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Cognitive-Behavioral Family Therapy

Article · October 2018

DOI: 10.1007/978-3-319-15877-8_40-1

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C

Cognitive-Behavioral Family Prominent Associated Figures

Therapy
Donald Baucom at the University of North
Jing Lan and Tamara G. Sher Carolina
The Family Institute at Northwestern University, Norman Epstein at the University of Maryland
Evanston, IL, USA Gerald Patterson at the Oregon Social Learning
Center at the University of Oregon
Neil Jacobson at the University of Washington
Name of Model Andrew I. Schwebel at the Ohio State University
Frank Dattilio at Harvard Medical School and the
Cognitive-Behavioral Family Therapy (CBFT) University of Pennsylvania

Theoretical Framework
Synonyms
Core Concepts
Behavioral family therapy (BFT) The main concepts of CBFT are rooted in behav-
iorism and cognitive-behavioral therapy. First,
within the paradigm of behaviorism, operant con-
Introduction ditioning is used as the central mechanism of
change. Social learning theory is incorporated
Cognitive-behavioral family therapy (CBFT) was by interpreting symptoms as learned responses
born as the family therapy correlate to cognitive- and emphasizing the impact of social reinforcers
behavioral therapy. That is, it integrates behavior- on shaping behaviors. Social exchange theory is
ism and cognitive approaches and applies them to also a primary component of CBFT, asserting that
family systems. Because of its flexibility and con- people strive to maximize rewards and minimize
tinued evolution, CBFT is able to focus on a costs in relationships. Thus, behaviors can be
variety of problems, from promoting changes changed directly by maximizing positive
within individuals in families to altering family exchanges and minimizing negative exchanges
interaction styles. Furthermore, CBFT provides (Lebow 2014; Lebow and Stroud 2016).
the fundamental principles and techniques to var- Second, from the perspectives of cognitive
ious empirically supported interventions and therapy, CBFT posits that an individual’s percep-
programs. tions and inferences are shaped by relatively
# Springer Nature Switzerland AG 2019
J. L. Lebow et al. (eds.), Encyclopedia of Couple and Family Therapy,
https://doi.org/10.1007/978-3-319-15877-8_40-1
2 Cognitive-Behavioral Family Therapy

stable underlying schema, which can be learned programs that will assist them in bringing about
early in life from primary sources which then change. Families then carry out the programs as
influence an individual’s automatic thoughts and the therapists monitor the progress and setbacks.
emotional responses in significant relationships. Throughout the process, therapists need to take an
Given the amount of shared experiences within a active role in designing and implementing specific
family, individuals often develop jointly held strategies and are required to have persistence,
beliefs that constitute a family schema. If the patience, knowledge of learning theory, and spec-
family schema involves cognitive distortions, it ificity in working with families (Gladding 2019).
may result in dysfunctional interactions (Dattilio
2009). Rationale for the Model
As the term implies, CBFT is the deliberate and
Theory of Change theory-based integration among cognitive ther-
As an integration of behaviorism, CBT, and sys- apy, behavior therapy, and family therapy. As
tem theory, CBFT views thoughts and behaviors such, its history can be seen as paralleling the
as central to the (dys)functioning of the family. history of cognitive-behavioral therapy (CBT)
Thus, the underlying principle of CBFT is that the generally. At its most basic, CBFT has its roots
behavior of one family member leads to certain in behavior therapy. During the 1960s and early
behaviors, cognitions, and emotions within the 1970s, behaviorists applied learning theory, with a
other family members. Those other family mem- particular focus on stimulus and response, to fam-
bers then affect the cognitive and behavioral pro- ily systems in order to train parents in behavior
cesses of the original family member in what is modification. Parallel to the addition of a cogni-
known as a feedback loop. Accordingly, the most tive component to traditional behavior therapy
efficacious pathways to change are seen as those practices, behavioral family therapy soon trans-
that directly alter dysfunctional thoughts and itioned to cognitive-behavioral family therapy
behavioral patterns in a family system through with an added emphasis on the need for attitude
changes at the individual and relationship levels. change to promote behavior modification. Here,
Specifically, the basic premise of behaviorism the system of the family was the focus of not just
is that behavior is maintained by its consequences. behavioral plans to encourage more adaptive
Thus, behavior will change when the contingen- responses to stimuli, but also helping family mem-
cies of reinforcement are altered. According to bers see how their thinking about themselves and
behaviorism, the general intent of therapy is to each other in the family can facilitate growth.
extinguish undesired behavior and reinforce pos-
itive alternatives. Similarly, the central tenet of a
cognitive approach is that our interpretation of Populations in Focus
other people’s behavior affects the way we
respond to them. Accordingly, the primary aim CBFT has been used across diverse presenting
of CBFT is to help family members recognize problems and forms of psychopathology. With
distortions in their thinking, restructure it, and the foci on increasing parenting skills and facili-
modify their behavior in order to improve their tating positive family interactions, CBFT has pro-
interactional patterns. Furthermore, with the ved effective for families with conduct problems,
incorporation of systems theory, CBFT maintains oppositional defiant disorder (ODD), child anxi-
the focus on interactive aspects of the family ety, depression, pediatric obsessive-compulsive
rather than on internal processes of individuals. disorder (OCD), pediatric bipolar disorder, eating
CBFT therapists take on the roles of experts, disorders, attention deficit/hyperactivity disorder
teachers, collaborators, and trainers. Therapists (ADHD), and trauma symptoms.
help families identify dysfunctional behaviors CBFT has also been found to be effective
and thoughts and then work with them to set up across various cultures and subcultures. For
behavioral and cognitive-behavioral management example, research conducted in several countries
Cognitive-Behavioral Family Therapy 3

