COGNITIVE-BEHAVIOUR THERAPY

Running head: COGNITVE-BEHAVIOR THERAPY

Cognitive-Behaviour Therapy from a Family Therapy Perspective John Laing University of Calgary CAAP 601 Assignment 3

COGNITIVE-BEHAVIOUR THERAPY

The goal of this paper is to outline my current view of therapy. Although I feel it is important to become an integrated and eclectic therapist, at this point in my development I feel it is important to narrow my view, so that I can first develop a strong underlying theory of human behaviour and client change. This paper will outline the two theories that I most identify with at this point in my education and career. In the following sections I will describe how cognitivebehaviour therapy principles can be utilized while working from an overarching family systems model. Philosophical Assumptions Based on my experience working with troubled children, adolescents, and their parents, I believe it is important to consider the family system when working with such clients. In my experience it has become apparent that individual problems are often situated in dysfunctional family dynamics. Through my experience it has also become evident that dysfunctional patterns of interaction between family members are also often exhibited outside the home as well, including antisocial behaviour in the community and school settings. Issues of poverty, isolation, inadequate health care, and access to transit also contribute to family dysfunction as it leads to more stress in the home. I believe it is important to view problematic behaviour using a systemic- and family therapy lens. Although there are many different forms of family therapy, they all emphasize the importance of addressing all components of the familys system if change is to be actualized and sustained (Corey, 2009). According to Corey, family therapists view problematic behaviour as serving a function within the family unit or a purpose for the family; as a result of the familys inability to adapt to situations; or a symptom of maladaptive patterns of functioning transmitted from one generation to the other.

COGNITIVE-BEHAVIOUR THERAPY

Although I believe a family systems approach is important for eliciting client change, family therapy does not adhere to one specific therapeutic theory and does not outline a specific theory about human nature. As an inexperienced counsellor I believe it is first important to develop a personal theory of client change that is somewhat prescriptive in its delivery. As my long term goal is to develop a therapeutic style that is integrated, I feel it is important to first adopt a stance of assimilative integration (Norcross & Beutler, 2011). According to Norcross and Beutler assimilative integration is an important first step to developing a sophisticated integrative therapeutic approach. I believe it is important to develop my expertise in cognitive-behaviour therapy theory and techniques. An exploration of cognitive-behaviour therapy theory and

techniques will allow me to effectively work with clients while using a family systems perspective and will provide a good theoretical foundation for me to expand my understanding and use of other therapy modalities. Nature of Humans Family therapy does not subscribe to a specific theory of personality; however, the underlying assumption is that all human development is dependent on family life (Goldenberg, Goldenberg, & Pelavin, 2011). Family therapy approaches are based on family-systems model of therapy (Carlson, Sperry, & Lewis, 2005). Family-systems models posit that individuals can only be understood within the context of their family and place in society. Human behaviour arises within a social system; therefore, it can only be understood within this context. Change in one part of the social system will affect all other part of that system. Family systems seek homeostasis; however, the tendency to seek balance can inhibit change and cause pathology if interactions and coping strategies are maladaptive (Carlson et al.).

COGNITIVE-BEHAVIOUR THERAPY

Close relationships foster the development of unique social capacities because of behavioural, emotional, and representational contingencies that emerge between family members (Laible & Thompson, 2007). Relationships with others are established early in life and begin within the family unit. Relationships are important to the healthy development of individuals due to the establishment of enduring emotional ties, mental representations, and behaviours towards others (Laible & Thompson). Early relationships provide the opportunity to learn about the world and how others behave. Early experiences as a result of relationships can have enduring effects on individuals behaviour as they progress through life. Early relationships within the family orient the child to a system of reciprocity and mutuality that influences childrens identification with their relational partners such as parents and siblings (Laible & Thompson). This is also important because relationships impact the childs motivation to respond cooperatively and affectionately toward others. The general quality of early relationships enhances or diminishes childrens receptivity to the socialization efforts of others and can affect the responsiveness of others to the child (Laible & Thompson). Quality relationships early in life have an important influence over healthy functioning later in life. Quality relationships can be characterized as warm, secure, and mutual. Warmth in early relationships is important because it promotes relational harmony and the childs development of trust and socioemotional competence (Laible & Thompson, 2007). Secure attachments early in life are also important because children in secure relationships are more receptive, cooperative, and responsive toward their environments and others (Bowlby, 1988). Security also impacts the childs development of social competencies leading to more positive experiences later in life with partners, peers, and authority figures (Laible & Thompson). Furthermore, according to Bowlby, secure attachments early in life help children create mental

