A Cognitive Behavioral Approach To Family Counseling

Running head: A COGNITIVE BEHAVIORAL APPROACH 1
A Cognitive Behavioral Approach To Family Counseling
Kimberly A. Osburn
Liberty University Online
October 14, 2011

A COGNITIVE BEHAVIORAL APPROACH 2
Abstract
Goldenberg and Goldenberg describe several empirically validated theoretical approaches to
family therapy. Cognitive behavioral therapy (CBT) is one such approach, with abundant
research supporting its efficacy for couples in conflict. Research has demonstrated the efficacy of
Cognitive-Behavioral Family Therapy (CBFT) in treating youth with mood and anxiety
disorders, showing a high rate of sustained long-term success in the treatment of pediatric
obsessive-compulsive disorder. Although critics denigrate the cognitive-behavioral approach for
its tendency to employ a Eurocentric view, CBFT is flexible enough to accommodate clients of
various cultural backgrounds, particularly in cultures where family cohesiveness and
interdependence are highly valued, such as African American, Middle Eastern, and East Indian
cultures. CBFT also integrates effectively with other theoretical approaches for those counselors
who favor using an eclectic approach in family therapy. Principles and techniques of CBFT are
easily integrated with Scriptural principles applicable to Christian counseling.

A cognitive behavioral approach to family counseling
Part I
Goldenberg and Goldenberg (2008) describe several empirically validated theoretical
approaches to family therapy. Cognitive behavioral therapy (CBT) is one such approach, with
abundant research supporting its efficacy for couples in conflict (Dattilio and Epstein, 2005).
Research has demonstrated the efficacy of Cognitive-Behavioral Family Therapy (CBFT) in
treating youth with mood and anxiety disorders (Katz, Fotti, & Postl, 2009), showing a high rate
of sustained long-term success in the treatment of pediatric obsessive-compulsive disorder
(McHugh O'Leary, Barrett, & Fjermestad, 2009). Although critics denigrate the cognitive-
behavioral approach “for adopting a Eurocentric view in research and practice” (LaTaillade,
2006, p. 347), CBFT is flexible enough to accommodate clients of various cultural backgrounds,
particularly in cultures where family cohesiveness and interdependence are highly valued, such
as African American (LaTaillade), Middle Eastern (Khodayarifard, Rehm, & Khodayarifard,
2007), and East Indian cultures (Dattillio & Bahadur, 2005). A culturally sensitive application of
CBFT techniques “allows for the modification of schemas in a way that is respectful to cultural
underpinnings and allows the family the freedom to change in a manner that does not
compromise their cultural values” (Dattillio & Bahadur, p. 367). CBFT also integrates
effectively with other theoretical approaches for those counselors who favor using an eclectic
approach in family therapy.
Liberman and Stuart, early behaviorists working with couples and families, were
primarily concerned with modifying observable behavior between individual family members,
using operant conditioning techniques to reinforce desired behaviors (Goldenberg & Goldenberg,
2008). As behaviorists began to take a more eclectic approach in the late 1970s, the influence of

internal cognitions on external behavior was recognized (Goldenberg & Goldenberg). As efforts
evolved to integrate techniques for changing of cognitions with behavior modification
techniques, cognitive-behavioral therapy was born.
Goldenberg & Goldenberg (2008) credit Albert Ellis and Aaron Beck as being the first
therapists to address cognitions in the resolution of conflict between couples. Ellis, “the
grandfather of cognitive behavior therapy” (Corey, 2005, p. 269), was influenced by Adler, who
believed that our emotional reactions and lifestyle are affected by our cognitive beliefs (Corey).
According to Dattilio and Epstein (2005), Ellis theorized a linear causality of relationship
conflict rooted in a person having “irrational or unrealistic beliefs about his or her partner and
relationship” (p. 7). The failure of one’s partner to live up to these unrealistic expectations leads
the individual to draw extreme negative conclusions about the partner and relationship, stirring
up extreme negative emotions and leading to negative behavior towards the partner. This resulted
in the development of Ellis’s “A-B-C Theory” (Goldenberg & Goldenberg, p. 312), in which “it
is not the activating events (A) of people’s lives that have disturbing consequences (C), but the
unrealistic interpretation they give to the events, or the irrational beliefs (B) about what has taken
place that cause them trouble” (p. 312). Ellis addressed this theorized cause of relational conflict
by developing Rational Emotive Therapy (RET), later renamed Rational Emotive Behavior
Therapy (REBT), a method of identifying irrational cognitions, restructuring them to develop
more rational, realistic, and constructive beliefs (Goldenberg & Goldenberg).
Petersen, Sweeten, and Geverdt (1990) offer the following example of an A-B-C
analysis: Joe is walking along a path, and sees a snake. Joe panics and runs away. The activating
event (A) is Joe’s encounter with the snake, and the consequential feeling and behavior (C) was
that Joe panicked and ran away. However, it would not be correct for Joe to say, “The snake

