Journal of Family Psychotherapy, 25132–144, 2014Copyright ©.docx

Journal of Family Psychotherapy, 25:132–144, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0897-5353 print/1540-4080 online
DOI: 10.1080/08975353.2014.910023
A Cognitive Behavioral Systems Approach
to Family Therapy
TERENCE PATTERSON
Department of Counseling Psychology, University of San
Francisco, San Francisco,
California, USA
Family therapy, including conjoint approaches to couples,
families,
and parent-child dyads, is infused with concepts adapted from
gen-
eral systems theory. Many of the most popular models during
the
period when family therapy flourished in the 1960s and 1970s
directly incorporated systems theory. As modifications and new
approaches came into vogue in the 1980s and 1990s, the
contribu-
tions of systems concepts were eclipsed and theorists,
researchers,
and practitioners often failed to acknowledge their contribution.
In an attempt to re-integrate these developments in state-of-the-
art
family therapy, this article will explore systems theory, its com-
plementary characteristics with cognitive behavioral therapy,
and

how these 2 approaches can be simultaneously applied to family
therapy in a comprehensive, integrative manner. The
distinctions
between cognitive therapy, behavioral therapy, and (combined)
cognitive behavioral therapy will be delineated; after which
cog-
nitive behavioral therapy interventions and their relationship to
systems concepts will be described. An illustrative model will
be
presented with recommendations for future research.
KEYWORDS behavior therapy, cognitive therapy, family
therapy,
systemic therapy, systems theory
Address correspondence to Terence Patterson, Department of
Counseling Psychology,
School of Education, 2130 Fulton Street, San Francisco, CA
94117-1071, USA. E-mail:
[email protected]
132
mailto:[email protected]
Cognitive Behavioral Systems Family Therapy 133
INTRODUCTION
An open system is a set of objects with attributes that
interrelate in an
environment. The system possesses qualities of wholeness,
interdepen-
dence, hierarchy, self-regulation, environmental interchange,
equilibrium,
adaptability, and equifinality. (Littlejohn, 1983, p. 32)

EVOLUTION OF FAMILY SYSTEMS AND COGNTIVE
BEHAVIORAL CONCEPTS
General systems theory (GST) involves a set of analogous
descriptors that
were originally applied to biology and later ascribed to physical
and social
systems. GST was all the rage in the intellectual world in the
1920s, with
worldwide conferences held to laud its avant-garde approach to
understand-
ing phenomena (von Bertalanffy, 1968). Systems theory1 as
applied to family
therapy/psychology entails a number of principles including, for
example
(Phipps, 2004; Phipps & Vorster, 2011; von Bertalanffy, 1968):
● Organization and wholeness: That a family behaves as a
whole, that is, the
change in each member depends on all others.
● Non-summativity: That the whole is greater than the sum of
its parts
suggests that: (1) the family behavior as a whole cannot be
reduced to
their functioning alone or independently of one another (i.e.,
interac-
tion); (2) one member affects another member who affects that
original
member (i.e., circular/non-linear causality); and (3) the meaning
of the
(individual’s) part is determined by the (family as a) whole
(i.e., context).
● Hierarchical order: That systems are subject to different

orders or levels
indicates that a family, on the basis of its functions (i.e., rules),
can be
divided into subsystems that are arranged on different levels.
● Open/closed nature: That open systems exchange input with
the environ-
ment highlights that, because an open family system is one that
constantly
interacts with the environment/other systems, it can tend toward
increasing
order and organization (i.e., negentropy).
● Feedback: That systems can be self-regulating or purposeful
by virtue of
the principle of feedback means that the family can achieve
homeostasis
(i.e., restoring a system via negative feedback) or heterostasis
(i.e.,
changing a system via positive feedback).
The application, therefore, of GST to family therapy meant that
for the
first time the family—and any other unit(s) of interaction for
that matter,
1 This article refers specifically to systems concepts applied to
family therapy, rather than the various
“systemic” models such as multisystemic (Huey, Henggeler,
Brondino, & Pickrel, 2000), Milan systemic
family therapy (Boscolo, Cecchin, Hoffman, & Penn, 1987), and
others.
134 T. Patterson