COGNITIVE-BEHAVIOUR THERAPY

representations of relationships, themselves, and the world around them that have lasting effects throughout life. Lastly, relationships early in life that are characterized by mutual reciprocity lead to positive outcome later in life. According to Laible and Thompson, early experiences of mutual reciprocity can have positive influence on the development of empathic responsiveness and conscience development. Taken together, family dynamics are important for healthy development of individuals and families because they provide the building blocks for all other experiences and perceptions of the world to be built upon. Family relationships impact the development of mental representations of the world and influence childrens behaviour in the moment and later in life. I believe cognitive-behaviour therapy compliments family therapy in how it explains human functioning. According to cognitive-behaviour therapists, personality development is based on the cognitive, affective, motivational, and behavioural responses one has to their environment (Beck & Weishaar, 2011). Personality characteristics can be witnessed through the schemas individuals hold of the world, as well as the strategies used in reaction to situations (Mash, 2006). According to Beck and Weishaar, human responses are developed through our history of learning and evolution and that thinking is important to our survival. People hold beliefs about others and the world around them that may lead to biased interpretation of certain situations which can lead to distorted thinking (Mash, 2006). The bases of personality development is the interactions between innate characterises and environment (Beck & Weishaar,). Cognitive-behaviour therapy is built on the idea that cognitions are the root of peoples actions and feelings (Corey, 2009). According to cognitive-behaviour therapy, a clients behaviour and feelings are a result of their inner dialogue. The underlying premise is that if cognitions change, behaviour, and feelings will also change.

COGNITIVE-BEHAVIOUR THERAPY

Healthy Functioning According to Goldenberg et al. (2011) the family unit is made up of three subsystems, each of which is imperative for healthy individual and family functioning. Healthy functioning of the spousal subsystem provides the child with a sense of security and teaches the child how to interact appropriately with others. Unhealthy functioning in this area may lead to the child feeling insecure as they may feel like they need to align themselves with one parent over the other. The parental subsystem is important to healthy development because it provides children with nurturance, guidance, boundaries, and consequences. Positive interactions between siblings are also important because it influences their learning to cooperate, negotiate, and compete (Goldenberg et al.). As each of these subsystems are important to the development of appropriate behaviour and functioning, family therapists believe that behaviour is a result of interactions with others and is rooted in past experiences with the family (Goldenberg et al.). Healthy functioning from a family systems perspective is dependent on the rules a family establishes and the narratives they create about life (Goldenberg et al., 2011; White, 2007). Rules influence family interactional patterns and establish what is expected and permitted during interactions and sets acceptable boundaries for behaviour. According to Goldenberg et al. rules help stabilize and regulate individual and family functioning. Families who see the world around them as friendly, trustworthy, and predictable are likely to pass on their view of the world to other family members. The narratives the family develops about itself and the world around them is influenced by past experiences and is typically passed on from member to member and can be intergenerational (Goldenberg et al.; White). Appropriate rules and positive and realistic narratives about the world have a profound influence on healthy functioning. Without such rules and narratives boundaries between systems can become blurred causing maladaptive functioning.

COGNITIVE-BEHAVIOUR THERAPY

Goldenberg et al. (2011) describes boundaries as figurative lines separating systems, subsystems, or individuals from outside influences. When boundaries around subsystems are strong the functioning of the subsystem will also be strong. It is important that families protect the integrity of the total system, as well as the functional autonomy of its parts (Minuchin, (1974). According to Minuchin, individual members and each family subsystem must establish autonomy, as well as interdependence. Healthy functioning families exhibit a flexible interchange between autonomy and interdependence. Flexible interchange between autonomy and interdependence promotes the psychological growth of family members (Minuchin). Patterns of interaction can be understood as personality traits that arise from cognitive responses to situations that have been ingrained and learned through experiences within the family unit (Carlson et al., 2005; Goldenberg et al., 2011). When cognitions are negative or distorted, negative behaviour can result thus further impacting family functioning or impacting interactions with individuals outside of the family. Cognitive-behaviour therapy can challenge distorted beliefs, problematic family rules, and negative narratives. Cognitive-behaviour therapy posits that healthy functioning is influenced by the selfawareness one has regarding learning and the persons appraisal of environmental events (Wilson, 2011). People learn better when they are aware of the rules and contingencies governing the consequences of their actions (Wilson). According to Wilson, people learn what behaviour is appropriate in specific situations by observing the consequences of behaviour. Peoples expectations and perceptions about what is happening to them or in situations affects their behaviour (Wilson). This perspective is consistent with family therapy in that it explains behaviours as a consequence of cognitive representations of what is acceptable based on observing

COGNITIVE-BEHAVIOUR THERAPY

other people and events. From a family therapy perspective, learning and modeling of behaviour begins within the family early in a childs life. Major Causes of Problems According to Corey (2009) dysfunctional behaviour stems from maladaptive patterns of interaction within the family or from negative interactions with society. According to Doherty and Baptiste (1993) family relationships are a major source of mental health problems and psychopathology for individuals. Individuals symptoms typically have meaning within the familys interaction or world view and such family interaction patterns and world views tend to repeat across generations. Dysfunctional behaviour is not only the result of problematic patterns of interaction but can also negatively influence the family or societal system in a reciprocal way (Goldenberg et al., 2011). Dysfunction in the familys spousal, parental, or sibling subsystems can lead to maladaptive behaviour and poor coping skills. Healthy boundaries between each of these subsystems are important to healthy functioning (Doherty & Baptiste). . Boundaries are essential to the functioning of systems because they differentiate those inside the system from those who are outside. Problems in family functioning arise when boundaries are either too rigid or too diffuse (Goldenberg et al., 2011; Minuchin, 1974). Rigid boundaries within families can lead to disengagement among family members leaving some members feeling isolated. Diffuse boundaries are also problematic because families can become enmeshed and overly involved in one anothers lives (Goldenberg et al.). Boundaries between the outside world and the family are also important because they modulate the flow of information between the two (Goldenberg et al., 2011). Boundaries that are healthy and flexible allow the family to be influenced by new experiences and to ignore or

