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chapter_8_cbt.pptxChapter 8: Cognitive-Behavioral and Mindfulness-Based Couple and Family Therapies
“The key thread that binds these diverse perspectives [behavioral therapies] is a demand for continual empirical challenge. Every strategy, and every case, is subjected to empirical scrutiny that aims to define the specific therapeutic ingredients that facilitate the achievement of the specific benefits desired by the family. In other words, every family presents a new experiment with the potential to advance therapeutic frontiers.” — Falloon, 1991
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Lay of the Land
Types of therapies
Behavioral family therapy: Focuses on parent training.
Cognitive-behavioral family therapy: Integrate cognitive elements into therapy with couples and families.
Integrative behavioral couples therapy: Enhanced version of behavioral couples therapy; humanistic component added in an attempt to improve long-term outcomes.
Gottman method couples therapy: Scientifically-based approach to couples therapy based on Gottman’s 30 years of research on key differences between happy/unhappy marriages.
Functional family therapy: Treatment for working with troubled teens and their families.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Behavioral and Cognitive-Behavioral Family Therapies
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
In a Nutshell: The Least You Need to Know
Cognitive-behavioral therapies (CBTs)
Roots in behaviorism, the premises of which are still widely used with phobias, anxiety, and parenting.
Until 1980s, most family CBT were primarily behavioral: behavioral family therapy and behavioral couples therapy.
Recently, approaches that more directly incorporate cognitive components have developed: cognitive-behavioral family therapy and Gottman method couples therapy approach.
Family CBTs integrate systemic concepts into standard cognitive-behavioral techniques.
Examining how family members reinforce one another’s behaviors to maintain symptoms and relational patterns.
Therapists assume directive, “teaching” relationship with clients.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Juice: Significant Contributions to the Field
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Parent Training
Influence on parenting
Reinforcement: Positive or negative responses from environment shape future behavior.
Consistency: Reinforcing every time is the key, especially in the beginning.
Parent training
Teaching compliance and socialization.
Improving parental requests.
Monitoring and tracking.
Creating a contingent environment.
Five-minute work chore
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Rumor Has It: The People and Their Stories
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Significant Contributors
Gerald Patterson and Marion Forgatch
Neil Jacobson and Andrew Christensen
Norman Epstein
John Gottman
Frank Dattilio
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Big Picture: Overview of Treatment
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Process for CBFTs
4 steps
Assessment: Obtain detailed behavioral and/or cognitive assessment of baseline functioning.
Target behaviors and thoughts for change: Identify specific behaviors and thoughts for intervention.
Educate: Educate clients on irrational thoughts and dysfunctional patterns.
Replace and retrain: Interventions designed to replace dysfunctional behaviors/thoughts with more productive ones.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Making Connection: The Therapeutic Relationship
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Directive Educator and Expert
Primary role
To serve as an expert who directs and educates client and family on how to better manage problems.
Then and now
Traditional CBFT therapists maintained distance from clients, diagnosing and prescribing interventions without achieving emotional connection.
Quality of therapeutic relationship being a strong predictor of positive outcomes.
Therapists are increasing use of empathy and warmth to create connection/clients.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Empathy in Cognitive-Behavioral Counseling
Use of Empathy
Cognitive-behavioral therapists use empathy for entirely different reasons than humanistic therapists.
CBT uses empathy to create rapport, which then allows for “real” interventions that will lead to change.
Idea is to make clients feel more comfortable with the process.
Doesn’t “integrate” experiential concepts, they are adapting it.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Contemporary Cognitive-Behavioral Alliance
Five practices for fostering counseling alliance
Actively collaborate with patient: Decisions about counseling should be jointly made with client.
Demonstrate empathy, caring, and understanding: Expressing empathy help clients trust the therapist.
Adapt one’s counseling style: Interventions, self disclosure, and directiveness adjusted for each client.
Alleviate distress: Helping clients solve problems and improving moods enhances counseling relationship.
Elicit feedback at the end of the session: By asking clients “how did it go?” at the end of each session, therapists can intervene early in cases of alliance rupture.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Written Contracts
Relationship on paper
Frequently use written contracts spelling out goals and expectations to help structure the relationship and to increase clients’ motivation and dedication.