including a couple—could be understood as whole, that is, not
just as indi-
viduals but also the relationship(s) between them. Accordingly,
then, this
constituted an early, important development in thinking.
In many ways, GST actually paralleled a later evolution of
psycholog-
ical theory, even art to a certain extent, in shifting away from
linear (i.e.,
straight-line), formal structure and causality to more free form,
expressionis-
tic models (Watzlawick, Weakland, Fisch, & Erickson, 1974).
Picasso in the
art world and Maslow in psychology represented these trends.
Developments
in GST and art also corresponded to the changes occurring in
the field
of psychotherapy in general, as formal structures and
procedures gradu-
ally gave way to greater flexibility and creativity.
Psychoanalysis evolved
into psychodynamic therapy, and figures such as Carl Rogers
(1961), Viktor
Frankl (1963), and B. F. Skinner (1938) introduced
revolutionary theories and
methods antithetical to psychoanalysis. The field of family
therapy emerged
in the 1950s, with pioneers such as Ackerman (1966) and
Bowen (1978)
applying psychoanalytic principles to treat families. Other
figures such as
Gregory Bateson at the Mental Research Institute (Bateson,
1980) embraced
a non-linear, more flexible systems therapy model that

incorporated newer
humanistic and short-term approaches that included the
concepts of GST.
As behavioral and cognitive theorists and practitioners entered
the
family therapy field, new applications of learning or
conditioning and cog-
nitive schemes emerged in psychotherapy. Robert Weiss
(Vincent, Weiss,
& Birchler, 1975), Richard Stuart (1998), Howard Markman
(Markman &
Floyd, 1980) and Neil Jacobson and Gayla Margolin (1979)
pioneered behav-
ioral couple therapy (BCT), and John Gottman (1999) later
became its
most prominent proponent. Andrew Christensen and Neil
Jacobson devel-
oped an integrative model (Christensen, Jacobson, & Babcock,
1995). Gerald
Patterson (Patterson & Chamberlain, 1994), James Alexander
(Alexander &
Robbins, 2010), and Robert Liberman (1970) introduced new
models of
parent-child and family therapy, and Norman Epstein and
Donald Baucom
(2002) and others developed cognitive procedures in couple
therapy. Today,
these models and variations thereof—which tend to draw on
elements of
behavior therapy (i.e., emphasizing observable behavior),
cognitive ther-
apy (i.e., focusing on schemas or cognitions), or cognitive
behavior therapy
(a combination of both)—are often more generally referred to as
cognitive

behavioral therapy (CBT).
Having considered some of the earlier developments in CBT and
sys-
tems theory, the aim of this article is to demonstrate that, as it
pertains to
the practice of family therapy, CBT fits comfortably with
systems theory and
incorporates many complementary concepts. To begin, the basic
concepts
of behavior therapy, cognitive therapy, and CBT within family
therapy will
be described. After this, an examination of the complementarity
between
CBT and systems theory will be undertaken, followed by an
illustration of
how a combination of these models may constitute an effective
method of
intervention with families.
BEHAVIOR THERAPY, COGNITIVE THERAPY, AND CBT
IN FAMILY THERAPY
It is important to clarify that the term CBT has come to be
considered as
an approach that attends to both cognitions and behaviors.
Common areas
can be identified between them and clinical practice usually
employs both
aspects, although purists exist in both areas, and radical
behaviorists and
cognitive psychologists often find the orientations to be

independent of each
other. Today “CBT” is a common response to surveys on
theoretical orienta-
tion (Solem, Vogel, & Hofmann, 2010), despite the fact that
many clinicians
are not well trained in either method and often use an eclectic,
ad hoc
approach.
Cognitive therapy per se, identifies internal processes and does
not
directly address the (stimulus-response) sequences of behavior
as conven-
tionally understood. “Cognitive” indicates that specific
attention is being
given to thought processes, and in pure cognitive therapy
thoughts are
viewed as the key to dysfunctional emotions and behaviors
(Beck, 1967).
Cognitive restructuring then becomes the primary intervention.
Behavior therapy, on the other hand, focuses on observable,
quan-
tifiable behaviors within the environment in context, and
addresses their
antecedents and consequences. Its theory and practice can be
summarized
as follows (Corey, Corey, & Callanan, 2012):
● Classical conditioning highlights certain respondent
behaviors, as in
changing a neutral stimulus into a conditioned stimulus or one
that elicits
a predictable response.
● Operant conditioning focuses on actions that operate on the