COGNITIVE-BEHAVIOUR THERAPY

manipulate undesirable interactions. Families become closed to new experiences and can become wary of outside influences if boundaries between them and the world around them become too rigid (Goldenberg et al.). Family therapy as a theory and a treatment method posits that clinical problems stem from negative transactional patterns within the family unit (Goldenberg et al., 2011). According to Goldenberg et al. a clients maladaptive pattern of behaviour and coping is maintained by dysfunctional functioning between family members and/or the community around them. A persons development and behaviour is related to and influenced by the actions and attitudes of other members of the family and those from outside the family. Psychopathology from a cognitive-behaviour therapy perspective stems from the result of a number of influences such as individual learning, inadequate responses to the environment or misinterpretations of the environment, and biological makeup (Beck & Weishaar, 2011). Problems arise as a result of faulty thinking, inaccurate interpretations of situations, and an inability to effectively differentiate reality from fantasy (Corey, 2009). According to Mash (2006) distorted thought patterns, including problems in thought content and process, can lead to psychological problems. For example, cognitive distortions and attributional biases have been identified is studies of depression, aggression, ADHD, and axiety (Mash). According to Mash, boys who were aggressive during social interactions tended to minimize perceptions of their own aggression and typically perceived others as more aggressive that they really were. From a cognitive-behaviour perspective maladaptive behaviour stems from individuals learning history (Beck & Weishaar, 2011). Based on early learning individuals can become distressed when they perceive a situation to be threatening.

COGNITIVE-BEHAVIOUR THERAPY

10

Nature of Change Family and individual health requires a balance of connection and individuation (Doherty and Baptiste, 1993). For families with enmeshed boundaries, the family therapist works with the family to strengthen boundaries to help promote individuation of family members (Minuchin, 1974). The goal of the family therapist in this case would be to help the family increase the clarity of the boundaries. For families that are overly disengaged from one another, it is important to decrease the rigidity of boundaries (Goldenberg, et al., 2011). According to Minuchin, decreasing the rigidity between subsystems increases the familys supportive functioning. Healthy boundaries also promote individuation and autonomy of family members (Minuchin). Individuation and autonomy can be promoted by appropriate rules governing family interactions. To support autonomy family members and the therapist should actively listen to one another and validate what was said. Furthermore, according to Minuchin, family members should talk to each other and not about each other, should not answer a question asked of another, nor talk negatively about others while they are present. It is important for the therapist to establish these boundaries during therapy sessions if the family struggles to do so on their own. According to Carlson et al. (2005) four main factors account for change from a family therapy perspective. Personal characteristics of family members such as inner strength, religious faith, ambition, and social support have a significant impact on the change process. Relationship factors between the therapist and the client/family are also important. Change is more likely to occur if the therapeutic relationship is characterized by mutual warmth, respect, empathy, and authenticity. Lastly, the specific model and therapeutic techniques used by the therapist are important to the change process. While using a family therapy frame of reference, I believe cognitive-behaviour therapy techniques can be utilized to facilitate change within families.

COGNITIVE-BEHAVIOUR THERAPY

11

To produce change family therapists help the family develop new understanding and awareness of family functioning including individual and family goals, purposes, and behaviours (Carlson et al., 2005). As the family gains insight into their pattern of functioning, the therapist helps the family enhance their skills and knowledge in areas such as communication, problem solving, and conflict resolution. The therapist also promotes change by encouraging the family to stay committed to ongoing change, growth, increased social interest, and positive connections with others (Carlson et al.). Such changes can be achieved through changes in perceptions, beliefs, values, and goals. Cognitive-behaviour therapy is a strong theory of change and offers effective techniques to challenge the latter. Cognitive-behaviour therapy is designed to help clients change dysfunctional thoughts, expectations, and attitudes (Goldenberg et al., 2011). According to Goldenberg et al. therapists help the client change distorted thoughts and help clients better evaluate their perceptions. Cognitive-behaviour techniques are designed to challenge distorted beliefs that were learned early in life through interactions within the family unit, as well as early influences from outside the family system. Cognitive-behaviour therapy addresses how individuals think, feel, and behave. Therapists who use this approach remain focused on current problems of their clients and follow a structured style of intervention (Somers & Queree, 2007). Cognitive-behaviour therapists teach, coach, and reinforce desirable behaviour changes in clients. Therapists also help clients identify their cognitive patterns and emotions that are linked with undesirable behaviours (Somers & Queree). Cognitive distortions are problematic because they contribute to negative emotions and maladaptive behaviour. Through cognitive-behaviour therapy clients learn to identify their automatic thoughts, analyze these thoughts and identify evidence that supports more positive