Putting goals and agreements in writing and having clients sign that they agree can be a very motivating experience that creates commitment to the process.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Viewing: Case Conceptualization and Assessment
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Defining Problems
Problem analysis
Process of taking vague descriptions and developing them into a clear description of behavioral interactions and emotional consequences.
Focuses on present-day behaviors, emotions, and cognitions.
CBFT therapists listen for the behaviors, emotions, and thoughts that make situations a problem.
Focus of treatment is on reducing undesirable thoughts, feelings, and behaviors and increasing more desirable ones.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Assessment of Baseline Functioning
Monitoring and tracking
Therapists conduct a baseline assessment of functioning, which provides a starting point for measuring change.
Ask clients to log the frequency, duration, and severity of specific behavioral symptoms.
Identify antecedent events that may have triggered symptoms.
Baseline assessment provides more detailed and accurate information than client recall alone.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Functional Analysis and Mutually Reinforcing Behaviors
Functional analysis
Identifies the precise contexts, antecedents, and consequences of the problem behavior.
Basic formula: antecedent behavior consequence.
Mutually reinforcing behaviors
Examine how patterns are maintaining the symptom.
Example: If a parent inconsistently reinforces a child’s problematic behavior, the behavior is likely to continue.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Functional Analysis Questions for Families
Examples
How does this specific problem handicap this person (and/or the family) in everyday life?
What would happen if the problem were reduced in frequency?
What would this person (and his or her family) gain if the problem were resolved?
Who (or what) reinforces the problem with attention, sympathy, and support?
Under what circumstances is the specific problem reduced in intensity?
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Functional Analysis Questions for Couples
Strengths and skills of the relationship
What are the major strengths of the relationship?
What is each spouse’s capacity to reinforce the other?
What behaviors are highly valued by the other?
Presenting problems
What are the primary complaints (defined behaviorally)?
What behaviors occur too frequently? Under what circumstances and with what reinforcements do they occur?
What behaviors occur too infrequently? Under what circumstances and with what reinforcements do they occur?
Sex and affection
Is either unsatisfied with the frequency or quality of their sex life? What behaviors are associated with the dissatisfaction?
Is either unsatisfied with the frequency or quality of nonsexual physical affection? What behaviors are associated with the dissatisfaction?
Is either in an extramarital affair? Is there a history of affairs?
Future prospects
Are both seeking to improve the relationship, or is one or both contemplating separation?
Have steps been taken toward separation or divorce?
Social environment
What are the alternatives to this relationship, and how attractive are they?
Is their social network supportive of separation?
If there are children, what are the current effects, and what might be the effects of divorce?
Individual functioning
Does either have a significant mental or physical health disorder?
What is the relationship history of each, and how does it affect the present relationship?
Adapted from Holtzworth-Munroe & Jacobson, 1991, pp. 106–107
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
A-B-C Theory
What it is
Developed by Albert Ellis to analyze irrational thinking with individuals.
Has also been applied to working with families.
How it works
A is the “activating event.”
B is the “belief” about the meaning of that event.
C is the emotional/behavioral “consequence” based on belief.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Ellis’s A-B-C Theory
In practice
Most clients report that A causes C:
“I am depressed because my husband does not help out with the kids.”
“I am angry because my son doesn’t listen to me.”
Therapist’s job is to help client identify the “B” belief that the client does not put into the equation.
“If he does not help with the children in the ways I want him to, he really does not care about me.”
“Good kids follow through on parental requests without questioning the parent.”
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Family Schemas and Core Beliefs
Eight types of cognitive distortions about families
Arbitrary inference: A belief based on little evidence.
Selective abstraction: Focusing on one detail while ignoring context and other obvious details.
Overgeneralization: Generalizing few incidents to make a sweeping judgment about another’s essential character.
Magnification and minimization: Overemphasizing or underemphasizing based on the facts.
Personalization: External events are attributed to oneself.
Dichotomous thinking: All-or-nothing thinking: always/never, success/failure, or good/bad.
Mislabeling: Assigning a personality trait to someone based on a handful of incidents, often ignoring exceptions.
