COUN 601 Variations on a Theme Family Therapy Approaches Utilizing.pdf

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Variations on a Theme: Family Therapy Approaches Utilizing

Principles from the Cognitive-Behavioral Paradigm

James A. Saunders

Liberty University

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Abstract

In response to the growing cognitive-behavioral influences upon systems-oriented family

therapy, Functional Family Therapy (FFT) emerged during the early 1970s as a viable treatment

option for at-risk adolescents and their families. The first section of this paper will explore the

core principles, techniques, and strengths of this evidence-based family therapy. Additionally,

FFTs similarities to other empirically validated family treatments will be explored. The second

half of this paper presents a theoretical integration model of family psychotherapy compatible

with a Christian worldview. The philosophical assumptions and models of personality, health,

and abnormality associated with Cognitive-Existential Family Therapy (CEFT) will be explored.

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Variations on a Theme: Family Therapy Approaches Utilizing

Principles from the Cognitive-Behavioral Paradigm

The use of cognitive-behavioral psychotherapeutic methods to treat symptoms of family

dysfunction is a relatively recent occurrence within the field of marriage and family therapy.

Goldenberg and Goldenberg (2013) posit that behavioral methods were first applied with

individuals as early as 1960; however, the specific use of cognitive modalities with whole

families did not come about until the early 1980s. Between these gaps in time, Functional

Family Therapy (FFT) emerged as an empirically verified, family-based approach to dealing

systemically with at-risk youth. As a family-based model, FFT attempts to integrate concepts

contained herein, as they relate to gender, ethnicity, or socio-economic issues have been omitted.

Functional Family Therapy

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The first section of this paper will examine the principle elements of Functional Family

Therapy (FFT), including its history and key figures, core philosophy, techniques and strengths

of the model, and similarities with other leading evidence-based family therapies.

Historical Development and Key Figures

In the early 1970s instances of juvenile delinquency, violence, and adolescent substance

abuse were steadily increasing while intervention programs were scant and seriously lacking in

both structure or continuity (Sexton & Alexander, 2000). Dr. James Alexander, the creator of

FFT, developed the model in an effort to reach out to those at-risk youth and their families who

(a) lacked resources, (b) were difficult to treat, (c) were diverse in terms of family organization,

cultural and ethnic concerns, presenting problems, and relational dynamics, (d) often presented

as hopeless and angry, and (e) were frequently perceived by other counselors or state agencies as

Turner (Oregon Research Institute), and co-progenitor Dr. B. V. Parsons. Each of these

individuals has contributed to the vast collection of research on the FFT model of treatment (for

examples of their work, see Sexton & Alexander, 2002; Waldron & Turner, 2008; Sexton &

Turner, 2010; Barton, Alexander, Waldron, Turner, & Warburton, 1985).

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Since its inception, three of FFTs hallmarks have been (a) its reliance upon empirical

validation to demonstrate that it is a well-established treatment intervention, (b) its

transportability across communities and cultures, and (c) its generalizability across client

populations and therapists (Barton et al., 1985). Sexton and Alexander (2002) report that “the

results of 13 published clinical trial studies suggest that FFT is effective in reducing recidivism

between 26% and 73% with offending, moderate, and seriously delinquent youth as compared to

both no treatment and juvenile court probation services” (p. 245). In one specific study on the

successful implementation of FFT across five different community agencies, Duncan, Davey,

and Davey (2011) found that “FFT provides quantifiable positive results in a very short period of

time and outcome measurements” (p. 45). According to Waldron and Turner (2008), studies

conducted on FFT have contained the following core parameters: (a) relatively large samples, (b)

clearly specified sample characteristics, (c) careful measurement, (d) extensive model

specifications, (e) manually guided treatments, (f) adherence monitoring, and (g) adequate

2012). In one specific study which reviewed the transport of FFT into a Dutch community,

Breuk, Sexton, van Dam, Disse, Doreleijers, Slot, and Rowland (2006) concluded that the FFT

model—when adhered to as designed—“can fit into this culturally diverse treatment setting” (p.

517). Breuk et al. (2006) also found that a strength of the model is its ability to retain fidelity

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(procedurally and with proposed outcomes) while matching “the unique cultural and ethnic

variations of the client” (p. 528; see the complete article for a thorough discussion of the

“growing pains” experienced in this transport process, including limitations, unexpected gains,

and areas for improvement).