COGNITIVE-BEHAVIOUR THERAPY

12

beliefs (Corey, 2009). As the therapist helps the client identify maladaptive thinking and by helping them to think differently about their experiences, clients will begin to think and behave differently. Behaviour is also important to how people think and feel. Cognitive-behaviour therapy also focuses on behaviour by helping clients learn new behaviours and new ways of coping with events (Somers & Queree, 2007). To influence change cognitive-behaviour therapists will help the client learn new skills. For example, therapists would help teach new social skills to clients who find social situations uncomfortable or anxiety provoking. By using new strategies in such situations the client will likely experience a different outcome than previously experienced in similar situations. Addressing dysfunctional thinking and maladaptive behaviour is paramount in cognitivebehaviour therapy; however, helping clients realize changes by replacing faulty perceptions and behaviours depends on many other factors as well. Somers and Queree (2007) posit that factors such as: the quality of the therapeutic relationship; goal-setting; focus on the present; therapeutic structure; comprehensive case formulation; and the development of skills to manage personal setbacks are also vital to the change process. I believe cognitive-behaviour therapy is an effective modality to utilize when helping clients and families change their interactional pattern. I think cognitive-behaviour therapy is useful when working with families because it requires a strong and collaborative therapeutic relationship and helps individuals discover new ways of thinking for themselves through specific questions from the therapist (Somers & Queree, 2007). As a novice counsellor I believe cognitive-behaviour

COGNITIVE-BEHAVIOUR THERAPY

13

therapy is an effective modality to couple with family therapy theory because it offers a structured, directive, and problem oriented approach while viewing the family as a whole. The Counselling Experience Personal Definition of Counselling I believe counselling is conversation between people that can facilitate change for individuals. The experience of counselling is different for each individual and produces change by providing a different perspective to a problem or by empowering them to take a stance against an identified problem. Counselling is likely more successful when the individual identifies their own problem and develops solutions of how to overcome it. Counselling is the facilitation of that conversation whereby the counsellor guides the individual toward self-discovery of problems and solutions. I believe people change when motivated to do so. I believe that often times people may need some guidance regarding why they may need to make some changes in their lives and what those changes may mean for their future. People who are motivated to change may not always know how to make the change they desire; therefore, counselling can help them develop their own strategies for change and/or suggest strategies that could be useful. Well timed questions of the individual/group regarding the problems, desires, and possible strategies to achieve change can also be effective. Studying theories of counselling and change is very important because it adds to my repertoire of strategies to help people make changes. People vary in many different ways including how they make changes in their lives; therefore, certain people will respond more positively to different techniques than others. Having an understanding of more than one theory

COGNITIVE-BEHAVIOUR THERAPY

14

will enhance my ability to be creative and effective when working with diverse populations. I believe that ongoing education of therapeutic theories and best-practices is an essential part of my personal theory of counselling. Counselling Process Counsellor-client relationship. I feel as though family therapy and cognitive-behaviour therapy are similar in their approach to the therapeutic relationship. Both models posit that the relationship between client and therapist is important and change is best realized when the relationship is collaborative (Goldenberg et al., 2011; Mash, 2006). However, according to Cory (2009) not all models of family therapy consider the therapeutic relationship as overly important for change to occur. For example, strategic and structural approaches to family therapy do not emphasize the importance of the relationship between therapist and client (Corey). Although many family therapists focus primarily on implementing therapeutic techniques and providing direct teaching methods to the client, I believe that the relationship is an important contributor to client change. I believe it is important to work together to understand the difficulties the family or individual is experiencing and what barriers may be in the way of overcoming these difficulties. Both the therapist and client work together in generating new ways for the client or family to think and behave. By creating an atmosphere where the family feels supported, family members are more likely to express difficult feelings, thoughts, and problems (Goldenberg et al., 2011). By working in collaboration the therapist conveys to the family that they are cared about and understood which allows the family to feel more comfortable dealing with difficult problems (Goldenberg et al.). According to Goldenberg et al. family therapists try to build a therapeutic

COGNITIVE-BEHAVIOUR THERAPY

15

alliance with the family beginning in the first session by accommodating to the familys transactional style, assimilating their language style and their style of affect. A collaborative relationship is also important when identifying goals (Mash, 2006). After identifying problems, it is important for the therapist and family to set goals together to deal with the problems (Somers & Queree, 2007). Cognitive-behaviour therapy compliments family therapy because therapists often coach the family toward new ways of acting, but also challenges the family to explore alternatives to thinking and behaving in a collaborative manner (Somers & Queree). Development of a strong therapeutic relationship is important to the application of therapeutic techniques (Lejuez, Hopko, Levine, Gholkar, & Collins, 2006). For example, clients are more likely to respond to suggestions, advice, or trust that homework assignments are worthwhile if they have a personal trust in the therapist (Mash, 2006). I see this as important to changing individual behaviour, but also useful when changing parenting techniques and family dynamics. Roles of the clients and counsellor. The client is encouraged to be an active participant in the therapeutic process and therapy is thought to be a highly interactive process between therapist and client. Cognitive therapy is seen as a collaborative process whereby therapist and client work together in identifying dysfunctional thinking and testing assumptions (Corey, 2009). Known as collaborative empiricism, the therapist and client work together to investigate problems, develop hypotheses, set goals, and challenge assumptions in hopes of changing the clients behaviour (Beck & Weishaar, 2011). The specific role of family therapists can differ depending on their underlying approach to therapy. However, according to Corey (2009), family therapists typically act as educators and