Mind-reading: Believing you know what the other is thinking or will do based on assumptions and generalizations.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Couple Cognition Types
Five cognitions
Selective perceptions: Focusing on certain events or information to the exclusion of others.
Attributions: Inferences about the causes of positive and negative aspects of the relationship.
Expectancies: Predictions about the likelihood of certain events in the relationship.
Assumptions: Basic beliefs or assumptions about the characteristics of the partner and/or the relationship.
Standards: Beliefs about the characteristics that the relationship and each partner “should” have.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Targeting Change: Goal Setting
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
General Goals
How they work
Goals are stated in behavioral and measurable terms.
Therapists use their authoritative role to identify goals that are agreeable to all.
Therapists obtain a commitment from couple or family to follow instructions and complete out-of-therapy assignments, often with a written contract.
Getting clients to promise to complete assignments greatly increases likelihood that clients will follow through.
Example of middle-phase CBFT goal
Replace perfectionist beliefs about child school performance with more realistic expectations.
Example of late-phase CBFT goal
Develop positive mutual reinforcement cycle to reduce negativity and labeling.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Doing: Interventions
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Classical Conditioning
Pavlov’s dogs
Developed by Ivan Pavlov in famous experiments with salivating dogs.
Trained dogs to salivate at sound of a bell by pairing dog’s natural response to salivate at the sight of food with a bell.
After enough repetition, the dog began to salivate with just the sound of the bell.
Procedure is technically described as conditioned and unconditioned stimuli and responses.
Used primarily to treat anxiety disorders.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
How Classical Conditioning Works
The natural state of affairs
Food (unconditioned stimulus; UCS) Salivation (unconditioned response; UCR)
Process of pairing conditional stimulus with response
Food (UCS) +Bell (conditioned stimulus; CS) Salivation (conditioned response: CR)
Resulting pairing
Bell (conditioned stimulus; CS) Salivation (conditioned response: CR)
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Operant Conditioning
Reinforcing techniques
Interventions based on operant conditioning use principles identified by B. F. Skinner.
The essential principle is to reward behavior in the direction of the desired behavior using small, incremental steps, a process called shaping behavior.
Once a certain set of skills has been mastered, the bar is raised for which behavior will be reinforced, with ever closer approximations to desired behavior.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Forms of Reinforcement and Punishment
Four options for shaping behavior
Positive reinforcement or reward: Rewards desired behaviors by adding something desirable (e.g., a treat).
Negative reinforcement: Rewards desired behaviors by removing something undesirable (e.g., relaxing curfew).
Positive punishment: Reduces undesirable behavior by adding something undesirable (e.g., assigning extra chores).
Negative punishment: Reduces undesirable behavior by removing something desirable (e.g., grounding).
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Summary of Operant Conditioning
| Increase Desired Behavior | Decrease Undesirable Behavior | |
| Add Something | Positive reinforcement; reward | Positive punishment |
| Remove Something | Negative reinforcement | Negative punishment |
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Frequency of Reinforcement and Punishment
Keys to increasing/decreasing behavior
Immediacy: The more immediate the reinforcement or punishment, the quicker the learning.
Consistency: The more consistent the reinforcement or punishment, the quicker the learning.
Involves rewarding/punishing a behavior every time it occurs.
Intermittent reinforcement: Inconsistent reinforcement often increases undesired behaviors; random positive reinforcement of well-established desired behaviors helps sustain them.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Encouragement and Compliments
Stay positive
Patterson and Forgatch (1987) strongly encourage positive reinforcement to increase desired behavior with children.
In distressed relationships, they coach families to increase compliments and expressions of appreciation to increase positive reinforcement.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Contingency Contracting
How it works
Can be used to promote new behaviors by creating a contingency that must be met to receive a desired reward.
Parents can use contingency contracting with children that detail how privileges will be earned and lost.
Ex.: If child’s GPA is above 3.0, the parents agree to an 11:00 p.m. curfew on Friday and Saturday.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Point Charts and Token Economies
What they are
Used to shape and reward positive behaviors by allowing children to build up points they can apply to privileges, treats, or purchases.
Rewards should be appropriate and readily approved by the parent.