scared me.” The snake was simply present on the path, and did not take an active role in scaring
Joe. What caused Joe to panic and flee was his underlying belief (B) that snakes are dangerous.
This arguably might not be an “irrational” belief, depending on the type of snake Joe
encountered on the path. Nonetheless, Joe’s underlying belief created an unpleasant state of
anxiety, interrupting his trip down the path. Employing an REBT approach, Joe might consider
altering his underlying belief statement “Snakes are dangerous” to “This snake may or may not
be dangerous, but if I do not bother it, it will not likely bother me.” Such a belief might help Joe
have the courage to calmly walk around the snake and continue walking along the path.
Beck combined cognitive behavior theory with a systems perspective, viewing family
interactive patterns as being equal in importance to cognitions (Goldenberg & Goldenberg,
2008). His theory of the role of cognition in dysfunctional behavior is rooted in his work with
persons with depression. Beck theorized that depression resulted from erroneous patterns of
thought. As people internalize negative attributions regarding difficult life experiences, they
develop “negative schemas (enduring sets of core beliefs and attitudes about people,
relationships, and so on, that organize subsequent thoughts and perceptions)” (Goldenberg &
Goldenberg, p. 313). Each time a new situation occurs that resembles the initial situation in
which the schema was formed, the schema and its accompanying negative emotions are
reactivated. This process leads to the development of cognitive distortions, altering the depressed
person’s perception of reality (Goldenberg & Goldenberg, p. 313).
Although there are many ways of defining cognitive distortions, Ping (2000) identifies
eight common distortions, referred to as “Thinking Bugs” (pp. 12-16):

1. Should: Thoughts of shame based on expectations of what should or should not be,
distracting the person from focusing on what actually is and moving towards problem
resolution.
2. Past: Focusing on past events and what could have been if only things had happened
differently, rather than accepting the reality of what happened and moving forward.
This focus is tied closely together with unforgiveness of the self and others for past
offenses.
3. Future: Ruminating over worries and fears about the future (“what if” thoughts) over
which the person has no control. Such thoughts drain the person’s energy, preventing
them from focusing on the here-and-now.
4. Perfection: The unrealistic belief that if something cannot be done perfectly, it is not
worth trying at all, this focus keeps a person trapped in a state of helplessness and
shame.
5. Magnification: Magnification involves what Ellis referred to as catastrophizing –
making extreme negative evaluations about a relatively commonplace event (e.g. “I
made a mistake; therefore I am completely worthless”) (Goldenberg & Goldenberg,
2008, p. 312). Thinking in unrealistic extremes such as “always” and “never”, a wife
might say to her husband, “You are always yelling at me!” Does the husband literally
yell at his wife nonstop from the moment he awakens in the morning to the moment
he falls asleep at night? Probably not. Such thought patterns keep the person trapped
in a pattern of blame and negative attributions, preventing them from recognizing
exceptions to the problem that might lead to resolution.

6. Invalidation: A person may become so entrenched in applying negative attributions
and evaluations to events that even positive occurrences are viewed in a negative light
(e.g. “My teacher gave me an A; I got lucky. I didn’t deserve it” rather than thinking,
“My teacher gave me an A; I did a good job!”).
7. Mind Reading: Making negative attributions and evaluations about another person’s
intent in behavior based on an erroneous belief that one knows what the other person
is thinking.
8. Blame: An unwillingness to take responsibility for one’s own behavior,
unrealistically externalizing blame to another person, or to circumstances presumed to
be beyond one’s control (e.g. “If that redneck cop hadn’t been on a power trip, he
wouldn’t have given me a speeding ticket,” as opposed to “I was speeding and got
caught; therefore I got a ticket.”).
Beck focused on creating situations for clients that disproved negative schemas and
cognitive distortions (Goldenberg & Goldenberg, 2008). Applied to family therapy, this
approach helps each family member to examine personal schemas regarding expectations of
marriage and family relationships and how such expectations influence individual behavior. The
family is also encouraged to examine collective schemas the family has developed regarding
their interactions. The family can then work together to modify these individual and collective
schemas to remove dysfunctional beliefs, thus bringing about positive behavioral change within
the family (Goldenberg & Goldenberg).
Some of the strongest modern-day proponents of CBFT include Frank Dattilio, Norman
Epstein, and Donald Baucom (Goldenberg & Goldenberg, 2008), whose names appear frequently
in research articles on the effectiveness of CBT techniques in therapy with couples and families