COGNITIVE-BEHAVIOUR THERAPY

16

collaborators that guide clients toward change. Therapists often take an active role in facilitating change in the family. Using cognitive-behaviour techniques, family therapists often direct and coach family members in developing strategies for dealing with situations and others (Corey). According to Corey, cognitive-behaviour family therapists explore alternative courses of action and their possible consequences with family members. Therapists are often directive and can act as consultants when working with families. Part of the therapists role is to directly teach skills though instruction, modeling, and feedback (Corey). According to Corey, family therapists are often directive, solution oriented, and use a variety of techniques from other treatment modalities. Cognitive-behaviour therapists expect clients to be active and involved in the therapy process (Beck & Weishaar, 2011; Corey, 2009). Family members are expected to participate in therapy sessions and follow through with therapeutic interventions including homework assignments and other strategies outside of the therapy session (Corey). Session length, duration, and number. According to Somers and Queree (2007) cognitive-behaviour therapy sessions are usually one hour and are structured. Although the number of sessions can vary, 10 to 20 sessions are typically seen as sufficient to produce desired change (Carlson et al., 2005; Laible & Thompson, 2007; Minuchin, 1974; Somers & Queree). Like cognitive-behaviour therapy, family therapy can be brief or extended (Goldenberg et al., 2011). The number of therapy sessions depends on the complexities of the problem, family engagement in the therapy process, and the goals of treatment (Goldenberg et al.; Mash, 2006). According to Goldenberg et al. the duration and number of family sessions is similar to cognitivebehaviour therapy, ranging from 10 to 20 sessions of approximately one hour in duration in most cases.

COGNITIVE-BEHAVIOUR THERAPY

17

Emphasis on past, present and future. Cognitive-behaviour therapy remains focused predominantly on what the family or individual is feeling and how they are coping in the present (Goldenberg et al., 2011; Somers & Queree, 2007). Past experiences are not entirely overlooked. Past experiences are explored only to the extent that they can provide insight into why the person thought certain behaviours or through patterns were useful. Current thought patterns can then be challenged as being no longer appropriate or functional. The focus on past events depends on the style of the family therapist. Many models contend that family history taking is important as it lend to the understanding of current family functioning (Goldenberg, et al, 2011). For example, object-relations family therapists pay attention to how and why marital partners chose each other because it offers the therapist insight into the current relationship (Goldenberg et al.). The choice is viewed by the therapist as an attempt by the partner to reconnect with attachment figures lost early in life (Goldenberg et al.). This allows the family and therapist to examine the interrelatedness of past personal connections to current connections in an attempt to identify new ways of positively connecting with one another and others outside of the family unit. Family therapy models such as structural, strategic, and social constructionist models pay less attention to past events and seem more in line with cognitive-behaviour therapy approaches. These family models pay closer attention to current family functioning and how the family views the world rather than focussing on past events (Goldenberg et al., 2011). Cognitive-behaviour therapy is similar to these family models in that it is present-centered and does not emphasize past event (Beck & Weishaar, 2011).

COGNITIVE-BEHAVIOUR THERAPY

18

Emphasis on beliefs, emotions, and behaviours. Cognitive-behaviour interventions with families focus on cognitive, affective, and behavioural processes (Mash, 2006). According to Mash, psychological disturbances are a result of faulty though patterns including erroneous beliefs, irregular thinking, and poor problem solving. The goal of cognitive-behaviour therapy is to identify maladaptive thought patterns and replace them with more adaptive ones (Mash). Cognitive-behaviour therapists also emphasize emotional factors such as affect (Beck & Weishaar, 2011). Cognitive-behaviour therapy has developed interventions for disturbances that are affective in nature including depression and anxiety symptoms (Mash, 2006). According to Mash, cognitive-behaviour therapists are concerned with emotional processes such as arousal and the influence over other types of behaviour including aggression. Furthermore, cognitivebehaviour models posit that individuals emotional state affects social-cognitive processes such as attributions of causality (Laible & Thompson, 2007; Mash). Cognitive-behaviour therapy aligns with family models regarding the importance of family life and interaction within families on healthy development. According to Mash, cognitive-behaviour therapy considers the emotional environment when looking at individual and family maladaptive functioning. Factors within the larger social system are considered when treating clients including maternal depression, maternal anxiety, marital conflict, and family communication patterns (Mash). According to Mash, the focus on affective processes has led to the creation of anger management and stress management programs. Cognitive-behaviour therapy emphasizes the importance of both cognitive techniques during treatment, as well as behavioural techniques (Beck & Weishaar, 2011). Cognitivebehaviour therapy employs behavioural strategies to influence problematic thoughts (Mash, 2006; Mash & Wolfe, 2005). Therapists utilize experiments to test maladaptive assumptions and foster