In most cases, punishment is added to a token economy by having the child lose points for poor behavior.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Behavior Exchange and Quid Pro Quo
Quid pro quo
Mutual behavior exchanges can be useful to help partners negotiate relational rules.
“If you make dinner, I will do the dishes.”
Couples relying primarily on quid pro quo arrangements have lower levels of marital satisfaction.
Use behavior exchange judiciously with couples.
Balance with more affective techniques to avoid framing marriage as a business deal.
Have each partner select a behavior to “give” rather than have each “ask” for what he/she wants.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Communication and Problem-Solving
Communication training
Begin with the positive
Single subject
Specific, behavioral problems
Describe impact
Take responsibility
Paraphrase
Avoid mind-reading
Disallow verbal abuse
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Psychoeducation
What it is
Teaching clients psychological and relational principles about their problems and how best to handle them.
Categories
Problem-oriented: Information about the patient’s diagnosis or situation.
Change-oriented: Information about how to reduce problem symptoms.
Bibliotherapy: Assigning readings that will be motivating and instructional for dealing with presenting problem.
Cinema therapy: Assigning clients to watch a movie that will speak to the problem issues.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Challenging Irrational Beliefs
How it’s done
Direct confrontation: Client is explicitly told that the belief is irrational.
Indirect confrontation: Therapist uses series of questions to help client see how the belief is irrational and/or contributing to the problem.
The use of direct or indirect approach depends on:
The therapeutic relationship.
The therapist’s style.
The client’s receptiveness to a particular approach.
Client and therapist cultural and gender issues.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Socratic Method and Guided Discovery
Guided discovery
AKA inductive reasoning
Gently encourages clients to question own beliefs.
Use open-ended questions that help clients “discover” that their beliefs are illogical/dysfunctional.
Therapists take a neutral stance, allowing client’s own logic, evidence, and reason to do the majority of convincing.
Tightly held beliefs are slowly eroded over time by client questioning and re-questioning their validity in different situations.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Thought Records
What it is
A type of structured journaling, clients analyze their own cognitions and behaviors and develop more adaptive responses.
How it works
Therapists ask clients to confront their own irrational thinking and problem behaviors by assigning “thought records.”
Thought records generally include the following information:
Trigger situation
“Automatic” or negative thoughts
Emotional response
Evidence for
Evidence against
Cognitive distortions
Alternative thought
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Homework Tasks
How they work
Homework tasks are designed to solve the client’s problem.
Ex: To reduce couple’s conflict, therapists may assign communication tasks.
Develop tasks for reducing depression.
Journaling positive thoughts.
Increasing recreational and social activities.
In CBFT, the tasks are logical solutions to reported problems.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Homework vs. Strategic Directives
How they differ
CBFT tasks are linear and literal.
Strategic and systemic therapists assign tasks designed to:
Metaphorically make the covert overt.
Interrupt problem interaction or behavioral pattern enough to allow system to develop new pattern.
Make the uncontrollable controllable.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Homework vs. Solution-Focused Tasks
How they differ
Solution-focused tasks are designed to enact the solution rather than reduce the problem.
Solution-focused tasks are:
Broken into small steps.
Developed from clients’ ideas and past successes.
Designed to increase motivation and hope as much as to solve problem.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Mindfulness-Based Therapies
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
In a Nutshell: The Least You Need to Know
Third wave of behavioral therapy
“Pure” behavioral therapy the first wave and cognitive-behavioral therapy the second.
Involves accepting difficult thoughts and emotions in order to transform them.
Encourage clients to curiously and compassionately observe difficult thoughts and feelings without the intention to change them.
By changing how clients relate to problems, they experience new thoughts, emotions, and behaviors in relation to the problem.
Used to help couples and families become more accepting of one another, improve their communication, and increase intimacy.
Practices rooted in Buddhist psychology, essentially a constructivist philosophy.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
A Brief History of Mindfulness in Mental Health
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Mindfulness Origins
A religious and spiritual tradition
Associated with Buddhist forms of meditation.
Found in virtually all cultures and religious traditions, including Christian contemplative prayer, Jewish mysticism, and the Islamic-based Sufi tradition.