(Dattilio & Epstein, 2005). Baucom and Epstein identified five cognitive distortions that
commonly affect couples (1990, as cited in Dattilio & Epstein, p. 9):
1. Selective perceptions of relational events
2. Distorted attributions about causes of events
3. Inaccurate expectations or predictions of future events
4. Inaccurate assumptions about the general nature of relationships
5. Unrealistic standards to which the relationship is held
Similar to Beck’s approach, Baucom and Epstein (1990, as cited in Dattilio & Epstein,
2005) advocate helping couples examine and modify these cognitions, developing healthier
communication patterns for future interactions.
Cognitive-behavioral theory is not the only theory to take internal thought processes into
consideration. Psychodynamic theory relies heavily on the effects of unconscious drives on
external behavior, and the necessity of gaining insight in order to achieve behavioral change.
While CBT focuses primarily on conscious thought, Beck proposed that negative schemas exist
on a level that might be considered subconscious in nature, if not completely unconscious.
Dattilio & Epstein (2005) point out that the use of reframing techniques in both structural and
strategic therapy acknowledge the significance of cognitions in sustaining negative interactional
patterns within a family, although structural and strategic therapists are less concerned with
helping families gain insight, placing greater emphasis on applying therapeutic techniques to
alter behavior (Goldenberg & Goldenberg). The Milan technique of positive connotation is
another reframing technique focused on altering cognitive attributions in attempt to bring about
resolution of symptomatic behavior, while the social constructionist use of narrative therapy
techniques may be seen as an attempt to replace negative cognitions with positive ones

(Goldenberg & Goldenberg). However, CBFT is the only theoretical perspective that employs
consistent “systematic methods… to assess and intervene with cognition in intimate
relationships” (Dattilio & Epstein, 2005, p. 9).
Part II
As a former consumer of psychotherapy, I found that REBT helped to revolutionize my
way of thinking, bringing about a vast improvement in symptoms of depression and anxiety.
Although I was in individual therapy, my husband attended a session with me in which the
counselor showed us a modified A-B-C technique devised by Petersen et al. (1990). We were
able to apply this technique to modify our cognitions about our relational interactions, thus
strengthening our marriage.
Additionally, as one who aspires to work in the future as a Christian counselor, I find the
principles of CBT to be easily integrated with the teachings of the Bible. Various Scriptures
support the concept that a person’s inner thoughts have a profound effect on outward behavior.
Proverbs 23:7 (New American Standard Bible) says of a man, “As he thinks within himself, so
he is.” Jesus said that it is out of the overflow of the heart that the mouth speaks (Luke 6:45). The
Greek word used for “heart” in this passage is similar to the word used for “mind” in other
passages (Petersen et al., 1990). In 1 Samuel 16:7 (New Living Translation), the Lord told
Samuel, “People judge by outward appearance, but the LORD looks at the heart,” implying that
our inner cognitions take greater precedence over our outward appearance and behavior.
REBT proponents believe human beings are fundamentally imperfect; one of the goals of
REBT is to help people learn to accept themselves and others unconditionally (Corey, 2005).
God’s unconditional love for people despite their imperfections is an overarching theme of the