COGNITIVE-BEHAVIOUR THERAPY

19

new ways of thinking such as homework assignments; hypothesis testing; exposure therapy; behavioural rehearsal and role playing; diversion strategies; activity scheduling; and graded-task assignments (Beck & Weishaar). Change process. Cognitive-behaviour therapy outlines a direction for the process of therapy beginning with the goal of the first session and outlining the focus for subsequent sessions (Beck & Weishaar, 2011). Cognitive-behaviour therapists help individuals and families realize change by creating a comprehensive case formulation in collaboration with the client(s). Case formulation is a model of the problems and factors that may be contributing to the problems (Somers & Queree, 2007). Such a model can be created through the use of journals or records that the client keeps. For example, the client may be asked to keep track of how many times he or she has a certain belief or acts in a certain way. The client will then log their feelings associated with the belief, the evidence for the belief, and possible alternative evidence in support of different conclusions (Mash, 2006). The logs chart thoughts, feelings, personal behaviour, events, and others responses in situations. The therapist uses the logs to help the client and family make connections between these elements to help explain what causes the problem (Somers & Queree). Case formulations are often comprehensive and evolving. If the client or family has several problems or if new information is presented through the course of therapy, the case formulation will be adjusted to meet the needs of the family. The therapist utilizes verbal techniques to identify the clients thought patterns, analyze the logic of the thoughts, and to highlight irrational thoughts (Beck & Weishaar, 2011; Mash, 2006). The therapist asks questions of the client pertaining to situations where the client felt upset and once the client has identified their thinking at the time, the therapist and client work together to

COGNITIVE-BEHAVIOUR THERAPY

20

identify dysfunctional thinking. The therapist does not interpret the clients thoughts, but rather explores the meaning of the thoughts with the client (Corey, 2009; Mash & Wolfe, 2005). Family therapists who use cognitive-behaviour approaches take an active, problems solving approach with families (Dunst, Trivette, & Deal, 1994; Goldenberg et al., 2011). Using this approach family therapists are concerned more with changing maladaptive interactions within the family than exploring problems from the past (Goldenberg et al.). Past issues may be uncovered, but only to provide further information to help identify behavioural patterns or faulty cognitions that need changing. Family therapists may seek structural changes within the family by challenging rigid and ongoing patterns that inhibit healthy functioning (Goldenberg et al., 2011). According to Minuchin (1974) structural changes may be necessary to relieve family stress resulting from poor coping skills. Structural changes will produce new rules for coping and interacting during stressful events that will produce new adaptive strategies in times of family stress. Helping families change maladaptive rules or coping skills will help produce clearer family boundaries and more open family interactions (Goldenberg et al.). Family therapists also help families make changes in functioning by focusing on behavioural changes, experiential changes, and cognitive changes (Goldenberg et al., 2010; Somers & Queree, 2007). To help elicit behaviour change family therapists are often directive in creating plans to change family dysfunction. Family therapists often use paradoxical interventions to create behaviour change including tasks, experiments, and homework assignments to be completed between sessions (Goldenberg et al.). According to Goldenberg et al. behavioural change results from the emotional experience gained from following through with the therapists directives. To

COGNITIVE-BEHAVIOUR THERAPY

21

elicit experiential change family therapists act as models of open communication and share their own feelings with the family (Goldenberg et al.). Family members are challenged to create new and more attuned relationships with one another while also establishing healthy personal autonomy. By helping family members ask each other what they want from one another and encouraging self-discovery, therapists help clients experience interactions within the family in a different and more positive way (Goldenberg et al.). To elicit cognitive change family therapists provide family members with insight about family interactional patterns and functioning. Family therapists help family members understand how relationship patterns are effecting family functioning and how these patterns are passed down through the generations (Goldenberg et al.). Interventions. Interventions from a family-systems approach focus on relationships within the entire system and not solely on the individual. Family meetings are held on a regular basis and all family members are encouraged to take part in the discussion under family therapy theory (Carlson et al., 2005). This is important because it allows each members views to be considered when making decisions. To improve communication within the family unit the therapist may encourage empathetic and active listening among family members; speaking only for yourself and not suggesting what other members think or feel; and the therapist would discourage blaming or scapegoating family members. Family therapy focuses on the entire family unit; therefore, parents are often taught how to use natural and logical consequences with their children to help teach their children without engaging in negative interactions such as power struggles. Cognitive-behaviour techniques can be effective when working from a family therapy perspective to help point out faulty personal logic of family members (Carlson, et al.). According to Goldenberg et al. (2011) and Mash (2006), family therapists use a number of therapeutic techniques to elicit change that compliment cognitive-behaviour approaches.