environ-
ment to produce consequences and involves response
prevention, and
reinforcement methods.
● Social learning gives prominence to the reciprocal
interactions between
an individual’s behavior and the environment.
In addition to the above, behavior analysis (O’Donohue &
Ferguson,
2006) also contributed much to the development of behavior
therapy.
Behavior analysis involves both classical conditioning and
operant principles
and relies on systematic assessment procedures rather than on
unverifiable
theories. Such behavioral models have either evolved into
approaches inte-
grating elements from other therapies or their methods have
expanded as
their evidence base has increased. Consider, for example, the
use of expo-
sure therapy. This therapy, which entails the gradual exposure
of the client
to a variety of fear stimuli while simultaneously providing an
opposite expe-
rience, such a relaxation, has now become an empirically
validated and
accepted treatment for post-traumatic stress disorder (PTSD;
Foa, 2011).
136 T. Patterson

Because family therapy generally focuses on behavioral
outcomes, the
focus of this article is primarily on the behavioral components
of CBT with
couples and families, while acknowledging that CBT is the most
commonly
used term for an integrative process. In fact, in considering the
role of cogni-
tive in comparison to behavioral components in couple therapy,
at least one
study (Halford, Sanders, & Behrens, 1993) found that while
clinically useful,
there is no empirical evidence that adding the cognitive
approach to basic
behavior therapy improves outcomes.
COGNITIVE BEHAVIORAL FAMILY THERAPY
In reality, as most cognitive behavioral family therapy was
developed and
is primarily practiced with couples, this article will frequently
refer to cou-
ple therapy as an aspect of family therapy (Patterson, 2005).
Two aspects
will be considered in this regard, namely BCT and cognitive
couple therapy
(CCT). The key focus in BCT is on the operant aspects, or the
responses that
occur following a behavior. For example, desirable behaviors
are appro-
priately reinforced, and undesirable ones are extinguished or
punished.
An action elicits a chain of responses initially from a
respondent, back to
the initiator, back to the respondent and multi-directionally to
others in the

environment/system. This operant factor illustrates that
responses do not
operate in isolation, that is, behaviors are not viewed as linear
or one-way
occurrences. Actions that precede and follow the event, the total
environ-
ment (work, home, community, family, etc.), and characteristics
of each
person are key factors in assessment, treatment, and prevention.
Applied to BCT, Jacobson & Margolin (1979) describe three
basic
elements:
● Communication—listening, receiving, and responding.
● Problem solving—respectful, collaborative, and systematic
generating of
solutions to priority issues.
● Behavior exchange—equity in task allocation.
If the change brought about by the behavior in BCT is
reinforcing, the
chances are strengthened that the desired behavior will occur
again. If the
behavior is not reinforced, the likelihood of its recurrence is
diminished.
BCT has been not only the most researched model of couple
ther-
apy, but also the most effective with specific populations,
including PTSD
(Monson, Fredman, & Adair, 2008); substance abuse (Fals-
Stewart, O’Farrell,
Birchler, Córdova, & Kelley, 2005); and juvenile offenders
(Sexton & Turner,

2010). Effectiveness studies have also demonstrated that BCT
can pro-
duce equal or better results than individual therapy with such
disorders
as depression (Beach, Whisman, & O’Leary, 1994), child
conduct disorder,
(Dadds, Schwartz, & Sanders, 1987), and eating disorders
(Bulik, Baucom,
Kirby, & Pisetsky, 2011), among others.
A CCT model that has been prominent in recent decades places
empha-
sis on the reciprocal cognitions and interactions of partners in a
relationship
(Epstein & Baucom, 2002). Expectations, attributions, and fixed
perceptions
are key to behavior, and intervention is geared toward changing
a range of
faulty cognitions. While some CCT therapists work directly
with behaviors,
the premise is that accurate cognitions will result in desirable
behaviors.
COMPLEMENTARITY BETWEEN CBT AND SYSTEMS
THEORY
The integration of systems theory with CBT forms a cognitive
behavioral
systems approach to family therapy that is simple and elegant
for the prob-
lems discussed in the previous section and other issues that

