
What behaviors are highly valued by the other?
Presenting problems
What are the primary complaints (defined behaviorally)?
What behaviors occur too frequently? Under what circumstances
and with what reinforcements do they occur?
What behaviors occur too infrequently? Under what
circumstances and with what reinforcements do they occur?
Sex and affection
Is either unsatisfied with the frequency or quality of their sex
life? What behaviors are associated with the dissatisfaction?
Is either unsatisfied with the frequency or quality of nonsexual
physical affection? What behaviors are associated with the
dissatisfaction?
Is either in an extramarital affair? Is there a history of affairs?
Future prospects
Are both seeking to improve the relationship, or is one or both
contemplating separation?
Have steps been taken toward separation or divorce?
Social environment
What are the alternatives to this relationship, and how attractive
are they?
Is their social network supportive of separation?
If there are children, what are the current effects, and what
might be the effects of divorce?
Individual functioning
Does either have a significant mental or physical health
disorder?
What is the relationship history of each, and how does it affect
the present relationship?

Adapted from Holtzworth-Munroe & Jacobson, 1991, pp. 106–
107
Diane R. Gehart
A-B-C Theory
What it is
Developed by Albert Ellis to analyze irrational thinking with
individuals.
Has also been applied to working with families.
How it works
A is the “activating event.”
B is the “belief” about the meaning of that event.
C is the emotional/behavioral “consequence” based on belief.
Diane R. Gehart
Ellis’s A-B-C Theory
In practice
Most clients report that A causes C:
“I am depressed because my husband does not help out with the
kids.”
“I am angry because my son doesn’t listen to me.”
Therapist’s job is to help client identify the “B” belief that the
client does not put into the equation.
“If he does not help with the children in the ways I want him to,
he really does not care about me.”
“Good kids follow through on parental requests without

questioning the parent.”
Diane R. Gehart
Family Schemas and Core Beliefs
Eight types of cognitive distortions about families
Arbitrary inference: A belief based on little evidence.
Selective abstraction: Focusing on one detail while ignoring
context and other obvious details.
Overgeneralization: Generalizing few incidents to make a
sweeping judgment about another’s essential character.
Magnification and minimization: Overemphasizing or
underemphasizing based on the facts.
Personalization: External events are attributed to oneself.
Dichotomous thinking: All-or-nothing thinking: always/never,
success/failure, or good/bad.
Mislabeling: Assigning a personality trait to someone based on
a handful of incidents, often ignoring exceptions.
Mind-reading: Believing you know what the other is thinking or
will do based on assumptions and generalizations.
Diane R. Gehart
Couple Cognition Types
Five cognitions
Selective perceptions: Focusing on certain events or information
to the exclusion of others.
Attributions: Inferences about the causes of positive and
negative aspects of the relationship.

Expectancies: Predictions about the likelihood of certain events
in the relationship.
Assumptions: Basic beliefs or assumptions about the
characteristics of the partner and/or the relationship.
Standards: Beliefs about the characteristics that the relationship
and each partner “should” have.
Diane R. Gehart
Targeting Change: Goal Setting
Diane R. Gehart
General Goals
How they work
Goals are stated in behavioral and measurable terms.
Therapists use their authoritative role to identify goals that are
agreeable to all.
Therapists obtain a commitment from couple or family to follow
instructions and complete out-of-therapy assignments, often
with a written contract.
Getting clients to promise to complete assignments greatly
increases likelihood that clients will follow through.
Example of middle-phase CBFT goal
Replace perfectionist beliefs about child school performance
with more realistic expectations.
Example of late-phase CBFT goal
Develop positive mutual reinforcement cycle to reduce

negativity and labeling.
Diane R. Gehart
The Doing: Interventions
Diane R. Gehart
Classical Conditioning
Pavlov’s dogs
Developed by Ivan Pavlov in famous experiments with
salivating dogs.
Trained dogs to salivate at sound of a bell by pairing dog’s
natural response to salivate at the sight of food with a bell.
After enough repetition, the dog began to salivate with just the
sound of the bell.
Procedure is technically described as conditioned and
unconditioned stimuli and responses.
Used primarily to treat anxiety disorders.
Diane R. Gehart
How Classical Conditioning Works
The natural state of affairs