Bible: “But God demonstrates his own love for us in this: While we were still sinners, Christ
died for us” (Romans 5:8, New International Version). At the same time, CBT encourages a
realistic view of the self and others, which is consistent with Romans 12:3 (New Living
Translation): “Be honest in your evaluation of yourselves, measuring yourselves by the faith God
has given us.”
Another goal of CBT is to alter dysfunctional behavior patterns by changing inner
thought processes. This concept is consistent with Paul’s admonition in Romans 12:2 (New
Living Translation): “Don't copy the behavior and customs of this world, but let God transform
you into a new person by changing the way you think.”
Petersen et al (1990) elaborated on Ellis’s A-B-C analytical technique to produce a
technique called Rational Self Analysis (RSA), from which the example below is adapted:
A: Activating Event
My perception of what
happened
“My husband said I look
nice today because I had
makeup on.”
B: Beliefs
What underlying beliefs
might have affected my
perception of what
happened, my
consequential feelings, and
my response?
“I look ugly without
makeup.”
“My husband only loves
me when I look nice.”
C: Consequential
Feelings
How did I feel
immediately after A
occurred?
Hurt, sad
D: Decisive
Behaviors
What did I do in response
to A?
Replied by saying “Yeah,
right!” sarcastically, then
slammed the door.
I: “Camera Check”
If a video camera had
recorded the Activating
Event, what would I see?
(i.e., an objective
perspective check)
“My husband smiled at me
and said, ‘You look nice
today honey.’ He never
mentioned noticing that I
was wearing makeup.”
II: Desired Beliefs
How might I modify my
underlying beliefs to avoid
negative feelings and
behaviors if this event
were to happen again?
“I am beautiful, inside and
out.”
“My husband thinks I’m
beautiful.”
“My husband loves me
unconditionally.”
III: Desired Feelings
How would I prefer to feel
if this event were to
happen again?
Happy, flattered, affirmed,
loved
IV: Desired
Behaviors
How would I prefer to
behave if this event were
to happen again?
Accept the compliment and
say “Thank you” instead
of reacting out of
insecurity.

The focus on Decisive Behaviors (D) in addition to Ellis’s traditional A-B-C outline
encourages clients to take responsibility for their actions, which are viewed as chosen rather than
consequential behaviors. The Camera Check (I) allows clients the opportunity to evaluate
whether their personal perspective of what happened is what actually happened – a concept
borrowed from the postmodern philosophy that we each construct our own personal view of
reality (Goldenberg & Goldenberg, 2008). The Desired Feelings (III) and Desired Behavior (IV)
sections are an extension of cognitive restructuring, helping clients envision the possibilities of
positive change. This is a similar concept to the restorying techniques employed in narrative
therapy (Goldenberg & Goldenberg).
The aforementioned cognitive distortions outlined by Ping (2000) may be presented to a
client couple or family in a psychoeducational session, then utilized alongside the Rational Self-
Analysis technique to analyze specific conflict situations. Alternatively, the therapist may allow
family members to relate their personal narratives of the family’s interactive processes, then
encourage them to reexamine their narrative in light of the list of cognitive distortions, looking
for potential “Thinking Bugs” (p. 12) in their narratives. For example, the couple described in the
previous RSA example may have experienced several cognitive distortions during the course of
this brief interaction. The wife may hold an underlying belief that “Unless I look perfect, my
husband won’t love me” (Perfectionism). She may fear that her husband will leave her in the
future if she does not maintain a high standard of appearance. Perhaps she has insecurities about
her appearance based on past negative comments her husband has made for which she has not
forgiven him. She believes her husband is only complimenting her appearance because she is
wearing makeup, but that he does not think she is beautiful without makeup (Mind-Reading). By
her sarcastic response, she is invalidating her husband’s compliment. The husband may respond

by thinking, “Nothing I say to my wife is ever good enough. She always takes things the wrong
way!” (Magnification). The husband may also think his wife shouldn’t be so overly sensitive.
CBFT techniques may be employed in analyzing child-parent conflict as well,
particularly with adolescents who tend to make negative attributions of their parents’ intentions
when conflict arises (e.g. “My parents are grounding me this weekend because they hate to see
me have a good time with my friends.”) (Goldenberg & Goldenberg, 2008, p. 314). From a faith
perspective, an adolescent can be encouraged to examine core spiritual beliefs, determine how
those beliefs influence current behavior, and consider how they might bring about desired
changes in behavior. Adolescents tend to question authority and search for inconsistencies in
societal rules (Feldman, 2008). Thus providing adolescents with opportunities to question and
reformulate their belief systems may help them to engage more willingly in the therapeutic
process rather than resisting it. However, extreme cultural sensitivity must be exercised at this
point, as the encouragement of such questioning and independent thought may be perceived as
subversive by Christian families who value unquestioning obedience to parents according to
Colossians 3:20 (New International Version): “Children, obey your parents in everything, for this
pleases the Lord.”
While CBFT can be a useful approach in many circumstances, it is important to
recognize that it requires a level of cognition that might not be present in very young children, or
persons with psychosis whose insight and ability to perceive reality is impaired. However,
research has demonstrated the success of CBFT in families of children and adolescents with
anxiety disorders as compared to other treatment methods (Katz et al., 2009). McHugh O'Leary
et al. (2009) conducted a 7-year post-treatment follow-up study of participants who received
either individual or group CBFT for the treatment of obsessive-compulsive disorder. Participant