Closely tied to FFTs transportability, is its historic capability to be generalized in a

variety of treatment settings and amongst diversified therapists. Much of FFTs success in this

area is tied to its system of delivery. Also, researchers have found that FFT can be taught to and

successfully implemented by bachelors, masters, or doctoral-level clinicians (Duncan, Davey, &

Davey, 2011). Beginning in the late 1990s, the developers of FFT refined their model

and introduced a systematic approach to training and program implementation (Sexton &

Alexander, 2000). According to Sexton and Turner (2010), the training protocol for

FFT includes three elements: (a) clinical training, (b) follow-up training, and (c) ongoing

supervision. One particular study found that greater clinician adherence to the FFT model is

this modality (Sexton & Turner, 2010; Duncan et al., 2011, Henggeler & Sheidow, 2012, etc.)

and its inclusion in contemporary graduate-level textbooks (see Goldenberg & Goldenberg,

2013, for a cursory overview of the FFT model). In order to further develop an understanding of

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this family-based modality, the core principles, techniques and strengths of the model will be

considered in the following subsection.

Core Principles, Techniques, and Advantages of the Model

Fundamentally, FFT is a cognitive-behavioral and systems-oriented family therapy

approach concerned with helping family members understand the “function” that behaviors (both

positive and negative) play in regulating relationships (Goldenberg & Goldenberg, 2013; Sexton

& Alexander, 2000). According to Sexton and Turner (2010), “a central premise of FFT is that

adolescent problem behaviors are a consequence of dysfunctional family processes. . .” (p. 341).

Consequently, FFT aims (a) to alter maladaptive family patterns which maintain the adolescent’s

problems, (b) to change negative family interactions through use of behavioral interventions, and

(c) to reinforce positive ways of responding and more effective problem-solving approaches

within the family (Rowe, 2012). In an interview conducted by Onedera (2006), Dr. James

Alexander (progenitor of FFT) made the following observation about the importance of family to

Waldron and Turner (2008) note that behavioral interventions such as communication and

problem-solving skills are introduced into a family system only after engagement and motivation

for change have taken place for the whole family system. Ongoing assessment which focuses on

“understanding the ways in which behavioral problems function within family relationship

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systems” is vital to the success of the interventions applied using the FFT process (Sexton &

Alexander, 2000, p. 4). Broadly defined, Sexton and Alexander (2000) observe that assessment

in FFT encompasses the following elements:

behavior problem

become targets of treatment

developmental level along with any potential psychological conditions, the family

context as it relates to daily family life routines (parenting, relating, examples of family

support, and the behavioral and contextual factors that help shape the adolescent (external

risk factors, presence or absence of community resources, peer group interactions).

FFT adopts a systematic and multi-phased approach to treatment in which the developers

focus. The therapist makes use of interpersonal skills (such as validation and reframing) during

this initial phase and maintains high availability to provide services. Once families are

motivated toward changed, the therapist’s goal is to address behaviors directly through the

development of individualized “change” plans and the introduction of relational

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skill building techniques. Specific interventions utilized during this phase include the use of

structure to focus each session, change plan implementation, and modeling/training of the

desired behaviors.

The final “generalization” phase incorporates plans to prevent relapse and the goal to

include community resources necessary to help maintain and support the changes which have

been introduced into the family system. In this phase, the therapist shifts to more of a case

manager concerned with acquiring resource helps and employing relapse prevention

interventions (for a complete description of these therapeutic phases, see Sexton and Alexander,

2000). It must be noted that the overarching goal of FFT is not to change the functions of

existing family interactions (Goldenberg & Goldenberg, 2013). As Slesnick and Prestopnik

(2009) have observed, “the therapist must replace maladaptive behaviors (running away and

alcohol use) with adaptive behaviors that maintain the interpersonal functions” (p. 262).

The advantages and appropriateness of the FFT model have been addressed in a study

problems, who have had other services in the past but have not had much success, (d)

provide intense in-home [and office-based] counseling services, (e) the program helps

families from a broad range of backgrounds as well as a range of problems going on in

the home or at school, (f) collaboration between agencies led to some unique

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temporality (Jones & Butman, 1991, p. 279). According to Jones and Butman (1991), “the crux

of Kierkegaard’s ideas comes in his assertion that to be a true self is to synthesize our opposing

tendencies as we are grounded in God” (p. 280). I believe that whole families as well as

individuals wrestle with these concepts. In essence, my CEFT perspective asserts that

individuals and families are constantly defining themselves—engaging in meaning-making—in

relation to the aforementioned three areas. Proper functioning—for individuals and families—

consists of striving for a balanced existence and making responsible choices in the face of

conflicting stimuli. Additionally, individuals and families become “known” to self and others

(we build our reputations) by the actions and approaches that they take in each arena (Comer,

1995, p. 55). This understanding of meaning-making, living a balanced life, and being known by

our actions is consistent with a Christian worldview (see Ecclesiastes 7:14-18 for a discussion of

meaning-making and living a balanced life; see Matthew 7:15-20 for a discussion about being

known by the “fruits” (actions) one produces).