clients present.
The cognitive and behavioral nature of direct, problem-focused
treatment
involving significant others allows for observation, feedback,
and interven-
tion with the structures and dynamics of systems as they present
themselves,
and for response patterns to be modified directly. While most
forms of family
therapy allow for the concepts from systems theory to come into
play, CBT
provides a flexible framework for assessment and a pathway for
treatment in
a focused and time efficient fashion. The interlocking concepts
that provide
integration between systems and CBT can be summarized as
follows:
● Structure and organization refers to patterns in which
individuals are
arranged (and rearranged) in a system. Highly organized
systems can
either be functional or dysfunctional, open or closed, and some
structure
is necessary if the system is not to disintegrate. CBT is a highly
structured
model, which involves identifying dysfunctional thinking,
connecting them
to behaviors, and modifying thinking that is more consistent
with desired
behaviors.2
● Contextuality a central tenet in both systems and behavioral
theory,
involves the concept that individuals and groups do not live in
isolation,

and that they affect the environment and are in turn influenced
by it.
In the operant sense, behavior elicits a response and is in turn
affected by
that response. Contextuality allows behavior to be fully
understood and
addressed.
2 It should be noted here that the cognitive component of CBT
relates to intrapsychic phenomena,
and when cognitive therapy is practiced independently, the
internal world of the individual is focused
upon. The more common application of CBT incorporates the
intrapsychic to some degree, but the
interactive and contextual aspects (observable behaviors) of the
relationship are also emphasized.
138 T. Patterson
● Communication and other overt behaviors involving
circularity are present
in open and closed systems; one action elicits a reaction in
which feedback
loops occur back and forth. These can expand to the
surrounding envi-
ronment and create multiple cross exchanges. Behavior
therapists look
for contingencies of response through communication patterns,
and how
those responses create new exchanges. Jacobson and Margolin
(1979), as
noted earlier, posited communication as one of the three key
elements
of BCT.

● Homeostasis is related to the above elements in that
individuals and
systems strive to maintain a balance that is constantly
challenged by inter-
action with the environment and the inevitable response-
initiation cycle
that ensues. Interaction requires a response, which can make the
status
quo impossible and a new adaptation unavoidable. The focus on
direct,
in-session and daily activities in CBT inevitably disrupts old
patterns and
aims directly at achieving a more functional balance within the
system.
APPLICATION OF COGNITIVE BEHAVIOR SYSTEMS
THERAPY
Comprehensive CBT involves systematic assessment that
includes the follow-
ing: Structured interviews, paper and pencil or computerized
inventories,
structured and coded observation, behavioral logs or records,
and physio-
logical measures. Data on logical categories and quantities of
behavior are
recorded and prioritized as a key to intervention and
modification of proce-
dures throughout treatment. A baseline of behaviors is
established and targets
for change are established. Collaboration with clients is key to
understanding
behaviors and developing and modifying treatment plans.
Intervention takes
place with an understanding of the contingencies of behavior

(antecedents
and consequences), and can include: Stimulus control, response
prevention,
positive and negative reinforcement, shaping and extinguishing
behaviors,
exposure and systematic desensitization, emotion modulation,
and cognitive
restructuring.
Ongoing assessment may indicate that behaviors have increased,
declined, or remained at baseline, and interventions may be
modified at any
point. Feedback is also obtained periodically so that the client’s
perception
of the treatment is fully understood and used to assess the need
for a change
in intervention. Assessment upon termination of treatment and
at periodic
intervals thereafter is common in research studies and useful in
clinical treat-
ment. CBT therapists evaluate not only improvement in target
behaviors, but
also the secondary impact of various interventions.
Many of these standard interventions are common to all
varieties of
CBT couple and family models, with the emphasis depending
upon the
orientation of the clinician. One who is more cognitively
oriented in couple
therapy would begin with the thoughts of each spouse about his

