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Cognitive-Behavioral Family Therapy (CBFT)

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					COGNITIVE-BEHAVIORAL FAMILY THERAPY (CBFT)
BETH MUGNO, MA November 30, 2009

historical overview
2




Behavior therapy for individuals
Behavior therapy for couples

1930’s – 1960’s



Adding a cognitive component as a supplement to behavioral couples therapy Integrating and emphasizing the cognitive component of behavioral couples therapy

late 1970’s



1980’s



Applying a CB approach to families
late 1980’s - early 1990’s

behavioral approach as applied to individuals
3

Ivan Pavlov


Joseph Wolpe


Developed classical conditioning (1932)

First described notion of systematic desensitization (1948)

B.F. Skinner


Developed principles of operant conditioning*

behavioral approach as applied to couples/families
4

Gerald Patterson


Robert Liberman


Pioneered the use of behavioral parent training to help parents control the behavior of aggressive children (1971)

Applied an operant framework to family problems



Introduced concepts of role rehearsal and modeling (1970)

Richard Stuart


Developed the notion of contingency contracting with reciprocal reinforcement (1969)

adding a cognitive component to couples therapy
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Rational Emotive Therapy (RET):


Ellis adapted his model of Rational Emotive Therapy to couples in conflict (1955)



Proposed that relationship distress occurs when one partner:




Holds irrational or unrealistic beliefs about the other or about the relationship Makes extreme negative evaluations when either the partner and/or the relationship do not live up to high expectations

 Developed his A-B-C model to illustrate the interconnectedness

of cognitions, emotions, and behavior.
 Taught the members of a couple to challenge their irrational thinking.

Ellis’ A-B-C Model
A B
Activating Event

Beliefs about Event

He is such a loser!

C

Emotional Consequences

LATER

D
E

Disputing Self-Defeating Beliefs

Effect of Consequences

6

adding a cognitive component to family therapy
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RET (1978):


Emphasizes each individual’s perception and interpretation of events that occurs in the family environment (i.e., family members create their own world by the view they take on what happens to them)



Therapy focuses on how particular problems of the family members affect their functioning and well-being as a unit
A-B-C theory: maintains that family members blame their problems on certain activating events in the family environment (A). In family therapy, individuals are taught to probe for irrational beliefs (B), which are then logically challenged by each member and finally debated and disputed.



REBT (1995):
Ellis later renamed his approach Rational Emotive Behavior Therapy (REBT) in order to more fully acknowledge the role of behavioral responses in an individual’s interpersonal problems

RET vs CBT
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

RET is devoid of any systems application whereas CBT is highly consistent with a family systems perspective



CBT is a more expansive and inclusive approach than RET in that it focuses in greater depth on family interaction patterns

(Beck, 1976; Ellis, 1978)

cognitive behavioral approach
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 An individual’s emotional and behavioral reactions to life

events are shaped by his/her particular interpretations of these events (cognitive appraisals), rather than solely by the events themselves
 THOUGHTS cause feelings and behaviors (i.e., your feelings

come from your thinking)
 In a family, relationships, cognitions, emotions, & behavior

mutually influence one another (consistent w/systems theory)
 If negative patterns of behavior develop, they are often

unknowingly maintained through reciprocal reinforcement.
.

key ideas
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 Social Learning Theory: Behavior is maintained by its

consequences


Reinforcements: consequences that affect the rate of behavior  Reinforcers (+ & -):  behavior  Punishers:  behavior Extinction: behavior (behavior stops when reinforcement fails to follow a response)





Theory of social exchange (Thibaut & Kelley, 1959): In relationships, individuals strive to maximize rewards while minimizing costs.

healthy families
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3 most important elements of a successful relationship or marriage: Communication* (Wills, Weiss, & Isaac, 1978) Affection Child care


Other significant elements:  High positive affect (Wills, Weiss, & Patterson, 1974)  Low negative affect (Gottman et al., 1977)  Good conflict resolution skills (Jacobson, 1981)  Use of a high rate of varied reinforcers

Good relationships  Learned coping behavior  Need to develop good relationship skills

behavior disorders
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  

Symptoms are a result of learned responses

Emphasis on the symptoms themselves
Search for reinforcers

Maintenance of Disordered Behavior is often the result of:


Incorrect Reinforcement


E.g., Inconsistency in reinforcers, delay in reinforcing, ineffective use of punishment, etc.