with families from various racial and socioeco- characteristics of each family member and the
nomic groups has demonstrated the efficacy of family as a whole and how the interactions
psychoeducational behavioral family therapy in between family members maintain or detract
reducing family stress and patient relapse of from optimal functioning. As a result, the thera-
major mental disorders (Lucksted et al. 2012). pist constantly assesses different behavioral and
This approach is largely based on CBFT princi- cognitive patterns within and between family
ples and procedures. Another example is trauma- members. Although assessment never really
focused cognitive-behavioral therapy (TF-CBT) ends, it tends to begin with a functional analysis
which has been applied in multiple cultures and of the behaviors of the family members. The func-
proved to be feasible for treating traumatized chil- tional analysis derives from three main sources of
dren of an Asian population (Kameoka information: individual and joint interviews with
et al. 2015). the family members, self-report questionnaires
Although there is limited empirical evidence and inventories, and the therapist’s behavioral
for the cultural sensitivity of CBFT, some multi- observation of family interactions (Dattilio
cultural strengths can be addressed based on its 2009). In addition, other methods of assessment
tenets. First, CBFT asserts that each individual is can include more formal psychological testing
different in his or her own right. Thus, CBFT and appraisals, consultation with previous thera-
therapists are taught to be careful in understanding pists and other mental health providers,
and defining behavioral norms and recognizing genograms, assessing motivation to change, and
that family values and relational interactions differ identifying automatic thoughts, core beliefs, cog-
between families and between cultures. Second, a nitive distortions, and schema.
central tenet of CBFT is that the therapist partners A number of valid and reliable measures have
with the family throughout the therapeutic pro- been developed to provide an overview of key
cess. As a result, differences in cultures are areas of family functioning. For example, ques-
discussed and brought to light so that all members tionnaires developed to assess general family
of the process understand expectations and norms. functioning include the Family Environment
Last but not least, its fundamental concepts tend to Scale (Moos and Moos 1986), the Family Assess-
be easily understood across diverse populations. ment Device (Epstein et al. 1983), and the Self-
Report Family Inventory (Beavers et al. 1985).
Other, more specialized assessment tools include
Strategies and Techniques Used in the Family Adaptability and Cohesion Evaluation
Model Scales-III (Olson et al. 1985), Family Coping
Coherence Index (McCubbin et al. 1996), and
CBFT applies cognitive-behavioral principles and the Family of Origin Inventory (Stuart 1995). In
techniques to family systems. In CBT for individ- addition to written measures, CBFT therapists
uals, assessment and education are basic and often rely on observational assessment tools
important components and a focus across the such as observing family members’ interacting
treatment. The same is true for CBFT. Within as they normally would or providing the family
CBFT, we can divide the primary interventions with specific topics for discussion in order to
into two categories: those that assess and modify obtain a behavioral sample of the family.
behavior patterns and those that assess and modify Once the therapists have completed a func-
distorted and extreme cognitions. tional analysis of family behavior, they move to
an instructor role as they teach families about the
Assessment and Education cognitive-behavioral model. This includes pro-
In order to intervene with families, several aspects viding a brief didactic overview and periodically
of their functioning have to be understood includ- referring to specific concepts during the therapy.
ing how the system functions in different contexts, In this way, the families can better understand the
the unique strengths, and problematic roles their cognitive distortions have played in the
4 Cognitive-Behavioral Family Therapy

