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Frank M. Dattilio

ABSTRACT: The field of couple and family therapy has grown in the direction of expanding its horizons by looking toward innovative ideas and whatever works to facilitate change. Despite its demonstrated track record with a broad range of behavioral and emotional disorders, the cognitive-behavior therapies (CBT) may have been underutilized by couples and family therapists unlike some of the more traditional and postmodern approaches. This article explores some of the basic tenets of the cognitive-behavioral approach with families and proposes it as both a useful intervention tool as well as a theoretically compatible model to systemic approaches. In addition, a number of contemporary myths and misconceptions are discussed that may be precluding CBTs utilization by therapists in the field.
KEY WORDS: cognitive-behavioral; therapy integration; myths; misconceptions.

Cognitive-behavior therapy (CBT) is currently at the forefront of contemporary psychotherapy and has been growing exponentially throughout the world since its early introduction almost four decades ago. Its broad application has been documented repeatedly in both individual and metaanalytic studies (Beck, 1993; Dobson, 1989). Despite CBTs demonstrated effectiveness, however, it has been somewhat underutilized by family therapists. This is particularly evi-

Frank M. Dattilio, PhD, is a Clinical Associate in Psychiatry at the University of Pennsylvania School of Medicine, and a guest lecturer at Harvard Medical School. Reprint requests should be forwarded to Frank M. Dattilio, PhD, ABPP, Suite 211-D, 1251 S. Cedar Crest Blvd., Allentown, PA 18103. *Portions of this article have been adapted from a grand rounds lecture presented by the author to the residents and faculty of the Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, March 31, 1997.
Contemporary Family Therapy 23(1), March 2001 2001 Human Sciences Press, Inc.


dent during the postmodern age of therapy with the advent of solution focused interventions and constructive/narrative approaches. The family therapy literature reflects very little attention on CBFT (Dattilio, Epstein, & Baucom, 1998). This is somewhat surprising since CBT has always been regarded as a highly effective short-term therapy that is used frequently by many practitioners in the field (Dattilio, 1998a). Much of the reason for CBTs lack of recognition is hypothesized to a number of myths and misconceptions that developed around some misunderstanding of CBT early in the evolution of the family therapy movement. This stems in part from general beliefs about the cognitivebehavior therapies and their perceived shortcomings in dealing with interpersonal dynamics, affect, and the specific role of the therapist in the treatment process. In order to address this issue sufficiently, it is necessary to briefly recapitulate the early introduction of behavior therapy to the family therapy movement and how the aspect of cognition evolved to become part of what constitutes contemporary CBT with families. Cognitive therapy, as it applies to families in general, developed as an extension of its application to couples in conflict in the early 1980s (Epstein, 1982). While Albert Ellis (1977) has stated that he adapted his model of rational emotive therapy (RET) to work with couples as early as the late 1950s, little was written in marital and family therapy journals on this topic prior to 1980 (Ellis, 1977, 1978, 1986). The later studies developed as an offshoot of the behavioral approach, which first described interventions with couples and families in the late 1960s and early 1970s. Principles of behavior modification were applied to interactional patterns of family members only subsequent to their successful application to couples in distress (Bandura, 1977; Patterson & Hops, 1972; Stuart, 1969, 1976). This work with couples was followed by several single case studies involving the use of family interventions in treating childrens behavior. For the first time, behaviorists recognized family members as highly influencing the childs natural environment and included them directly in the treatment process (Faloon, 1991). Several years later, a more refined and comprehensive style of intervention with the family unit was described in detail by Patterson, McNeal, Hawkins, and Phelps (1967) and Patterson (1971). Since that time, the professional literature has addressed applications of behavioral therapy to family systems, with a strong emphasis on contingency contracting and negotiation strategies (Gordon & Davidson, 1981; Jacobson & Margolin, 1979; Liberman, 1970; Patterson, 1982, 1985). Its