or her
partner, and focus intervention on developing more functional
cognitions
and behaviors. A more behavioral CBT therapist would begin
with the
antecedents and consequences of the target behaviors, note the
thoughts of
each about these behaviors, and apply positive reinforcement
and response
prevention as primary methods.
Applied in conjunction with systems concepts, then, CBT relies
heavily
on organization and wholeness, placing emphasis on the
structural elements
of client behaviors (antecedents and consequences), and views
clients in
the entire context of their environment. Therapeutically, CBT
adheres to
a fluid structure involving assessment, treatment formulation,
and ongoing
evaluation. Non-summativity applies to CBT in viewing the
functioning of
whole system rather than the individual member alone as the
essential focus
of intervention.
Hierarchical order is evident in CBT in recognizing that
boundaries are
necessary in subsystems in terms of age, roles, and relative
influence, and
without them structure and order are not possible. Feedback
applies to CBT
in the emphasis on multi-directional, clear communication in
relationships;
the openness of a system both within itself and to the

environment affects
the degree and type of communication that occurs.
As can be seen from the above, intervention in (integrated)
cognitive
behavior systems therapy requires a constant focus on systems
components
while using a flexible structured approach. One of the most
salient advan-
tages of this model is maintaining the focus on the interactive
aspects of
the couple or family, rather than on the internal processes of
individuals.
In circular and non-summative fashion, the therapist uses a wide
angle lens
in viewing the family, seeing the unit as a whole rather than as
individual
members.
A brief practical illustration of the use of CBT and its
complementarity
with systems concepts will highlight the simplicity and ease of
use in family
therapy.
Illustration of Cognitive Behavioral Systems Approach to
Family
Therapy
Let us now look at two examples of processes in family
systems.
Example A: Family A is faced with the death of a close
grandparent, the
job loss of the mother, and an accident by the teenage son. They
typ-

ically do not discuss difficult matters nor express their emotions
to each
other easily. There is no clear delineation of responsibility for
chores, such
as bill paying or for social activities, and the children do not
know who
140 T. Patterson
to go to for advice or permission. They tend to be reactive to
events
in the sense that they rarely plan ahead, and have generally
maintained
the same routines and relationships among themselves for 20
years. They
also are not “joiners,” in that they are not members of churches,
com-
munity organizations, or social groups. They maintain their
equilibrium
by neither openly discussing these issues nor planning to
address them.
Consequently, the anxiety is mounting within and among them,
a younger
son is becoming depressed, and a financial crisis is
approaching.
Example B: Family B is facing the same stressors as Family A,
but as their
routine is to have dinner together each evening when they
discuss major
issues, they are aware of the details of these events and of each
others’
reactions to them. The parents are clearly in charge of major
decisions and

responsibilities are well defined. They are organizers and
planners and the
children have developed this approach as well. The family has
clear ideas
of how to decrease spending and increase income, deal with the
accident,
and they are planning a memorial for the beloved grandparent
together.
They participate regularly in school, church, and community
activities,
and as an open system, others are stepping forth to assist and
offer con-
dolences. They maintain an equilibrium as well, and the
emotional climate
is positive and no family members are symptomatic.
Systems concepts can be clearly seen in both families. Family A
lacks
organization, structure, boundaries, communication (feedback
loops) and
exemplifies a closed system. Their homeostasis maintains them
as a unit,
but also allows the tension to mount as a potential crisis and
disintegration
looms. Their connection to a larger ecosystem is lacking,
furthering their
tendency toward disorder and pathology. Conversely, Family B
is organized
with an appropriate parental hierarchy, clear rules and
boundaries, and flex-
ibility in adapting to critical life changes. Their stress is by
moderated by
these factors and their ties to outside groups. Their balance and
wholeness
can facilitate their growth as a unit and protect those
individuals who might

otherwise become symptomatic.
Now add to this CBT principles and the therapist may then
proceed as
follows with Family A:
● A thorough assessment would be conducted to obtain a view
of the entire
context of the family and each individual’s views and
behaviors;
● A plan would be developed with the family to identify
changes that would
be reinforcing to each family member and the entire system, and
an
appropriate hierarchy would be developed between parents and
children;
● Goals such as open communication and connection with the
larger com-
munity would be identified and prioritized, with responsibility
assigned to
specific individuals;
● Potential obstacles to success and ways to circumvent them
would be
discussed; progress would be monitored daily by family
members and
evaluated regularly in therapy sessions;
● Ongoing feedback would be elicited from each family member
and