Entered mental health as a non-religious “stress reduction” technique.
Jon Kabat-Zinn began researching Mindfulness Based Stress Reduction (MBSR) program at the University of Massachusetts.
8-week group curriculum that teaches mindful breathing, mindful yoga postures, and mindful daily activities.
MBSR shows great promise as an effective treatment for a wide range of physical and mental health disorders:
Chronic pain, fibromyalgia, psoriasis, depression, anxiety, ADHD, eating disorders, substance abuse, compulsive behaviors, and personality disorders
Mindfulness has been integrated into two counseling approaches:
Dialectic behavioral therapy and acceptance and commitment therapy
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Mindfulness Basics
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Basics
Mindfulness process
Involves observing the breath (or focusing on a repeated word, a mantra) while quieting the mind of inner chatter and thoughts.
Focus is maintained on the breath, grounding in the present moment without judging the experience as good or bad, preferred or not preferred.
Within seconds, mind loses focus and wanders off.
Realize the mind has wandered off and returns to the object of focus without berating self for “failing” to focus.
This process of focusing, losing focus, regaining focus, losing focus, regaining focus continues for an established period of time, usually 10-20 minutes.
Mindfulness used to help first-year therapists learn how to develop therapeutic presence.
Trainees report being better able to be emotionally present with clients, less anxious in session, and better able to respond in difficult moments.
Most report overall level of stress noticeably decreases, they also report better relationships and a greater sense of inner peace.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Specific Mindfulness Approaches
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Mindfulness-Based Stress Reduction
Eight groups in MBSR
Session 1: Introduction to mindfulness
Foundations of mindfulness and body scan meditation.
Session 2: Patience
Working with perceptions and dealing with the “wandering mind.”
Session 3: Non-striving
Introduction to breathing meditation; mindful lying yoga; qualities of attention.
Session 4: Non-judging
Responding vs. reacting; awareness in breath meditation; standing yoga; research on stress.
Session 5: Acknowledgment
Group check in on progress; sitting meditation.
Session 6: Let it be
Skillful communication; loving kindness meditation; walking meditation; day-long retreat.
Session 7: Everyday mindfulness
Mindful movement and everyday applications; practicing on one’s own life.
Session 8: Practice never ends
Integrating with everyday life.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Mindfulness-Based Cognitive Therapy
Eight groups of MBCT
Session 1: Automatic pilot
Introduce mindfulness; eating mindfulness exercise; mindfulness body scan.
Session 2: Dealing with barriers
Explore mental chatter using the body scan exercise.
Session 3: Mindfulness of the breath
Introduce mindfulness breath focus and 3 Minute Breathing Space exercise.
Session 4: Staying present
Link mindfulness to automatic thoughts and depression.
Session 5: Allowing and letting be
Introduce acceptance and “allowing” things to just be.
Session 6: Thoughts are not facts
Reframe thoughts as “just thoughts” and not facts.
Session 7: How can I best take care of myself?
Introduce specific techniques for depressive thoughts.
Session 8: Using what has been learned to deal with future moods?
Motivate to continue practice.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT)
Emotion precedes development of thought; strong emotions, traumatic experiences, and attachment wounds are source of psychopathology.
Helps clients be present with, tolerate, and accept strong emotions in order to transform them.
Client’s attempts to avoid painful emotions are root of the problem.
Manage dialectic tension, the tension between two polar opposites.
Helps clients increase balance in their lives by managing inherent dialect tensions in life:
Being able to both seek to improve oneself as well as accept oneself.
Being able to accept life as it is and also seek to solve problems.
Taking care of one’s own needs as well as those of others.
Balancing independence and interdependence.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT)
Construct realities through language, which shapes our thoughts, feelings, and behaviors.
Human suffering is in large measure created and sustained through language.
Attempts to control thoughts/feelings and avoid direct experience are problem, not solution.
Advocate experiencing to promote acceptance of full range of human emotions.
The process
A=Accept and embrace difficult thoughts and feelings.
C=Choose and commit to a life direction that reflects who the client truly is.
T=Take action steps toward this life direction.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Mindfulness in Couple and Family Therapy
The evidence
Cultivating mindfulness may be particularly helpful for couples.