reported applications remain oriented toward families with children who are diagnosed with specific behavioral problems (Sanders & Dadds, 1993). Since its introduction almost 30 years ago, behavioral family therapy has received only minimal attention among practitioners of marriage and family therapy as a useful intervention. This neglect of an effective modality occurs for a number of reasons: First, because of the overwhelming popularity of the strategic, structural, and more recently the postmodern approaches to family therapy, many practitioners have been influenced primarily by such noted theorists as Minuchin (1974), Bowen (1978), Satir (1967), Madanes (1981), and White and Epston (1990) to the exclusion of more empirically tested interventions. In addition, the behavioral approach may be perceived in some circles as being too rigid and rigorous in methodology to apply to families, and as failing to capture some of the commonly occurring dynamics of a familys interaction (Dattilio, 1998c). An additional reason may also have to do with the fact that behavioral approaches have traditionally been considered to be linear in perspective and are viewed by many as inconsistent with systemic constructs (Nichols & Schwartz, 1998). In fact, it does appear that the pure behavior therapys strength lies more with addressing specific behavioral problems such as poor communication or acting out behaviors (common among children and adolescents) than with understanding the comprehensive system of family dynamics (Sanders & Dadds, 1993; Goldenberg & Goldenberg, 1991). Specifically, the behavior therapies focus on observable behavior (symptoms) rather than on efforts to establish any intrapsychic or interpersonal causality. Certain targeted behaviors are directly manipulated through external means of reinforcement. Families are also trained to monitor these reinforcements and make modifications where necessary (Jacobson & Addis, 1993). Regarding the development of cognition in family therapy, a cognitive approach or cognitive component to behavioral marital therapy subsequently received attention as providing a supplement to behavioral-oriented couples and family therapy (Margolin, Christenson, & Weiss, 1975). In addition to the work of Ellis (1977), an important study by Margolin and Weiss (1978), which suggested the effectiveness of a cognitive component to behavioral marital therapy, sparked further investigation of the use of cognitive techniques with dysfunctional couples (Baucom & Epstein, 1990; Baucom & Lester, 1986; Beck, 1988; Dattilio, 1989, 1990a, 1990b, 1992, 1993a, 1993b; Dattilio & Padesky, 1990; Doherty, 1981; Ellis, Sichel, Yeager, DiMattia, & DiGiuseppe,


1989; Epstein, 1992; Fincham, Bradbury, & Beach, 1990; Schindler & Vollmer, 1984; Weiss, 1984). This interest in behavioral approaches to couples also led behavioral family therapists to recognize that cognition plays a significant role in the events that mediate family interactions as well (Alexander & Parsons, 1982; Bedrosian, 1983). The important role of cognitive factors not only in determining relationship distress, but also in mediating behavioral change has become a topic of increasing interest among researchers and practitioners (Epstein, Schlesinger, & Dryden, 1988; Alexander, 1988; Dattilio, 1993a). While marital and family therapists began to realize decades ago that cognitive factors played a very important role in the alleviation of relationship dysfunction (Dicks, 1953), it took some time before cognition was formally included as a primary component of treatment (Munson, 1993). This is rather unfortunate since it appears that cognitive restructuring and inducing behavioral change is much of what therapists attempt to do regardless of the modality that they espouse (Bedrosian, 1993; Baucom & Lester, 1986; Dattilio, 1993a, 1994, 1998b; Dattilio & Bevilacqua, 2000).


Cognitive-behavioral couples therapy grew out of the behavioral approach, first as a supplemental component and later as a more comprehensive system of intervention. The same progression holds true to some degree for cognitive-behavioral family therapy (Dattilio, 1998a). Munson (1993) notes that there are at least 18 different subtypes of cognitive therapy used by various practitioners, with the result that it would be impossible to discuss cognitive family therapy broadly in a single article. This discussion is therefore limited to those approaches proposed by the rational emotive theories (Ellis et al., 1989, 1982, 1978; DiGiuseppe & Zeeve, 1985) and the cognitive-behavioral theories (Beck, 1988; Epstein et al., 1988; Dattilio, 1993a, 1998; Teichman, 1984, 1992). The rational-emotive approach (REBT) to family therapy, as proposed by Ellis (1978), places emphasis on each individuals perception and interpretation of the events that occur in the family environment. The underlying theory assumes that family members largely create their own world by the phenomenological view they take of what happens to them (p. 310). The therapy focuses on how particular problems of the family members affect their well-being as a unit. During the process of treatment, family members are treated as individuals, each