modifications would be employed as needed.
QUESTIONS FOR FUTURE RESEARCH
This article has described CBT as one of the most widely
researched forms
of family therapy and illustrated how it can be integrated with
systems con-
cepts. Yet, as in any model, there are no simple prescriptions on
how to
proceed, and the methods are not cut and dried. Questions
remain on how
the integration of cognitive, behavioral, and systems principles
can extend
its benefits more deeply and broadly in family intervention
science. Having
identified that these approaches would appear to be highly
complementary,
future research could shed light on important questions such as:
● Which proximal and distal antecedents to couple, family, and
parent-child
behaviors should be prioritized across cultures, problems,
settings, and
specific family forms?
● How far should circular effects of problems and resulting
interactions be
explored and which can be viewed more linearly (i.e., in terms
of cause
and effect)?
● How can homeostasis be maintained in terms of maintaining
old patterns
of behavior and dealing with potential disintegration of a family
or abuse

of a member?
● How can the perceptual styles and cultural backgrounds of
individual fam-
ily members be assessed more precisely in order to achieve an
optimal
balance of cognitive and behavioral techniques?
● What are the keys to determining which and when direct
behavioral or
cognitive interventions will be effective for couples and
families most likely
to drop out of therapy after a few sessions?
SUMMARY AND LIMITATIONS
This article has demonstrated that systems and cognitive
behavioral
approaches interlock organically and, in combination, form a
pragmatic
approach to therapy with couples and families. In fact, systems
concepts
can expand the scope of any type of therapy, including
treatment of indi-
viduals and groups, as long as clients are viewed in their larger
contexts
and multiple factors are considered in assessing and treating
presenting
142 T. Patterson
problems. Behavior and cognitive therapies in isolation have
been fre-
quently viewed as overly intellectual and mechanistic and,

indeed, without
a systems lens they can be limited. CBT approaches add
structure and tech-
niques to the systems approach, while systems concepts broaden
basic CBT
methods.
However, limitations exist in the application of CBT and
systems mod-
els to family therapy. CBT in isolation can result in rigid,
formulaic methods,
while systems models can ignore situations where clear cause
and effect
sequences exist, temporary equilibrium may rapidly lead to
family break-
down, and urgent situations may not be addressed in a timely
manner.
An example of when the concept of reciprocity or circularity is
taken to the
extreme is in a family where repeated, one-way abuse of a
family member
occurs. Such abuse should not be viewed solely in terms of
cause and effect
or circularity; there is clearly a perpetrator and a victim, as well
as precipitat-
ing events, and swift action must be taken to provide safety. An
appropriate
view would be to assess the antecedents and consequences of
the abuse,
and immediately take action to protect the victim in an ethical
and legal
manner. An integrated CBT and systems approach would take
the assess-
ment of reciprocity into account while using effective CBT
methods. This
approach would increase the opportunity for safety and

autonomy of the
victim of abuse.
Understood holistically, a cognitive behavioral systems
approach can be
applied effectively to many different types of problems,
settings, and pop-
ulations. But just as with any specialized approach, a significant
amount of
intensive training is required in order for results to be robust
and reliable.
Rigid adherence to a single school of therapy can be ineffective
in multi-
cultural, naturalistic, dynamic settings such as schools,
community agencies,
correctional facilities, and crisis situations. The flexibility of a
(integrated)
cognitive behavioral systems approach to family therapy makes
it applicable
to multiple, diverse environments and populations.
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ABSTRACTINTRODUCTIONEVOLUTION OF FAMILY
SYSTEMS AND COGNTIVE BEHAVIORAL
CONCEPTSBEHAVIOR THERAPY, COGNITIVE THERAPY,
AND CBT IN FAMILY THERAPYCOGNITIVE BEHAVIORAL
FAMILY THERAPYCOMPLEMENTARITY BETWEEN CBT
AND SYSTEMS THEORYAPPLICATION OF COGNITIVE
BEHAVIOR SYSTEMS THERAPYIllustration of Cognitive
Behavioral Systems Approach to Family TherapyQUESTIONS
FOR FUTURE RESEARCHSUMMARY AND
LIMITATIONSREFERENCES

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