COGNITIVE-BEHAVIOUR THERAPY

22

Reframing is common technique used by therapists. Reframing helps family members view problems in a more positive way. Reframing techniques alter the perception of behaviour by family members. Reframing behaviour changes the interpretation of the behaviour and leads to new and more appropriate reactions to the behaviour (Goldenberg et al.). Family therapists also use paradoxical interventions to elicit behaviour change. In this case, family members are instructed to carry on their negative interaction patterns to demonstrate to the family that they are in control of their behaviour (Goldenberg et al.). Paradoxical interventions are designed to empower families to take control of their behaviour by showing that they can control it. Family therapists also use enactments to introduce new strategies for coping with problems. According to Goldenberg et al. enactments/role-plays are used to demonstrate family interactional patterns and coping styles. Family members act out their behaviour patterns so that the therapist and family can identify problems and create new solutions. Cognitive restructuring is another technique used by cognitive-behaviour therapists (Goldenberg et al.; Mash, 2006). Cognitive restructuring involves changing behaviour by changing family members perceptions of events and interactions. According to cognitive-behaviour family therapists, cognitive restructuring is an effective technique to modifying faulty perceptions of family members (Goldenberg et al.). Cognitive-behaviour therapy techniques are evidence-based interventions designed to treat specific problems such as anxiety, depression, child-parent issues, family interaction problems and so on. According to Mash (2006) other effective cognitive-behaviour strategies include: parent management training; modeling and role-playing; relaxation procedures; desensitization; exposure and response prevention; self-control and self-management methods; operant techniques such as fading, shaping, reinforcement, and punishment; stress inoculation; cognitive coping strategies; social skills training; token systems; and behavioural contracting.

COGNITIVE-BEHAVIOUR THERAPY

23

Success. According to Goldenberg et al. (2011) family therapy is effective in resolving relationship problems between parent-child and husband-wife. Family therapy is particularly useful when problems are systemic and when all family members contribute to the problem without any awareness (Goldenberg et al.). For treatment to be successful faulty cognitions will be replaced with appropriate thinking and as a result the client will experience cognitive, emotional, and behavioural changes (Beck & Weishaar, 2011; Mash & Wolfe, 2005). The effectiveness of cognitive-behaviour family therapy is measured using multiple indicators (Mash, 2006). According to Mash, indicators include a reduction in symptoms; improved functioning in the home, at school, or in the community; increased self-reports of happiness and well-being; evaluations from those outside the family unit that things have improved; and prevention of further problems in individual and family functioning. According to cognitive-behaviour therapists it is important to demonstrate changes in behaviour that place individuals and the entire family unit within the boundaries of normal developmental, sociocultural, and personal functioning and improve the quality of life for those involved in cognitive-behaviour family therapy (Mash, 2006). Empirical support for cognitivebehaviour therapy is strong (Mash; Wilson, 2011). Cognitive-behaviour therapy interventions are evidence-based practices and are considered the treatment of choice for certain mood and anxiety disorders. According to Wilson, evidence for the utility of cognitive-behaviour interventions is based on well-controlled efficacy research. Research has show that cognitive-behaviour therapy is effective for treating such problems as anxiety disorders, posttraumatic stress disorder, depression, eating and weight disorders, schizophrenia, and a varity of childhood disorders (Mash; Wilson). Application. Cognitive-behaviour therapy is based on empirical evidence and can be considered an evidence based practice (Beck & Weishaar, 2011; Corey, 2009; Mash, 2006). Many

COGNITIVE-BEHAVIOUR THERAPY

24

experimental studies support the efficacy of cognitive-behaviour therapy and a plethora of literature supports the use of cognitive therapy for a wide range of populations (Beck & Weishaar, 2011; Corey, 2009; Mash, 2006; Mash & Wolfe, 2005). According to Mash and Wolfe (2005), cognitive-behaviour therapy has been shown to be especially effective when used with clients experiencing depression and anxiety. Others have noted that cognitive-behaviour therapy can be use effectively in setting such as: individual therapy, short or long term therapy; marriage therapy; family therapy; and for childhood therapy and problems within the classroom (Pledge, 2004). According to Wilson (2011), cognitive-behaviour techniques have been shown to be effective in treating health problems such as headaches, pain, asthma, nausea reaction in cancer patients, and fears related to being hospitalized. Evidence also supports the use of cognitive-behaviour therapy in treating sleep disorders, alcoholism, suicidal ideation, and compliance to medical treatments (Wilson). Family therapy and cognitive-behaviour therapy are useful for treating a variety of people and a plethora of problems (Beck & Weishaar, 2011; Corey, 2009; Goldenberg et al., 2011; Mash, 2006; Wilson, 2011). Family therapy is effective in helping families change dysfunctional transactional patterns (Goldenberg et al.). Family therapists are able to work with entire family units or different subsystems as needed. Because family therapists view problems as situated in larger systems, they are able to work with blended families, divorced families, and with larger systems outside of the family unit including communities and schools the family is involved with (Mash). Because family therapy is a systems based approach, it is useful in working with people from different cultural backgrounds (Corey, 2009). According to Corey, family therapy provides a framework for therapists to understand cultural differences and to understand family functioning in relation to larger cultures and systems.