(p. 286). As it relates to an individual’s or family’s sense of “being,” I believe that my role as a

practitioner of CEFT is to enter into the “world” of a family and work to understand how “it is

being experienced by the individual family members as well as the family as a functioning

whole” (Goldenberg & Goldenberg, 2013, p. 251).

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Borrowing from cognitive-behavioral family therapy, my CEFT model recognizes that

early attempts at meaning making are synonymous with core schematic development. When

applying this principle to families, “each member’s set of schemas include attributions about

why certain events occurred in the family, . . . what responsibilities each family member should

have, . . . and similar cognitions about family life” (Goldenberg & Goldenberg, 2013, p. 338).

The thoughts, assumptions, and attitudes of a person directly influence behavior towards self, the

world, and others. Therefore, I believe that individual or family core schemas that are faulty can

easily contribute to distorted realities in each of these realms. In order to correct these cognitive

distortions through CEFT, my task is to assist families to restructure their dysfunctional beliefs

and change existing behavioral patterns (Goldenberg & Goldenberg, 2013). Edwards (1990) has

noted that “articulation of the clients’ personal meanings is a necessary first step, and this is

followed by a testing of those meanings against other aspects of their experience and meaning

framework” (p. 109). Additionally, borrowing from object relations family therapy, my CEFT

Traditional models of existential therapy have viewed health and abnormality in terms of

“authentic” living. Accordingly, themes of health involve courage, determination, and a

willingness to grapple with personal anxieties related to our experiences of “being” (or not

“being”) in the world and in relation to others (Murdock, 2009, p. 187). Conversely, themes of

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abnormality revolve around the inability to effectively and genuinely “manage” life experiences.

Jones and Butman (1991) applaud the fact that existential therapy is a leading modality in

encouraging individuals and families to consider such issues as (a) death, (b) choice, (c)

isolation, (d) meaning, (e) growth, (f) responsibility, and (g) guilt (p. 289). In my CEFT model, I

adopt the premise that a modicum of anxiety is healthy and serves to keep individuals and

families honest as they wrestle with such weighty matters. Healthy angst humbly reminds us of

the significance of our freedoms and calls us to consider the weight of our responsibilities and

the often powerful consequences of our choices (Jones & Butman, 1991, p. 286).

Another “authentic” health theme of traditional existentialism is the ability to live in such

a way as to not deceive oneself or others. Jones and Butman (1991) have asserted that “in order

to fulfill our destiny, we must be a self in truth, relentlessly. To be whole, we must be deeply

rooted in our being, not the being of others” (p. 286). From my CEFT perspective, then, it is

imperative that personal attempts at meaning-making involve clearly established identities and

importance of consistency in relating to others: “Just say a simple, ‘Yes, I will,’ or ‘No, I [will

not].’ Your word is enough. To strengthen your promise with a vow [or superfluous speech or

behavior] shows that something is wrong.” (Matthew 5:37, New Living Translation). Ultimately,

CEFT views personal and family health as an achievement of balance in the following areas: (a)

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being responsible, (b) being honest with self and others, (c) appreciating personal limitations and

one’s finitude, and (d) acting in a beneficial and respectful manner toward others. How

individuals and whole families interact with these dynamics is an essential aspect of my CEFT

model.

Yalom, an early proponent of humanistic existential therapy, espoused the notion that

people “fall into despair as a result of a confrontation with harsh facts of the human condition”

(as quoted in Murdock, 2009, p. 187). My CEFT model modifies this position by incorporating

an appreciation for the cognitive distortions and core maladaptive schemas which contribute to

the development of such a fatalistic mindset. Beck (as quoted in Ottens & Hanna, 1998) asserts

that freedom from despair, maladaptive living, and a negative mindset “is dependent on the

development of versatility, flexibility, and adaptability . . . accepting one’s own limitations . . .

and widening the span of acceptable goals so that ‘all the eggs are not in one basket.’” (p. 317).

To that end, the CEFT perspective asserts that cognitive restructuring of core schemas is

(self), Mitwelt (self in relation to others), and Umwelt (the world in which we exist).