interactions and how they inadvertently reinforce change and which might not be a priority.
undesirable behaviors. It is also important for “Charting” is a skill whereby families are taught
families to understand and buy into the idea that to keep an accurate record of the children’s prob-
improvements in relationships often happen lematic behavior. They are taught how to specially
through deliberate, rule-governed strategies define the behavior and in what quantity it should
(such as direct instruction and skill training) and be recorded such as every day or every time it
that most problems are solvable with constructive happens. This can be used when parents want to
skills and actions. Thus, families may be encour- establish a baseline of the occurrence of targeted
aged to attend lectures, read books and watch behavior before and after the intervention in order
videos together, and have discussions based on to assess it across time. It should be noted here that
what they have heard, read, or seen (Dattilio 2009; charting is both a tool of assessment and the
Goldenberg et al. 2017). intervention because the charting itself often
changes behaviors without other intervention
Intervention Techniques being necessary. Another example of an operant
CBFT emphasizes behavior change. The cogni- behavioral technique is based on the “Premack
tive component of the intervention comes into principle” whereby family members must first do
play when clients’ attitudes and assumptions get less pleasant tasks before they are allowed to
in the way of positive behavior changes. engage in pleasurable activities. Here, the more
pleasant tasks serve as positive reinforcers for the
Interventions to Modify Behavior Patterns less pleasant ones. Finally, in order to apply these
The interventions in this category can be summa- operant techniques to the level of the family,
rized into two main sections: operant conditioning “behavior-change agreements” are used. Here,
and contracting and skills training. They have the each family member learns that when they engage
common characteristics of being operationally in a specific behavior, another family member will
definable, precise, and measurable. They are usu- be prompted to engage in a different behavior and
ally applied in combination so that family mem- so on. Rather than setting this up as a “tit for tat”
bers learn individually and collectively how to negotiation, it is used to delineate how each per-
give recognition and approval for desired behav- son’s behavior affects and is affected by the
iors instead of rewarding maladaptive ones. These behaviors of the other members of the family
fundamental behavioral concepts can lead to sig- (Gladding 2019; Nichols 2017).
nificant change in a short period of time (Gladding The most commonly used skill trainings are
2019). communication training, problem-solving train-
Operant conditioning is used most effectively ing, and parenting skills training. Communication
in parent-child relationships where the aim is to training improves skills for expressing thoughts
increase desirable behavior patterns of children by and emotions, as well as for listening effectively
modifying the contingencies of reinforcement to others. Therapists begin by presenting instruc-
coming from the adults (Table 1). tions to family members about specific behaviors
There are several examples of operant condi- involved in each type of expressive and listening
tioning interventions. Contingency contracting is skill with the assistance of handouts describing
a specific, usually written schedule or contract the communication guidelines. They then coach
describing the terms for the exchange of behaviors the families during session and often model good
and reinforcers between family members. One skills for them. Session skills are then practiced as
action is contingent, or dependent, on another. homework in order to increase and maintain
For example, parents might use a point system improvement. In problem-solving training, thera-
or “token economy” to reward children for spe- pists use verbal and written instructions, model-
cific behaviors such as doing chores or speaking ing, and behavioral rehearsal and coaching to
nicely. The parents also work with the children to facilitate effective problem-solving with family
decide which behaviors should be a focus of members. The steps include achieving a clear
Cognitive-Behavioral Family Therapy 5