COGNITIVE-BEHAVIOUR THERAPY

25

According to Corey (2009) family therapy is not limited to working only with families. Family therapy provides a useful framework to working with individuals as well. According to Corey, family therapy concepts can also be useful for individual and group counselling. Family therapists focus on the family dynamics of the client which provides context and creates a more comprehensive picture of the person seeking therapy. Understanding family background and functioning provides context around clients experiences, view of others, and schemas they hold of the world.

Reflection According to Corey (2009) a major criticism of a family systems approach is that there is a potential to overlook the individual by focusing too much on larger systems such as the family unit. Therapists run the risk of placing too much attention on the family unit and not enough attention on individual experiences. A weakness of cognitive-behaviour approaches is that therapists can become to directive and overlook the familys voice in the therapeutic alliance. According to Corey, therapists can influence clients toward ways of thinking or making behaviour changes that the client did not choose or is not comfortable with. Another criticism is that cognitive-behaviour approaches can be become overly prescriptive and do not address life concerns that existential therapists would address (Corey, 2009). Although cognitive-behaviour therapy is a useful modality to use when working from a family systems perspective, a major downfall of my personal theory is that it is not fully integrated. Although I believe it is important to become proficient in an underlying theory of client change,

COGNITIVE-BEHAVIOUR THERAPY

26

most experienced therapists today operate from a much more diverse and integrated approach. Most therapists today are eclectic and integrated and understand a variety of theories (Mash, 2006). This is important because it allows such therapist a diverse set of techniques to utilize when working with clients of different backgrounds and with different problems. My goal is to become an integrated therapist; however, at this point in my development, cognitive-behaviour techniques provide me evidence-based techniques to utilize when working with clients whos problems appear to be situated in broader social systems such as the family unit, the community, and the school environment.

Conclusion I currently identify most with family therapy and cognitive-behaviour therapy. Family therapy provides a framework to understand human behaviour and the development of maladaptive behaviour. I also believe that interventions aimed at multiple risk factors including the home environment, the school, and community environments are far more effective than treating only personal factors. Although I wish to become integrated and expand my competencies, I believe cognitive-behaviour therapy provided effective evidence-based interventions to use when working with families.

COGNITIVE-BEHAVIOUR THERAPY

27

References Beck, A.T. & Weishaar, M.E. (2011). Cognitive therapy. In R.J. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed.) (pp.276-309). Belmont, CA: Cengage Learning. Bowlby, J. (1988). A secure base. New York: Routledge Corey, G. (2009). Student manual for theory and practice of counseling and psychotherapy (8th ed). Belmont, CA: Brooks/Cole. Dunst, C., Trivette, C., & Deal, A. (1994). Supporting and strengthening families: Methods, strategies and practices. Cambridge, MA: Brookline Books. Goldenberg, I., Goldenberg, H., & Pelavin, E. G. (2011). Family Therapy. In R. J. Corsini & D. Wedding (Eds.), Current Psychotherapies (9th ed) (pp. 417 - 453). Belmont, CA: Brooks/Cole, Cengage Learning.

COGNITIVE-BEHAVIOUR THERAPY

28

Laible. D. & Thompson, R. (2007). Early socialization: A relationship perspective. In J.E Grusec & P.D Hastings (Eds.), Handbook of socialization theory and research (pp. 181-207). New York: The Guilford Press. Levine, S., Gholkar, R, & Collins, L. (2006). The therapeutic alliance in behavior therapy. Psychotherapy: Theory, Research, Practice, Training, 42, 456-468. Doi: 10.1037/00333204.42.4.456 Mash, E. J. (2006). Treatment of child and family disturbance: A cognitive-behavioral systems perspective. In E.J. Mash & R.A. Barkley (Eds.), Treatment of childhood disorders (3rd ed.) (pp. 3-64). New York: The Guilford Press. Mash, E.J. & Wolfe, D.A. (2005). Abnormal child psychology (3rd ed.). Belmont, CA: Thomson Wadsworth. Minuchin, S. (1974). Families and family therapy. Cambridge, MA; Harvard University Press. Pledge, D.S. (2004). Counseling adolescents and children: Developing you clinical style. Belmont, CA: Thomson Wadsworth. Somers, J. & Queree, M. (2007). Center for applied research in mental health and addictions. From www.carmha.ca White, M. (2007). Maps of narrative practice. New York: W.W Norton and Company. Wilson, G. (2008). Behaviour Therapy. In Corsini, R.J. & Wedding, D. (Eds.) Current Psychotherapies. (9th ed.). (pp. 235-275). Belmont, CA: Brooks/Cole, Cengage Learning.

COGNITIVE-BEHAVIOUR THERAPY

29

Hello John, This is well-written paper. I wished you integrated more of your personal positions/reflections in the process of exploring the approaches you associate with. Assignement #3: 47/47; 100%, A+ Online participation: 19/20 Final grade: A+