Predicted greater marital satisfaction, lower emotional stress after conflict, and better communication.
Used to enhance parent-child relationships as well as to help children with ADHD and other conduct issues.
Mindfulness-based parenting programs have been developed and researched, including: mindful parenting, mindfulness-based parenting training, and mindfulness-based childbirth and parenting.
Potential non-medication based treatment for ADHD that may “correct” brain functioning by increasing activity in prefrontal cortex and decreasing activity of limbic system.
Used with adolescents to decrease aggressiveness and improve ability to regulate emotion.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Loving Kindness Meditation
Improving couple and family relationships
Involves sending well wishes to various people — typically an acquaintance, significant other, person with whom one has a difficult relationship and oneself.
Loving kindness meditation
Acquaintance: Bring to mind an acquaintance.
May this person be happy and joyful.
May this person be free from suffering.
May this person experience radiant health.
May this person have ease of wellbeing.
May this person be deeply at peace.
May this person be at peace with people in his/her life.
Continue this with each of the following:
A significant other
A person with whom you have a difficult relationship
Yourself
All beings
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Gottman Method Couples Therapy Approach
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
In a Nutshell: The Least You Need to Know
Gottman’s model
Developed from observational and longitudinal research on communication differences between couples who stayed together and ones who divorced.
Therapist coaches couples to develop interaction patterns that distinguish successful marriages.
Grounded entirely in research results rather than theory.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Debunking Marital Myths
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Myth 1: Communication Training Helps
Communication helps couples stay together: FALSE
Better communication produces short-term gains.
All married couples engage in defensiveness, criticism, and stonewalling.
Contempt is seen mostly in marriages heading for divorce.
Couples who stay together maintain a ratio of 5:1 positive-to-negative interactions during conflict.
20:1 during nonconflict conversations.
Improving communication not as important as increasing the ratio of positive to negative interactions during conflict.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Myth 2: Anger Is a Dangerous Emotion
Anger is bad: FALSE
Expressing anger did not predict divorce.
Contempt (feeling superior to one’s partner) and defensiveness do.
Anger associated with lower marital satisfaction in the short term, but with increased marital satisfaction long term.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Myth 3: Quid Pro Quo Error
This for that: NOT ALL THAT
Quid pro quo actually characterizes unhappy marriages.
Contingency contracting is not appropriate when treating couples.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Big Picture: Overview of Treatment
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Process
Assessment
Highly detailed system with numerous written and oral assessment tools to assess couples and target areas of change.
Intervention
Extensive psychoeducation about what works and what does not, as well as structured exercises.
Should include:
A positive affect experience
Primarily dyadic
Emotional learning
Easy
Nonidealistic
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Making Connection: The Therapeutic Relationship
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Therapist as Coach
Relationship coach
Empowers couples to take ownership of their relationship.
Therapist doesn’t soothe couple during difficult conversations but coaches them on how to soothe themselves and each other.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Viewing: Case Conceptualization and Assessment
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Assessing Divorce Potential
Predicting divorce
Gottman can predict a couple’s potential for divorce in the next 5 years with 97.5% accuracy with only five variables.
Identified several key predictors of divorce:
Four Horsemen of the Apocalypse
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Four Horsemen of the Apocalypse
The Horsemen
Criticism: A statement that implies something is globally wrong with the partner.
Defensiveness: Used to ward off attack, defensiveness claims.
Contempt: Seeing oneself as superior to one’s partner.
Single best predictor of divorce.
Stonewalling: Listener withdraws from interaction, either physically or mentally.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
5:1 Ratio
Conflict ratio
Most couples criticize, defend, and stonewall to a certain extent.
Difference between those who stay together and those who don't is ratio of positive to negative interactions during conflict conversations.
Stable couples have five times as many positive interactions as negative interactions during conflict.
Distressed couples may have a 1:1 ratio.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Negative Affect Reciprocity
What it is
Increased probability that one partner’s emotions will be negative immediately following negativity in the other.
Most consistent correlate of marital satisfaction and dissatisfaction, regardless of the culture studied.