(unconditioned response; UCR)
Process of pairing conditional stimulus with response
Food (U
(conditioned response: CR)
Resulting pairing
response: CR)
Diane R. Gehart
Operant Conditioning
Reinforcing techniques
Interventions based on operant conditioning use principles
identified by B. F. Skinner.
The essential principle is to reward behavior in the direction of
the desired behavior using small, incremental steps, a process
called shaping behavior.
Once a certain set of skills has been mastered, the bar is raised
for which behavior will be reinforced, with ever closer
approximations to desired behavior.
Diane R. Gehart
Forms of Reinforcement and Punishment
Four options for shaping behavior
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).
Diane R. Gehart
Summary of Operant Conditioning
Increase Desired BehaviorDecrease Undesirable BehaviorAdd
SomethingPositive reinforcement; rewardPositive
punishmentRemove SomethingNegative reinforcementNegative
punishment
Diane R. Gehart
Frequency of Reinforcement and Punishment
Keys to increasing/decreasing behavior
Immediacy: The more immediate the reinforcement or
punishment, the quicker the learning.
Consistency: The more consistent the reinforcement or
punishment, the quicker the learning.
Involves rewarding/punishing a behavior every time it occurs.
Intermittent reinforcement: Inconsistent reinforcement often
increases undesired behaviors; random positive reinforcement of
well-established desired behaviors helps sustain them.

Diane R. Gehart
Encouragement and Compliments
Stay positive
Patterson and Forgatch (1987) strongly encourage positive
reinforcement to increase desired behavior with children.
In distressed relationships, they coach families to increase
compliments and expressions of appreciation to increase
positive reinforcement.
Diane R. Gehart
Contingency Contracting
How it works
Can be used to promote new behaviors by creating a
contingency that must be met to receive a desired reward.
Parents can use contingency contracting with children that
detail how privileges will be earned and lost.
Ex.: If child’s GPA is above 3.0, the parents agree to an 11:00
p.m. curfew on Friday and Saturday.
Diane R. Gehart
Point Charts and Token Economies

What they are
Used to shape and reward positive behaviors by allowing
children to build up points they can apply to privileges, treats,
or purchases.
Rewards should be appropriate and readily approved by the
parent.
In most cases, punishment is added to a token economy by
having the child lose points for poor behavior.
Diane R. Gehart
Behavior Exchange and Quid Pro Quo
Quid pro quo
Mutual behavior exchanges can be useful to help partners
negotiate relational rules.
“If you make dinner, I will do the dishes.”
Couples relying primarily on quid pro quo arrangements have
lower levels of marital satisfaction.
Use behavior exchange judiciously with couples.
Balance with more affective techniques to avoid framing
marriage as a business deal.
Have each partner select a behavior to “give” rather than have
each “ask” for what he/she wants.
Diane R. Gehart
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
Diane R. Gehart
Psychoeducation
What it is
Teaching clients psychological and relational principles about
their problems and how best to handle them.
Categories
Problem-oriented: Information about the patient’s diagnosis or
situation.
Change-oriented: Information about how to reduce problem
symptoms.
Bibliotherapy: Assigning readings that will be motivating and
instructional for dealing with presenting problem.
Cinema therapy: Assigning clients to watch a movie that will
speak to the problem issues.
Diane R. Gehart
Challenging Irrational Beliefs
How it’s done

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.
The use of direct or indirect approach depends on:
The therapeutic relationship.
The therapist’s style.
The client’s receptiveness to a particular approach.
Client and therapist cultural and gender issues.
Diane R. Gehart
Socratic Method and Guided Discovery
Guided discovery
AKA inductive reasoning
Gently encourages clients to question own beliefs.
Use open-ended questions that help clients “discover” that their
beliefs are illogical/dysfunctional.
Therapists take a neutral stance, allowing client’s own logic,
evidence, and reason to do the majority of convincing.
Tightly held beliefs are slowly eroded over time by client
questioning and re-questioning their validity in different
situations.
Diane R. Gehart
Thought Records
What it is
A type of structured journaling, clients analyze their own

cognitions and behaviors and develop more adaptive responses.
How it works
Therapists ask clients to confront their own irrational thinking
and problem behaviors by assigning “thought records.”
Thought records generally include the following information:
Trigger situation
“Automatic” or negative thoughts
Emotional response
Evidence for
Evidence against
Cognitive distortions
Alternative thought
Diane R. Gehart
Homework Tasks
How they work
Homework tasks are designed to solve the client’s problem.
Ex: To reduce couple’s conflict, therapists may assign
communication tasks.
Develop tasks for reducing depression.
Journaling positive thoughts.
Increasing recreational and social activities.
In CBFT, the tasks are logical solutions to reported problems.
Diane R. Gehart
Homework vs. Strategic Directives
How they differ

CBFT tasks are linear and literal.
Strategic and systemic therapists assign tasks designed to:
Metaphorically make the covert overt.
Interrupt problem interaction or behavioral pattern enough to
allow system to develop new pattern.
Make the uncontrollable controllable.
Diane R. Gehart
Homework vs.
Solution
-Focused Tasks
How they differ

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