ages ranged from 6-17 years old at the time of treatment. Results showed that “around 87 percent
of the sample were diagnosis free 7 years post-treatment” (McHugh O'Leary et al., 2009, p. 976).
The idea that CBFT would be effective in reducing anxiety symptoms is consistent with a
Scriptural view of anxiety. In his letter to the Philippians, Paul writes:
Don’t worry about anything; instead, pray about everything. Tell God what you need, and
thank him for all he has done. Then you will experience God’s peace, which exceeds
anything we can understand. His peace will guard your hearts and minds as you live in
Christ Jesus. And now, dear brothers and sisters, one final thing. Fix your thoughts on
what is true, and honorable, and right, and pure, and lovely, and admirable. Think about
things that are excellent and worthy of praise. Keep putting into practice all you learned
and received from me – everything you heard from me and saw me doing. Then the God
of peace will be with you. (Phil. 4:6-9, New Living Translation)
In this passage, Paul suggests that if one releases anxious thoughts to God through prayer,
and then changes the focus of his or her thoughts to things that are positive, that person will
experience inner peace.
CBFT techniques may be integrated with prayer and Scripture as appropriate, either
implicitly or explicitly (Tan, 2007). Implicitly, the counselor may silently pray for client families
during and between sessions, maintaining a mindfulness of Scriptural principles while doing
CBT exercises with clients to challenge distorted cognitions. Explicitly, the counselor might use
Scripture to confront client beliefs that are contrary to Scripture, and offer to pray with clients for
God to help them change their thought patterns and heal relationships. Extreme caution must be
exercised in such a directive, confrontational approach, due to the inherent power differential
that exists in the therapist-client relationship (American Association for Marriage and Family

Therapy, 2001, Section 1.3), as well as differences in Scriptural interpretation among different
denominations.

References
American Association for Marriage and Family Therapy (2001). Code of ethics. Retrieved
September 12, 2011, from
http://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx
Corey, G. (2005). Theory and practice of counseling and psychotherapy (7th ed.). Belmont, CA:
Brooks/Cole.
Dattilio, F., & Bahadur, M. (2005). Cognitive-behavioral therapy with an East Indian family.
Contemporary Family Therapy, 27(3), 367-382. doi:10.1007/s10591-005-6215-8
Dattilio, F., & Epstein, N. (2005). Introduction to the special section: The role of cognitive-
behavioral interventions in couple and family therapy. Journal of Marital and Family
Therapy, 31(1), 7-13. doi:10.1111/j.1752-0606.2005.tb01539.x
Feldman, R. (2008). Development across the life span (5th ed.). Upper Saddle River, NJ: Pearson
Education, Inc.
Goldenberg, H., & Goldenberg, I. (2008). Family therapy: An overview (7th ed.). Belmont, CA:
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therapy; Adaptations required to treat adolescents. The Psychiatric Clinics of North
America, 32(1), 95-109. doi:doi:10.1016/j.psc.2008.10.005
Khodayarifard, M., Rehm, L., & Khodayarifard, S. (2007). Psychotherapy in Iran: A case study
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Retrieved from http://proquest.umi.com
McHugh O'Leary, E., Barrett, P., & Fjermestad, K. (2009). Cognitive-behavioral family
treatment for childhood obsessive-compulsive disorder: A 7-year follow-up study.
Journal of Anxiety Disorders, 23(7), 973-978. doi:10.1016/j.janxdis.2009.06.009
Petersen, A., Sweeten, G., & Geverdt, D. (1990). Rational Christian thinking (2nd ed., Rev.).
Cincinnati, OH: Equipping Ministries International, Inc.
Ping, D. (2000). Renewing the mind: Replacing destructive thinking with Biblical truth.
Cincinnati, OH: Equipping Ministries International, Inc.
Tan, Sian-Yang (2007). Use of prayer and Scripture in cognitive-behavioral therapy. Journal of
Psychology and Christianity, 26(2), 101-111.

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