COGNITIVE-BEHAVIORAL

THERAPY,
GROUP THERAPY, FAMILY
THERAPY
 BACKGROUND
• Cognitive therapy seeks to modify or change patterns of thinking that are
believed to contribute to a patient’s problems.
• These techniques have a great deal of empirical support and in combination
with behavioral approaches (i.e., CBT) are seen as among the most efficacious
of all psychological interventions.
• Most large- scale clinical trials examining the effects of psychotherapy and/or
pharmacotherapy have revealed that the combination of both approaches offers
more significant symptom reduction than either alone
THE MOVE TOWARD COGNITIVE-
BEHAVIORAL THERAPY
• it was clear that a number of frequently encountered clinical conditions (e.g.,
depression) were not so easily addressed by treatments based on classical or
operant conditioning.
• the present blending of behavioral and cognitive methods was stimulated by the
limitations of both psychodynamics and radical behaviorism.
• This blending was also facilitated by the presence of several theoretical models
that incorporated cognitive variables along with the scientific and experimental
rigor.
1. MODELING

• Bandura advocated the use of modeling, or observational learning, as a

means of altering behavior patterns, particularly in children.
• A new skill or a new set of behaviors can be learned more efficiently by
observing another person. Seeing others perform a behavior can also help
eliminate or reduce associated fears and anxieties.
• Perhaps the most widespread use of modeling has been to eliminate
unrealistic fears.

• In participant modeling, for example, the patient observes the

therapist or model holding a snake, allowing the snake to crawl over
the body, and so on.

• Next, in guided participation, the patient is encouraged to try out a

series of similar activities, graded according to their potential for
producing anxiety.
 As noted by Thorpe and Olson (1997), observational learning is best and
most efficient when the following four conditions are met:
1. Patients attend to the model. Incentives may be helpful to facilitate
attention.
2. Patients retain the information provided by the model. It may be helpful to
use imagery techniques or verbal coding strategies to help patients organize
and retain the information provided.
3. Patients must perform the modeled behavior. It is important that the
behavior be mimicked and practiced to facilitate learning and behavior
change.
4. Finally, patients must be motivated to use the behavior that is modeled. It
is suggested that reinforcing consequences be used to increase the likelihood
that the modeled behavior will
be used.
2. RATIONAL RESTRUCTURING

• To facilitate this rational restructuring of events, the therapist may sometimes use
argument or discussion in an attempt to get patients to see the irrationality of their
beliefs.
• In other instances, the therapist may have patients in the therapy room imagine
particular problem situations. All of this may be combined with behavior rehearsal,
in vivo assignments, modeling, and so on. Thus, rational restructuring is not a self-
contained, theoretically derived procedure but an eclectic series of techniques that
can be tailored to suit the particular demands of the patient’s situation.
• A good example of rational restructuring is Ellis’s (1962) rational-
emotive therapy (RET).
• Ellis was clearly a pioneer in what has become cognitive-behavior
therapy. RET aims to change behavior by altering the way the patient
thinks about things.
• In the ABCs of RET, Ellis argued that it is beliefs (B) about activating
events or situations (A) that determine the problematic emotional or
behavioral consequences (C). The basic goal of RET is to make people
confront their own illogical thinking. Ellis tried to get the client to use
common sense. Although certain principles and strategies of RET are
incorporated into other forms of cognitive- behavioral treatments, it
seems that “pure” RET is now much less frequently used than in the
past.
 3. STRESS INOCULATION TRAINING
• Meichenbaum (1977) developed stress inoculation training (SIT). SIT aims to prevent
problems from developing by “inoculating” individuals to ongoing and future
stressors.
• It proceeds in three overlapping phases
• 1. Conceptualization phase: The client is taught how to identify potential threats or
stressors and how to cope with them.
• 2. Skill acquisition and rehearsal phase: The client practices coping skills (e.g.,
emotional self- regulation, cognitive restructuring, using support systems) in the clinic
and then gradually out in the “real world”.
3. Application phase: Additional opportunities arise for the client to apply
a wide variety of coping skills across a range of stressful conditions. To
consolidate these skills, the client may be asked to help others who are
experiencing similar problems.
SIT has been used for the treatment of several clinical problems, including
rape and assault trauma, posttraumatic stress disorder, and anger
dyscontrol.
4. BECK’S COGNITIVE THERAPY