Aversive Control Techniques
Attempt to control through the use of name-calling, crying, withdrawal, nagging, etc.  Aversive behavior is often reciprocated (reciprocal reinforcement), leading to a cycle of negative behavior.


7 types of cognitive distortions
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1.

Arbitrary inference


A conclusion is drawn from an event in the absence of supporting substantiating evidence.
Information is perceived out of context. An isolated incident or two is allowed to serve as a representation of similar situations, whether or not they are truly related. A case or circumstance is perceived as having greater or lesser significance than is appropriate.

2.

Selective abstraction


3.

Overgeneralization


4.

Magnification and minimization


7 types of cognitive distortions (cont.)
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5.

Personalization


A form of arbitrary inference in which external events are attributed to oneself when insufficient evidence exists to render a conclusion.
Experiences are classified as either all or nothing – as complete successes or total failures.

6.

Dichotomous thinking


7.

Labeling and mislabeling


Behaviors such as mistakes made in the past are generalized to traits to define oneself or another family member.

goals of CBFT
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

Primary Behavior Change


Increasing positive behavior and extinguishing maladaptive behavior
*Behavior change better achieved through  pos behavior than  negative behavior



Secondary Cognitive Change


Facilitating the family's ability to recognize and challenge distorted thinking



Tertiary  Education (skill-building)


Teach skills in regard to communication (expressive & listening skills), negotiation, and problem-solving (i.e., teach families how to heal themselves in the future)

logistics of CBFT
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 


   

structured goal-oriented time-limited (10-20 sessions typically; weekly basis) sequentially delivered core components Collaborative relationship with therapist highly individualized treatment plan present-focused therapy

 Session structure: mood check-in, homework review, agenda

setting, processing session content, homework assignment, feedback/summaries

process of behavior change
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

To achieve behavior change, alter the contingencies of reinforcement.

 Identify behavioral goals  Conduct a functional analysis  Employ learning theory techniques to achieve goals  Use social reinforcers to facilitate and maintain change  Train significant others to use contingency management techniques to influence family members and provide appropriate consequences for behavior

process of cognitive change
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To achieve cognitive change:  Identify dysfunctional cognitions of individual family members as well as distorted family schemas (i.e., jointly held beliefs among family members).  Teach family members to challenge these dysfunctional cognitions/schemas.

specific therapeutic techniques
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1) Parent Management Training


teach parenting skills (e.g., ways to make requests to increase child compliance) & behavioral principles (e.g., differential attention, counter-conditioning, material and social reinforcements, modeling) via therapist-guided practice, role-play, feedback, and coaching

2) Cognitive Restructuring


identifying and challenging distorted cognitions via Socratic questioning, reframing, and reality testing, e.g.

3) Psychoeducation

rise of CBFT
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1980’s & 1990’s Rapid expansion of literature on CBFT
AAMF National Survey (2002)
 

N = 292 randomly selected MFT’s Asked to report their primary treatment modality in a word or two

Results:


27 different models were identified modality (most frequently mentioned tx)

 27.3% of therapists identified CBFT as their primary

factors leading to the adoption of CBFT by MFT’s
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1)

Research evidence supports its efficacy (coupled with a much greater emphasis on evidence-based therapies by consumers and insurers)
This type of therapy seems to appeal to clients


2)

Clients value the proactive approach to problem-solving and skill-building that the family can use to help solve future problems as well

3)

Easily integrated with other treatment approaches (very flexible)

clinical applications
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   

Patients in chronic pain Suicidal adolescents Children with medical disorders Children going through a highconflict divorce Children with anxiety disorders Caregivers of patients with Alzheimer’s disease Schizophrenics Children with brain injury

(Khoadyarifard et al., 2006) (Piacentini et al., 2009) (Mazzone et al., 2009)

(Spillane-Grieco, 2000)

 

(Suveg et al., 2009)

(Marriott, Tarrier, & Burns, 2001)

 