of whom subscribes to his or her own particular set of beliefs and expectations (Huber & Baruth, 1989; Russell & Morrill, 1989). The family therapist helps members realize that illogical beliefs and distortions serve as the foundation for their emotional distress. The use of the A-B-C theory is introduced, which maintains that family members blame their problems on certain activating events in the family environment (A) and are taught to probe for irrational beliefs (B), which are then to be logically challenged by each family member and finally debated and disputed (C). The goal is to modify the beliefs and expectations to fit a more rational basis (Ellis, 1978). The role of the therapist, then, is to teach the family unit in an active and directive manner that the causes of emotional problems lie in irrational beliefs. By changing these self-defeating ideas, family members may improve the overall quality of the family relationship (Ellis, 1978). Unfortunately, REBT is limited by virtue of the fact that it is devoid of any systems application. The cognitive-behavioral approach, on the other hand, balances the emphasis on cognition and behavior and takes a more expansive and inclusive approach by focusing in greater depth on family interaction patterns and by remaining consistent with elements derived from a systems perspective (Epstein et al., 1988; Leslie, 1988). In fact, cognitive-behavioral family therapy, in most cases, is conducted against the backdrop of a systems approach. Within this framework, family relationships, cognitions, emotions, and behavior are viewed as exerting a mutual influence upon one another, so that a cognitive inference can evoke emotion and behavior, and emotion and behavior can likewise influence cognition. Once such a cycle among family members is initiated, dysfunctional cognitions, behaviors, or emotions can result in conflict. Teichman (1992) describes in detail the reciprocal model of family interaction, proposing that cognitions, feelings, behaviors, and environmental feedbacks are in constant reciprocal process among themselves and sometimes maintain the dysfunction of the family unit. CBFT is grounded in cognitive mediation of individual functioning which purports that an individuals emotional and behavioral reactions to life events are shaped by the particular interpretations that the individual makes of the events, rather than solely by objective characteristics of the events themselves (Beck, 1976; Ellis, 1978). Behaviors of family members are then viewed as constant life events that are interpreted and evaluated by other family members (Epstein & Schlesinger, 1996). For a more detailed explanation of this concept, see Dattilio (1998). Consistent and compatible with systems theory, the cognitive-be-


havioral approach to families includes the premise that members of a family simultaneously influence and are influenced by each other. Consequently, a behavior of one family member leads to behaviors, cognitions, and emotions in other members, which, in turn, elicit cognitions, behaviors, and emotions in response in the former member (Dattilio, Epstein, & Baucom, 1998). As this cycle continues, the volatility of the family dynamics escalates, rendering family members vulnerable to a negative spiral of conflict. As the number of family members involved increases, so does the complexity of the dynamics, adding more fuel to the escalation process. Epstein and Schlesinger (1991, 1996) cite four ways in which family members cognitions, behaviors, and emotions may interact and build to a volatile climax. They each serve as stimuli or combinations of stimuli during family interactions that often become ingrained in family patterns and permanent styles of interaction. These are outlined below: 1. The individuals own cognitions, behaviors, and emotion regarding family interaction (e.g., the person who notices himself or herself withdrawing from the rest of the family). 2. The actions of individual family members toward the individual. 3. The combined (and not always consistent) reactions that several members have toward the individual. 4. The characteristics of the relationships among other family members (e.g., noticing that two other family members usually are supportive of each others opinion; Epstein & Schlesinger, 1996). Cognitive therapy, as set forth by Beck (1976), places a heavy emphasis on schema or what have otherwise been defined as core beliefs (Beck, Rush, Shaw, & Emery, 1979; DeRubeis & Beck, 1988). As this concept is applied to family treatment, the therapeutic intervention is based on the assumptions with which family members interpret and evaluate one another and the emotions and behaviors that are generated in response to these cognitions. While cognitive-behavioral theory does not suggest that cognitive processes cause all family behavior, it does stress that cognitive appraisal plays a significant part in the interrelationships existing among events, cognitions, emotions, and behaviors (Epstein et al., 1988; Wright & Beck, 1993). In the cognitive therapy process, restructuring distorted beliefs has a pivotal impact on changing dysfunctional behaviors. Schema are also very important in the application of cognitivebehavior therapy with families. Just as individuals maintain their own


basic schema about themselves, their world, and their future, they maintain a schema about their family. Some therapists believe that heavier emphasis should be placed on examining cognitions among individual family members as well as on what may be termed the family schemata (Dattilio, 1993a). These are jointly held beliefs of the family that have formed as a result of years of integrated interaction among members of the family unit. It is suggested that individuals basically maintain two separate sets of schemata about families. These are family schemata related to the parents family of origin and schemata related to families in general or what Schwebel and Fine (1994) refer to as personal theory of family life. It is the experiences and perceptions from the family of origin that shape the schema about both the immediate family and families in general. These schemata have a major impact on how the individual thinks, feels, and behaves within the family setting. Epstein and associates (1988) propose that these schemata are the longstanding and relatively stable basic assumption that he or she holds about how the world works and his or her place in it (p. 13). Schwebel and Fine (1994) elaborate on the term family schemata as used in the family model by describing it as: All of the cognitions that individuals hold about their own family life and about family life in general. Included in this set of cognitions are an individuals schema about family life, attributions about why events occur in the family, beliefs about why events occur in the family, and beliefs about what should exist within the family unit (Baucom & Epstein, 1990). The family schema also contains ideas about how spousal relationships should work, what different types of problems should be expected in marriage and how they should be handled, what is involved in building and maintaining a healthy family, what responsibilities each family member should have, what consequences should be associated with failure to meet responsibilities or to fulfill roles, and what costs and benefits each individual should expect to have as a consequence of being in a marriage (p. 50). Elsewhere (Dattilio, 1993a, 1998d), it has been suggested that the family of origin of each partner in a relationship plays a crucial role in the shaping of immediate family schema. Beliefs funneled down from the family of origin may be both conscious and unconscious and contribute to a joint schema or blended schema that leads to the development of the current family schema (see Figure 1). This family schema then is disseminated and applied in the rearing