• Aaron Beck has been a pioneer in the development of modern cognitive-

behavioral treatments that have been applied to a variety of clinical
problems. This model of intervention entails the use of both cognitive and
behavioral techniques to modify dysfunctional thinking patterns that
characterize the problem or disorder in question. For example, depressed
individuals are believed to harbor negative/pessimistic beliefs about
themselves, their world, and their future
The following cognitive therapy (CT) techniques might be used in the treatment
of depression.
1. Scheduling activities to counteract his relative inactivity and tendency to focus
on his depressive feelings.
2. Increasing the rates of pleasurable activities as well as of those in which some
degree of mastery is experienced.
3. Cognitive rehearsal: Have the patient imagine each successive step leading to
the completion of an important task (e.g., attending an exercise class) so that
potential impediments can be identified, anticipated, and addressed.
4. Assertiveness training and role-playing
5. Identifying automatic thoughts that occur before or during dysphoric episodes
(e.g., “I can’t do anything right”).
6. Examining the reality or accuracy of these thoughts by gently challenging
their validity
7. Teaching the patient to reattribute the “blame” for negative
consequences to the appropriate source.
8. Helping the patient search for alternative solutions to his problems
instead of resigning himself to their insolubility.
It is worth repeating that cognitive therapy has proven to be one of the
most effective techniques available for treating depression. In addition,
cognitive therapy has been adapted for use with patients suffering from
anxiety disorders, eating disorders and personality disorder.
5. DIALECTICAL BEHAVIOR THERAPY

• Dialectical behavior therapy (DBT; Linehan, 1993) is a relatively new

cognitive-behavioral treatment for borderline personality disorder (BPD) and
related conditions involving emotional dysregulation and impulsivity.
Linehan developed DBT based on her clinical experience with women
diagnosed with BPD who engaged in self-injurious behavior.
• DBT involves skills training in problem-solving techniques, emotional
regulation, and interpersonal skills.
 DBT therapist as well as group DBT skills training. Clients in DBT cycle twice through four
skills training modules:
(a) mindfulness (the ability to be aware of the moment, not to be distracted, and to be
nonjudgmental);
(b) emotional regulation
(identifying emotions, appreciating the effects of emotions on oneself and others, learning to
counteract negative emotional states and to engage in behavior that will increase positive
emotions);
(c) distress tolerance (learning to cope with stressful situations and to self-soothe); and
(d) interpersonal effectiveness (learning to deal effectively with inter- personal conflict, to
appropriately get one’s desires and needs met, and to appropriately say no to unwanted
demands from others). Individuals are asked to commit to 12 months of DBT treatment.
STRENGTHS OF CBT

• 1. Efficacy
• On average, a client who received any of these forms of behavior therapy was
functioning better than at least 75% of those who did not receive any treatment.
More recent meta-analyses have reached similar conclusions across a range of
disorders. Further, the majority of meta-analytic studies that have compared the
effectiveness of behavioral or cognitive-behavioral techniques with that of other
forms of psychotherapy (e.g., psychodynamic or client-centered) have found a
small but consistent superiority for behavioral and cognitive-behavioral methods
2. EFFICIENCY

• The CBT movement also brought with it a series of techniques that were
shorter and more efficient. The interminable number of 50- minute
psychotherapy hours was replaced by a much shorter series of consultations
that focused on the patient’s specific complaints.
• It enables a larger patient population to be reached than can be treated by the
in-depth, one-on-one procedures of an exclusively psychodynamic approach.
3. AN ARRAY OF EVIDENCE-BASED
TECHNIQUES

• Behavior therapy has evolved to the point that it includes a broad array of
techniques, from systematic desensitization to cognitive restructuring. Unless
a CBT therapist is unalterably committed to a single set of procedures, this
broad spectrum demands that choices be made. To increase the probability of
making the correct choice, the therapist is likely to gather information that
will best match technique with patient.
4. SYMPTOM SUBSTITUTION

• CBT will have a secure and valued position in the history of psychology because it
helped lay to rest the hallowed notion of symptom substitution.
• After years of research and clinical experience, it is now clear that not every
patient’s complaint can be labeled as a symptom of some underlying psychic
illness—an illness that will surely return in the form.
• of another symptom if the present one is removed without attending to the
underlying pathology. Attacking a patient’s anxieties directly will not necessarily
force the anxieties to return in another guise.
5. BREADTH OF APPLICATION.