(Sellwood et al., 2006) (Wade et al., 2006)

references
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Dattilio, F. M. (2005). The restructuring of family schemas: A cognitive-behavior perspective. Journal of Marital & Family Therapy, 31(1), 15-30. Dattilio, F. M. (2001). Cognitive–behavior family therapy: Contemporary myths and misconceptions. Contemporary Family Therapy: An International Journal, 23(1), 3-18. Dattilio, F. M. (1998). Cognitive-behavioral family therapy. In F. M. Dattilio (Ed.), Case studies in couple and family therapy: Systemic and cognitive perspectives. (pp. 62-84). New York, NY, US: Guilford Press. Epstein, N., Schlesinger, S. E., & Dryden, W. (1988). Cognitive-behavioral family therapy: Summary and future directions. In N. Epstein, S. E. Schlesinger & W. Dryden (Eds.), Cognitivebehavioral therapy with families. (pp. 361-366). Philadelphia, PA, US: Brunner/Mazel. Friedberg, R. D. (2006). A cognitive-behavioral approach to family therapy. Journal of Contemporary Psychotherapy, 36(4), 159-165. Dattilio, F. M., & Epstein, N. B. (2005). Introduction to the special section: The role of cognitivebehavioral interventions in couple and family therapy. Journal of Marital & Family Therapy, 31(1), 7-13. Khoadyarifard, M., & Abedini, Y. (2006). Cognitive-behavioral family therapy for patients with musculoskeletal pain. Journal of Iranian Psychologists, 2(8), np.

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references
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Khodayarifard, M., Rehm, L. P., & Khodayarifard, S. (2007). Psychotherapy in Iran: A case study of cognitive-behavioral family therapy for Mrs. A. Journal of Clinical Psychology, 63(8), 745-753. Marriott, A., Tarrier, N., & Burns, A. (2001). "Effectiveness of cognitive–behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer's disease": Reply. British Journal of Psychiatry, 178, 84-84. Mazzone, L., Battaglia, L., Andreozzi, F., Romeo, M. A., & Mazzone, D. (2009). Emotional impact in β-thalassaemia major children following cognitive-behavioural family therapy and quality of life of caregiving mothers. Clinical Practice and Epidemiology in Mental Health. Nichols, M. P. & Schwartz, R. C. (2006). Cognitive-behavioral family therapy. In M. P. Nichols & R. C. Schwartz, Family therapy: Concepts and methods (7th ed., pp. 246-280). Boston: Allyn and Bacon. Piacentini, J. C., Rotheram-Borus, M. J., & Cantwell, C. (1995). Brief cognitive-behavioral family therapy for suicidal adolescents. In L. VandeCreek, S. Knapp & T. L. Jackson (Eds.), Innovations in clinical practice: A source book, vol. 14. (pp. 151-168). Sarasota, FL, US: Professional Resource Press/Professional Resource Exchange.

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references
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Schwebel, A. I., & Fine, M. A. (1992). Cognitive-behavioral family therapy. Journal of Family Psychotherapy, 3(1), 73-91. Sellwood, W., Wittkowski, A., Tarrier, N., & Barrowclough, C. (2007). Needs-based cognitivebehavioural family intervention for patients suffering from schizophrenia: 5-year follow-up of a randomized controlled effectiveness trial. Acta Psychiatrica Scandinavica, 116(6), 447-452. Spillane-Grieco, E. (2000). Cognitive-behavioral family therapy with a family in high-conflict divorce: A case study. Clinical Social Work Journal, 28(1), 105-119. Suveg, C., Hudson, J. L., Brewer, G., Flannery-Schroeder, E., Gosch, E., & Kendall, P. C. (2009). Cognitive-behavioral therapy for anxiety-disordered youth: Secondary outcomes from a randomized clinical trial evaluating child and family modalities. Journal of Anxiety Disorders, 23(3), 341-349. Wade, S. L., Carey, J., & Wolfe, C. R. (2006). The efficacy of an online cognitive-behavioral family intervention in improving child behavior and social competence following pediatric brain injury. Rehabilitation Psychology, 51(3), 179-189.

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DOCUMENT INFO
Description: A PPT presentation on the use of cognitive-behavioral models of family therapy (CBFT) to treat anxious and behaviorally maladjusted youth. Includes an historical overview detailing the beginnings of CBFT as well as specific information about the characteristics of this type of therapeutic approach (e.g., the key tenets, the techniques utilized by therapists, and the presently-identified clinical applications).