Cognitive-Behavioral Family Therapy, Table 1 Some reinforcers in operant conditioning (Gladding 2019)
Techniques Brief description
Classical In families, classical conditioning is used to associate a person with a gratifying behavior, such as
conditioning a pat on the back or a kind word
Positive A positive reinforcer is usually a material (e.g., food or money) or a social action (e.g., a smile or
reinforcement praise) that increases desired behaviors
Extinction Extinction is the process by which previous reinforcers of an action are withdrawn so that
behavior returns to its original level
Time-out The process of time-out involves removing children from an environment in which they have been
reinforced for certain actions for a limited amount of time (approximately 5 min)
Grounding Grounding is a disciplinary technique used primarily with adolescents. They are removed from
stimuli to limit their reinforcement from the environment
Job card Job card grounding is a behavior modification technique that is used with adolescents. In this
grounding procedure, parents make a list of small jobs that take 15–20 min to complete and are not a part of
the adolescent’s regular chores. When a problem behavior begins, the adolescent is given one of
the jobs to complete and is grounded until the job is finished successfully

specific definition of the problem, generating spe- Regardless of the form of the training, parents
cific behavioral solutions to the problem, evaluat- are asked to chart the problem behavior over the
ing the advantages and disadvantages of each course of treatment. Successful efforts are
alternative solution, and selecting and agreeing rewarded through encouragement and compli-
on implementing one solution. Finally, the main ments by the therapist (Dattilio and Epstein
aim of parenting skills training is to change par- 2016; Goldenberg et al. 2017).
ents’ responses to children by educating parents
about operant learning principles, developing
Interventions to Modify Distorted and Extreme
their ability to observe children’s behavior sys-
Cognitions
tematically, and coaching them in using develop-
Generally speaking, this category of interventions
mentally appropriate skills to set constructive
includes (1) cognitive restructuring techniques,
limits on children’s behavior and reinforce posi-
which aim to help family members better monitor
tive behaviors. As parents learn better ways to ask
the validity (how accurate one’s thoughts are) and
for good behavior, children learn better ways of
the appropriateness (the utility of one’s beliefs) of
behaving. Parents are also taught that if they give
their cognitions, and (2) self-monitoring skills, by
up focusing on less important behaviors (e.g.,
which therapists teach family members how to
wearing a coat in colder weather), more important
actively and consciously assess and intervene
behavioral changes are more likely to be incorpo-
their cognitions in any given situation.
rated. Here, the therapist begins by defining a
Specifically, in order to restructure the cogni-
specific problem behavior and monitoring it in
tions, therapists can teach older family members
regard to its antecedents and consequences. The
to identify automatic thoughts and associated
parents are then trained in social learning theory
emotions and behaviors and identify cognitive
with verbal and performance training methods.
distortions and label them. Children can also be
Verbal methods involve didactic instruction, as
taught to identify and express their emotions
well as written materials, with the aim of influenc-
appropriately. Then, therapists can test and chal-
ing thoughts and messages. Performance training
lenge the automatic thoughts and reinterpret them
methods may involve role-playing, modeling,
by considering alternative explanations. In this
engaging in behavioral rehearsal, and prompting,
process, some specific techniques are commonly
with the focus on improving parent-child interac-
used. For example, “behavioral experiments,”
tions that are easily understood by the children,
where families are encouraged to test their pre-
given their current level of development.
dictions that particular actions will lead to certain
6 Cognitive-Behavioral Family Therapy