Far superior measure than total amount of negative affect in the relationship.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Repair Attempts
What they are
When one partner tries to “make nice” and end conflict, soothe the other, or soften complaint.
Happy couples are more responsive to repair attempts and need fewer.
Distressed couples frequently reject repair attempts, resulting in a higher number of total attempts.
Failed repair attempts combined with the Four Horsemen predict with 97.5% accuracy whether a couple will divorce in the next five years.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Accepting Influence
Equality
Marriages in which men are unwilling to accept influence from their wives (e.g., suggestions, requests) are 80% more likely to end in divorce.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Harsh Startup
What it is
Raising an issue using negative affect in the first minute of a conversation.
For 96% of couples, only the first minute of data is necessary to predict divorce or stability, and harsh start up is one of several key variables in predicting divorce in that first minute.
Relationships in which the woman uses harsh startup are more likely to end in divorce.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Distance and Isolation Cascade
No Horsemen in Sight
If problems go unresolved, often couples become emotionally disengaged, starting the distance and isolation cascade.
Couples often say, “Everything is okay,” but there is underlying tension and sadness.
Couples characterized by:
Absence of emotional expression.
Lack of friendship.
Unacknowledged tension.
High levels of physiological arousal in conflict.
Few efforts to soothe the other.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Typologies of Happy Marriages
Different strokes for different folks
Three different types of stable, happy marriages.
All maintain the 5:1 ratio but do so at different rates.
Volatile couples: Volatile couples are more emotionally expressive, expressing more positive and negative emotions. Passionate fighting and passionate loving characterize their relationships.
Validating couples: Validating couples have moderate emotional expression and strong marital friendships.
Conflict-avoiding couples: Conflict-avoiding couples have the least emotional expression, minimize problems, prefer to talk about the strengths of their marriage, and end conversations on a note of solidarity.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Sound Relationship House
Elements of working marriage
An overall sense of positive affect.
An ability to reduce negative affect during conflict.
Sound marital house increases these elements:
Love maps: Fondness and admiration system
Turning toward vs. turning away: The emotional bank account
Positive sentiment override
Problem-solving
Solving the solvable
Dialogue with perpetual problems
Physiological soothing
Making dreams come true
Creating shared meaning
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
The Doing: Interventions
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Session Format
Intervention phase
Catch-up
Pre-intervention marital interaction: The boxing round
Give an intervention
The spouses make the intervention their own
Got resistance?
No resistance?
Homework
Specific interventions
Love maps
Couples develop knowledge of each other by answering questions:
Who are your partner’s friends?
Who are your partner’s potential friends?
Who are the rivals, competitors, “enemies” in your partner’s world?
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Soften Startup
Rules to Soften Startup
Be concise.
Keep the initial statement brief and to the point.
Complain but don’t blame.
Complain about a specific incident rather than blame or label.
Start with something positive.
Pose problems by starting with something positive.
Use “I” instead of “You” statements.
Start statements with “I” rather than “you” to avoid blaming and to increase personal responsibility.
Describe what is happening rather than judge.
Keep statements behavioral rather than global.
Ask for what you need.
Clearly describe the behavioral changes you desire.
Be polite and appreciative.
Express appreciation for what your partner does do; be respectful.
Express vulnerable emotions.
When possible, describe more vulnerable than blaming emotions.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Dreams Within Conflict
Working with the gridlock
Therapist asks each partner about deeper meanings and dreams that are beneath his/her rigid stance in the gridlock.
In session, partners are directed to ask each other the following questions:
What do you believe about this issue?
What do you feel about it? Tell me all of your feelings about it.
What do you want to happen?
What does this mean to you?
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Negotiating Marital Power
Discussion of gender roles
Do not advocate a particular division of labor.
Helps couple arrive at their own definition of “fair and equitable.”
Purpose is to increase respect for the roles and duties of each partner.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Tapestry Weaving: Working with Diverse Populations
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Ethnic, Racial, and Cultural Diversity
Define behavioral norms
Carefully apply this approach with diverse populations to avoid conflicts in values and relational styles.
Men and certain culture groups (such as Latinos, Asians, and Native Americans) often prefer active, directive therapy.