In terms of achieving healthy living, my CEFT model strives to help individuals and

whole families recognize that changes in their perspective will directly impact their sense of

meaning-making. To that end, CEFT endeavors to help people understand that “meanings are

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not carved in stone[.] [People are free] to investigate, experiment with, and invent meanings of

their own—meanings that may be more compatible with their pattern of interests and needs than

those with which they started” (Efran, Lukens, & Lukens, 1990, p. 53). From the Christian

perspective, this view is tempered by the exhortation of St. Paul in Romans 12:2: “[Do not] copy

the behavior and customs of this world, but let God transform you into a new person by changing

the way you think. Then you will know what God wants you to do, and you will know how good

and pleasing and perfect his will really is” (New Living Translation).

The Therapeutic Process

From the CEFT perspective, the role of family counseling is to provide insight into the

early maladaptive core schemas and relational attachments that individuals and whole families

construct in an effort to make meaning out of their life experiences. Coupled with this goal of

awareness is the intentional cognitive restructuring of beliefs, assumptions, and attitudes toward

more healthy, balanced perceptions of self or family in relation to the core domains (Eigenwelt,

human nature and of the possibilities of the therapy situation. It provides a framework in

which client and therapist can grapple with issues that are ill-defined or that emerge from

the deeper levels of meaning in the client’s world (p. 118).

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Similar to traditional modalities of cognitive-behavioral family therapy and existential

therapy, I will take an active role in the counseling process as a CEFT therapist. Comer (1995)

notes that the therapeutic relationship is a central determinant to the success of therapy and that

the following elements of collaboration must exist: (a) therapist and client(s) must be open to

each other, (b) each must commit to working hard, and (c) each must adopt a willing position

toward growth and learning (p. 155). Additionally, from the existential perspective, “the

therapist’s authenticity serves as a model for the client[s] as they examine the meaning of

existence and scrutinize the therapy encounter itself” (Comer, 1995, p. 155). Unlike traditional

models of existential therapy, as a Christian CEFT therapist, I can demonstrate authenticity by

drawing my client’s attention to the ultimate need for an encounter with a higher being. This is

in keeping with the original existential theory of Kierkegaard, who postulated that humans move

through three distinct phases in their quest of meaning-making: (a) “the aesthetic stage, wherein

the essence of life is believed to be having one’s own way”; (b) “the ethical stage, wherein one

principal techniques utilized in CEFT are (a) the downward arrow, “where the meanings of an

event are traced to its fundamental consequences” and faulty core beliefs (Ottens & Hanna, 1998,

p. 320); (b) guided imagery, where the use of images and role-play help to “conjure up the

problem situation” and assist the family members to “identify cognitions associated with the

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feelings” (Murdock, 2009, p. 342); (c) questioning, where through inquiry I will draw

“inferences from a client’s attitudes and expressions until a particular belief is identified . . . It

can also be done by exploring the presuppositions inherent in a dysfunctional belief and

identifying them at that deeper level” (Ottens & Hanna, 1998, p. 320); and (d) thought recording,

which involves having family members “recording various occurrences of [automatic thoughts]

between counseling sessions” (Murdock, 2009, p. 339) coupled with counselor review of the

responses to these automatic thoughts at the next session. All CEFT goals and interventions

serve to expose individuals and whole families to the following principles in the context of

meaning-making: (a) the role of schemas in mediating emotional responses to situations, (b) the

importance of construing personal and family meaning from experiences, (c) faulty information-

processing that contributes to distorted perceptions of reality, (d) and value in the scientific

method for providing evidence to adjust a deeply held (and often problematic view of reality

FFT can be replicated among clinicians and within a variety of treatment settings. FFT’s focus

on the functionality of behaviors and building positive relational contexts was also explored.

Lastly, FFT was compared with other evidence-based family therapies. Although similarities

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with other models do exist, FFT is unique and proves its worth as a system-oriented, cognitive-

behavioral family therapy.

In the second section of this paper, Cognitive-Existential Family Therapy (CEFT) was

presented as a theoretical integration model which comports with a faith perspective. CEFT

blends additional concepts of existential theory with the cognitive aim of identifying faulty core

schemas which exist for individuals and whole families in the three domains of “being.” Health,

according to CEFT, is found in living a balanced life with full awareness of individual and family

limited freedoms, responsibilities, choices, and impact on others. CEFT is conducted

collaboratively and focuses on guided discovery, the cognitive restructuring of automatic

thoughts and core maladaptive schemas, and fostering adaptive meaning-making. In summary,

the proposed model of family therapy has promise for practitioners who embrace both

Christianity and theoretical integration.

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