responses from other members, can provide first- adaptable program is the “Triple P (positive par-
hand evidence in order to reduce one’s negative enting program).” Triple P is a parenting and
expectancies. When family members attempt to family support system designed to prevent and
identify their thoughts and responses that treat behavioral and emotional problems in chil-
occurred in past incidents and have difficulty dren and teenagers and create family environ-
recalling pertinent information, imagery or role- ments that encourage children to realize their
playing techniques can be helpful to recollect the potential. The sophistication of this program is
past interactions. Furthermore, the “downward that it has been used in a number of different
arrow” technique can be used to track the associ- formats including work with individual parents,
ations among one’s automatic thoughts and to groups of parents, agencies working with parents,
identify the underlying core beliefs beneath and even government agencies states responsible
one’s automatic thoughts (Dattilio 2009; Dattilio for the dissemination of parenting guidelines
and Epstein 2016). (Sanders and Turner 2017).
Self-instructional training is a form of self-
management that focuses on people instructing
themselves. It is assumed that problems may be Research About the Model
based on maladaptive self-statements and self-
instruction affects behavior and behavioral Research on the effectiveness of CBFT is exten-
change. In self-instructional training, a self- sive in terms of individual outcomes but lean in
statement can serve as a practical clue in recalling terms of family outcomes. The outcome studies
a desirable behavioral sequence, or it can interrupt have focused mostly on the effectiveness of
automatic behaviors or thought chains and behaviorally oriented family interventions in
thereby encourage more adaptive coping strate- treatment of major mental disorders in individual
gies. In families, it is more often employed in members, such as the psychoeducation and train-
helping impulsive children modulate their impul- ing in communication and problem-solving skills
sivity through deliberate and task-oriented “self- (Mueser and Glynn 1999), rather than on allevi-
talk” (Gladding 2019). ating general conflict and distress within the fam-
In conclusion, CBFT uses behavioral and cog- ily. For example, some studies have demonstrated
nitive interventions to both assess behavior across the efficacy of training parents in behavioral inter-
time and change it for more adaptive family inter- ventions for conduct disorders (Forgatch and
actions. Most commonly, behavioral components Patterson 2010). Other studies provide empirical
play a larger role than cognitive ones, but both support for behavioral family therapy for child-
categories provide the therapist with a large “tool hood ADHD (Kaslow et al. 2012). There is also
box” of possible interventions for different fami- strong evidence for the effectiveness of family-
lies, presenting problems, and pathology. based/family-focused CBT in the treatment of
childhood anxiety disorders (Kaslow et al.
Intervention Models 2012), adolescent eating disorder (Le Grange
There are a number of specific types of therapy et al. 2015), pediatric bipolar disorder (West
based on the general principles of CBFT. For et al. 2014), pediatric OCD (Selles et al. 2018),
example, parent-child interaction therapy (PCIT) trauma symptoms (Kameoka et al. 2015), and
addresses child behavioral problems with a two- prevention of suicide attempts (Asarnow
stage intervention model including a relationship et al. 2017).
enhancement phase and a discipline phase Little research has been conducted on CBFT
(Galanter et al. 2012). Similarly, functional family for difficulties in the family as a whole, either in
therapy (FFT) is a family-based, empirically adapting to developmental life-stage changes or in
supported treatment for behavioral problems, coping with external stressors affecting the family
especially with adolescents (Alexander and Rob- (Dattilio and Epstein 2016). However, CBFT
bins 2018). Perhaps the best known and most principles and methods have been adapted to the
Cognitive-Behavioral Family Therapy 7