FIGURE 1 The Development of Family Schemata


of the children, and, when mixed with their individual thoughts and perceptions of their environment and life experiences, contributes to the further development of the family schema. The family schemata are subject to change as major events occur during the course of family life (e.g., death, divorce), and they also continue to evolve over the course of ordinary day-to-day experience. Consequently, family schema is a very important area to address in CBFT, one in which the greatest area of change usually occurs. This is accomplished by a series of cognitive and behavioral strategies used in restructuring the basic or core beliefs of the family and altering or modifying behavioral patterns. The behavioral component of CBFT focuses on several aspects of family members actions. These include (1) excess negative interaction and deficits in pleasing behaviors exchanged by family members; (2) expressive and listening skills used in communication; (3) problem solving skills; and (4) negotiation and behavior changes skills. The theoretic models underlying behavioral approaches to family therapy are social learning theory (e.g., Bandura, 1977) and social exchange theory (e.g., Thibaut & Kelly, 1959). Unfortunately, the use of cognitive-behavioral strategies and techniques have not received as much visibility in the family therapy literature which may be due to misconceptions about how they can be used with other modalities. Below are a number of myths and misconceptions that may still be affecting CBFTs reception among contemporary family therapists. Myth #1: CBFT only addresses the superficial aspect of change and is not concerned with underlying dynamics. Initially, when CBFT was applied to couples and families, its main focus was on behavioral change. However, even though the initial target may have been to address overt behaviors and surface thinking about family relationships, interpersonal dynamics were still considered an important aspect of treatment. The majority of CBFT is conducted against the backdrop of a systems approach (Leigh, 1988; Dattilio, 1998a, 1998b; Watts, in press). Therefore, such issues as how circularity and the multidirectional flow of how family members influence each other are addressed in the cognitive-behavioral approach. The manner and style of how this is executed however, is quite different from other modalities in that the therapist may initially assume a more directive role, confronting the issue early in the treatment process while examining family members beliefs or


schemas about the familys functioning. The process of change usually involves a collaborative approach between therapist and family members that is to some degree didactic, yet suggestive. A primary component of CBFT is the focus on individual and family schema and how to affect alterations so that change with behavioralinteraction occurs. Myth #2: The role of the therapist in CBFT is too direct and does not allow for the family to engage in any self-reflective change. This is unfortunately one of the major misconceptions of what therapists using CBFT do. While it is true that CBFT is directive, the therapist operates more in the role of a coach, albeit an active coach, particularly as the process of therapy progresses. The majority of the early work beyond the assessment phase is didactic and relies heavily on socializing the family to the cognitive-behavioral model. However, one of the main goals of CBFT is to facilitate family members in engaging in the self-monitoring of distorted thinking and beliefs and to recognize and correct maladaptive behavior patterns on their own. Once this is achieved, the therapist is free to fall back into a more non-directive, self-reflective mode, which, in my opinion is often desirable and very effective. The basic tenet of CBFT is to teach families how to think for themselves and recognize what they need to do to heal themselves. Much like anything else in life, people first need to see that change must occur before they can be coached and educated on how to employ certain tools to make those changes. Myth #3: CBFT forces families into its model and ignores the basic tenets of each familys individual style. This is a cognitive distortion in and of itself, one that most likely developed through gross misperception during CBFTs evolutional process. The fact of the matter is that quite the opposite is true. The CBFT model is designed to be flexible to various family dynamics and specific needs (Dattilio, 1998c). A benefit of the cognitve-behavioral model is that it is based on individual (or family) schema and perceptions. Therefore, a familys thinking style and behavior is evaluated based on collect-


