CBT in Family Therapy

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]

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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.

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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.

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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).

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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

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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.

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● 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

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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

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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;

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● 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

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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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