treatment of a variety of problems that families Both Jenny and Davonti said they had no idea.
face in coping with forms of dysfunction in indi- The therapist then educated the family on how
vidual members and have demonstrated their family therapy can be helpful in terms of improv-
effectiveness, such as estrangement in family of ing communication and relationships. Davonti
origin (Dattilio and Nichols 2011). Another exam- indicated that they got along just fine. At this
ple is that, a psychoeducational parenting pro- point, Jenny looked at her mother and squirmed
gram, rooted in cognitive-behavioral principles, in her chair. When the therapist directed a question
has been found to be especially effective as an to Jenny about how she thought they all got along,
intervention for at-risk parenting behavior, such as she said that nobody really talked to each other,
child abuse (Nicholson et al. 2002). but that was fine with her. Jane then interjected
that she tries to get Jenny to come out of her room
and takes away her screen time when she refuses.
Case Example The therapist then asked Jane about her feelings
about all the separateness at home. She said that
This is an adoptive, multiracial family. Jane is a she values privacy because she grew up in a house
51-year-old Caucasian female. She was born in that was very small with her and her two sisters
the United States and works as an IT engineer. sharing a bedroom and having no personal space
Davonti is a 49-year-old African-American male or place in the home to keep any possessions. She
who is a stay-at-home father, having been let go also noted that Davonti is really the one who
from his job as an adjuster for an insurance com- spends all of his time in their room, sleeping
pany. They define themselves as middle class most of the day. Davonti then was able to interject
which is important to them, given that Jane was that he is sick of hearing how poor Jane was
raised in a working/lower-class family that strug- growing up. At this point, Jenny pulled out her
gled with money, while Davonti comes from an headphones and put them on.
upper middle-class family where his mother was a While Davonti seemed indifferent to this
lawyer and his father was a university professor. behavior, Jane reached over, grabbed the head-
The two struggled with infertility for about phones, and told Jenny that the headphones were
10 years before adopting Jenny, a 10-year-old “going away for a long time.” From this point on,
girl from China, 6 years ago. Jane was very insis- Jenny refused to speak. The therapist asked the
tent on having children and took the lead in both family if it would be ok to talk to Jenny alone. All
fertility treatment and in the adoption process. agreed. He asked Jenny when her parents left the
Davonti was less sure about adding a child to the room if this family interaction was typical. She
family given that they had a history of financial said yes, that her father let her do pretty much
difficulties due to neither of them paying attention whatever she wanted and her mother didn’t under-
to a family budget. They presented for therapy stand her at all. She also said she was sick of
after finding out that Jenny was caught stealing hearing how poor her mother had been and how
lunches out of lockers at school and lying to her lucky she should feel now.
teachers and parents about it. Jane wanted therapy When the therapist brought everybody back
because she wanted to understand why Jenny together, he made a few observations. First, he
stole the lunches. Davonti believes that this was gently wondered aloud if Davonti might be
a child “being a child” and that Jane and the depressed (individual psychopathology). He also
teachers were overreacting to a minor infraction. asked the parents if they had ever talked to Jenny
The therapy began with the therapist assessing about her early years (communication). They both
the nonverbal behaviors of the family members. indicated that they assumed she would not want to
He noted that each person in the family sat apart reflect on such a painful time (cognitive distor-
from the rest, with both Davonti and Jenny tion). At this point, Jenny burst into tears saying
appearing sullen. When the therapist then asked that all they cared about was money and that they
each person why they were here, only Jane spoke. assumed that she didn’t want to talk about China
8 Cognitive-Behavioral Family Therapy

on the idea that she had been raised in a poor Cross-References

community in China by various foster parents
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that her mother complains about her being in her ▶ Baucom, Donald
room all the time, but in fact it is her mother who is ▶ Behavioral Parent Training in Couple and Fam-
always on her phone (reinforcers). ily Therapy
The therapist at this time knew enough to make Cognition in Couple and Family Therapy
a tentative intervention plan. He suggested that he ▶ Cognitive Behavioral Couple Therapy
would teach them how to talk about feelings in a ▶ Communication Training in Couple and Family
way that felt respectful and validating (education) Therapy
and could help them decrease the assumptions ▶ Contingency Contracting in Couple and Family
they had been making (cognitive distortions). He Therapy
also said that he would help each of them identify ▶ Epstein, Norman
which behaviors of the others they would want ▶ Functional Family Therapy
changed and what they were willing to change ▶ Homework in Couple and Family Therapy
themselves (contingency contracting). Finally, he ▶ Jacobson, Neil
told them that he would help them devise a family ▶ Modeling in Couple and Family Therapy
responsibility chart based on what behaviors the Parent-Child Interaction Family Therapy
others wanted to see changed and what they each ▶ Parenting Skills Training in Couple and Family
wanted as a reward for making their own changes Therapy
(reinforcement). Throughout the delivery of the ▶ Patterson, Gerald
treatment plan, the therapist was careful to ask for ▶ Role Playing in Couple and Family Therapy
understanding and agreement from each family ▶ Schemas in Families
member before proceeding to the next interven- ▶ Token Economy in Couple and Family Therapy
tion idea (partnering). At the end, he noted that he ▶ Triple P: Positive Parenting Program System
would like to meet with each person alone over
the next few weeks for part of the sessions in order
to understand what individual issues might be
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