ing evidence and weighing alternatives as they exist in the family system. There are no precast assumptions made about families in general. CBFT does follow a distinctive model, but in a flexible manner that accommodates the variance that belies each familys unique dynamics. The fact that CBFT is structured and time sequenced may have given some the impression that it imposes certain techniques rather than facilitates change. Much of this depends on the style and expertise of the family therapist conducting the treatment. Myth #4: Cognitive-behavior therapy is not integratable with other modalities of couple and family therapy. Many theorists and practitioners are under the mistaken belief that CBFT is not compatible or integratable with other modalities of family therapy due to its rigorous scientific approach and rigid posture that the therapist must assume in order to apply its principles. Once again, because cognitive-behavioral approaches have traditionally been considered linear in perspective, they may be viewed by many as being inconsistent with systemic constructs. On the contrary, CBFT directs its focus regarding the unit of treatment on the family as opposed to the individual. It takes into consideration the interrelation of family members cognitions and behaviors as contributing to the overall family dynamics (Dattilio, 2000). In addition, CBFT is one of the most integratable modalities of couple and family therapy, particularly since its basic philosophical and theoretical principles are rooted in a number of diverse modalities, such as psychodynamic theory, Adlerian psychotherapy, and a sundry of other modalities. Cognition and behavior appear to be a part of the fabric of most modalities. In a general sense, because most approaches to family therapy involve human communication, many therapies may be said to be cognitive. For similar reasons, most modalities may be said to be behavioral as well because communication is behavior and all behavior is communicative. And because the human condition involves emotion, most modalities address emotion to a significant degree. Consequently, any given therapy can be viewed through a variety of lensesas cognitive, behavioral, emotional, and so on (Dattilio, 1998a). In this respect, because CBFT involves all three of these aspects, it renders it very compatible with other modalities, some more than others, depending on the particular posture of the therapist.


Myth #5: Cognitive-behavioral family therapy only works with family members who have specific behavioral problems (e.g., acting-out child/adolescent, eating disorder, etc.). Even though CBFT is excellent with family situations that involve a circumscribed behavioral problem, its scope extends far beyond this realm. In fact, CBFT can be very effective with more diffuse problems since it tends to focus on schemas, which govern all family interaction. For example; the family schema held by an adolescent member, I need to act-out and make some noise in order for other members to listen to me, may be based on a cognitive distortion that evolved from maladaptive behavior patterns established early in the familys history. Consequently, both parents or child may act according to this schema when they believe that they are being ignored or not heard. Unfortunately, the way they decide to go about it may incur more negative reaction, alienating them farther from the rest of the family. What CBFT attempts to do is to define events more in cognitive or behavioral terms so that they are more operational and can be dealt with more clearly. At the same time, other factors are evaluated aside from overt cognitions and behaviors. The issue of power and control is explored by the therapist as well as specific perceptions about each members role in the family and how they are directly or indirectly reinforced by the overall dynamics. Focus is also placed on the dynamics that have shaped the parents view of their role, namely, experiences with their respective families-of-origin. Myth #6: CBFT tends to focus only on cognition and behavior and grossly ignores emotional and affective content. This has been a long-standing misconception of cognitive-behavior therapy by many who espouse to the traditional intrapsychic models of family therapy. Even in the early days of behavior therapy, emotion was always considered to be important component of treatment (Wolpe, 1973). The misconception occurs with the amount of emphasis that cognitive-behaviorists place on affect as a change agent in treatment. Cognitive-behavior therapy places more emphasis on cognition and behavior since these components are believed to be the primary mechanisms that affect emotion. This is not to say that emotion is ignored, it is just used differently in the treatment process. Cognition and behavior are therefore the central mechanisms of action with the view of emotion being a byproduct of the two. The affectual component of treat-


ment is used in a more subtle view, but by no means is downplayed or ignored (Safran, 1998).

Unfortunately, it appears that CBFT may have received less attention over the years due to several of the aforementioned myths that developed via misperceptions by many in the field. In addition, perhaps some of the blame may be attributed to a select group of cognitivebehaviorists who have assumed too rigid a posture when working with couples and families, attempting to force-fit the staunch scientific principles of CBT to facilitate change with the family and ignoring some of the more salient underlying family dynamics. There is no doubt that CBFT has come of age in the 21st century and has maximized it potential as an integrative approach that may blend well with other therapeutic modalities. The art to using CBFT is to know its potential strengths and limitations and how it can be respectable in its integration with other modalities of treatment. To do this however, means to keep an open mind as to what CBFT can offer.

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