Hierarchical difference may cause a rebellious reaction in some or an overly compliant and withholding response in others.
CBTs help clients conform to dominant cultural values because that is “functional” within a given society.
Researchers identifying in which contexts ethnicity plays greatest role:
No significant difference when using CBT for depression with European-American, Latino, and Asian-Americans.
Ethnicity had significant role in the strength of the therapeutic relationship over the course of therapy with perpetrators of domestic violence.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Hispanic and Latinos
Addressing language needs: Prefer to discuss private and emotional issues in native language.
Increasing experiential components: Increase applied and experiential components when adapting CBT techniques.
Respecting familismo: Family highly valued, with individual interests often placed second to family needs; careful to avoid labeling “irrational.”
Respecting personalism: Culture values warm and trusting personal relationships; integrate into therapeutic relationship.
Respecting respeto: Formal expectations of respect to parents and elders; clients may prefer to be addressed with formal titles.
Respecting machismo: Refers to a man’s sense of leadership, loyalty, and responsibility to provide and care for the family.
Working with spirituality: Prayer, church, and church community are resources to tap into; discuss use of prayer to ensure it facilitates problem-solving rather than reduce sense of efficacy or responsibility.
Attitude to gay/lesbian relationships: May have a highly negative response to a child’s coming out, often viewing same-sex attraction as a “sin.”
Addressing immigration, migration, and acculturation: Many Hispanics clients have complex immigration and migration patterns; acculturation issues between parents and children.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
African-Americans
Useful for African-Americans
Helps to directly dispute problematic social beliefs and focus on present behaviors.
Forming a collaborative relationship.
Focusing on behaviors and skills.
Focus on problems experienced in present.
Empower clients by helping them develop coping and communication skills and to expand support networks.
Help identify and logically dispute internalized stereotypes and expectations; increase personal sense of purpose and opportunities.
Help mitigate effects of discrimination by specifically identifying how they cope with discrimination and how it relates to how they perceive and relate to the world.
Functional analysis examines symptom in behavioral terms; can help circumvent potential therapist and client bias and prejudice.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Chinese-Americans
Use with Chinese-Americans.
Educate about process/goals of therapy to increase acceptance.
Learn about client’s cultural background and its significance to client.
Focus on psychoeducational aspects and reinforce efforts to reduce stigma.
Cultural bridging: Link Western concepts to client’s cultural beliefs.
Presenting therapist as an expert often is helpful.
Respect family orientation of Chinese culture and involve family whenever possible.
Be patient because Chinese may not be as comfortable discussing emotions.
Integrate cultural healing traditions, such as QiGong or acupuncture, into treatment plan.
Be aware of the ethnic differences in expressing distress.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Sexual Identity Diversity
Working with GLBTQ
Assess:
Overt acts of harassment, abuse, and violence.
Internalized homophobia.
Existence of social support networks.
Development of identity as a sexual minority.
Disclosure of sexual orientation to family, friends, others.
Development of platonic and romantic relationships with other gay, lesbian, bisexual, or transgendered persons.
Stress due to social stigma.
Stress due to concealing stigma and distress.
Common irrational beliefs
“I can’t stand rejection.”
“Because people will often accept or reject me on the basis of my physical attractiveness, age, socio-economic status, masculinity or femininity, I have to use these same criteria and accept or reject myself.”
“I can't stand being alone. Since I can't stand being alone, it is better to be in an emotionally — and even physically — damaging relationship than to be alone.”
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
Research and the Evidence Base
CBFT theorists have modified approach based on research outcomes to incorporate more affective and relational components.
Neil Jacobson reformulated his couples therapy to include more affective aspects; integrative behavioral couples therapy.
For certain issues, such as adolescent conduct issues, systemic approaches have been found to be superior to CBT.
CBT critiqued on basis that its claims to superiority rest on the volume of research rather than any substantive advantage.
Miller (2012) reports that a massive effort to transform all mental health in Sweden to CBT resulted in no effect on overall outcome of those diagnosed with depression and anxiety, with over 25% dropping out of treatment.
Mastering Competencies in Family Therapy (2nd ed.)
Diane R. Gehart
©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only.