• Traditional psychotherapy had been reserved for the middle and upper
classes who had the time and money to devote to their psychological woes
and for articulate, relatively sophisticated college students with well
developed repertoires of coping behaviors who were attending colleges or
universities that made counseling services available to them at little if any
cost. Behavior therapy has changed all that.
6. SCIENTIST-PRACTITIONER AND CLINICAL
SCIENTIST.

• For those who support the scientist-practitioner or clinical scientist model of

clinical psychology, CBT is an approach that seems to encourage a blending
of the two roles. The CBT tradition springs from a heritage that is
experimental and oriented toward research.
 LIMITATIONS
1. Linking Practice to Science.
Research rarely has been conducted to “dismantle” CBT techniques to determine the most
effective components of this approach that seem to be most strongly associated with
symptom reduction. Consequently, it cannot be ruled out that other, nonbehavioral aspects
of therapy are actually as responsible for symptom relief as the techniques that are the
focus of CBT treatment. For instance, is systematic desensitization the technique that
causes anxiety symptom reduction, or is it perhaps the therapeutic alliance between the
therapist and patient that occurs during systematic desensitization that is more efficacious?
2. DEHUMANIZING?

• The use of mechanistic-sounding terms such as response, stimulus,

reinforcement, and operant need not imply that either the therapist or the
method is detached, sterile, or dehumanizing.
3. INNER GROWTH

• CBT has also been criticized as ameliorative but not productive of any inner
growth. It has been said to relieve symptoms or provide a few skills while
failing to offer fulfilling creative experiences. Although it may alter behavior,
it falls short of promoting understanding. It leaves out the inner person,
values, responsibility, and motives.
4. MANIPULATION AND CONTROL.

• Criticisms of CBT centers on the issue of manipulation and control. The argument
seems to be that cognitive-behavior therapies represent insidious and often direct
assaults on the patient’s capacity to make decisions, assume responsibility, and
maintain dignity and integrity. But patients typically seek professional assistance
voluntarily, thereby acknowledging their need for help and guidance in altering their
lives. Thus, the patient does have the opportunity to accept or reject the procedures
offered (though this defense may not apply as well in institutional settings).
5. GENERALIZATION

• A particularly damaging criticism of several forms of CBT concerns their

effectiveness in settings other than those in which they are conducted. In
other words, do the effects of CBT programs generalize beyond the situations
in which they are practiced?
6. LACK OF A UNIFYING THEORY.

• A final problem with behavior therapy may be its potential for theoretical
chaos. At present, it is an amalgam of techniques—some from the operant
tradition, others from a classical conditioning base, and still others that are
heavily cognitive in nature.
G R O U PT H E RAPY

A HISTORICAL PERSPECTIVE
• One of the earliest formal uses of group methods was Joseph H. Pratt’s
work with tubercular patients in 1905. This was an inspirational approach
that used lectures and group discussion to help lift the spirits of depressed
patients and promote their cooperation with the medical regimen.
• A major figure in the group movement was J. L. Moreno, who began to
develop some group methods in Vienna in the early 1900s and, in 1925,
introduced is psychodrama to the United States. Moreno also used the
term group therapy.
• Trigant Burrow was a psychoanalyst who used the related term group
analysis to describe his procedures.
• In the 1930s, Slavson encouraged adolescent patients to work through
their problems with controlled play. His procedures were based on
psychoanalytic concepts. These and other figures have been identified as
pioneers of the group movement
APPROACHES TO GROUP THERAPY

• 1. Psychoanalytic Group Therapy.

• The group becomes a vehicle through which the individual can express and
eventually understand the operation of unconscious forces and defenses and
thereby reach a higher level of adjustment.
• Wolf (1975) has emphasized that psychoanalysis can occur in groups as well
as on the individual couch. Wolf believes that the dynamics of the group are
secondary to the individual analysis and that the role of the therapist is key.
• Typically, these groups consist of eight to ten members (equal
numbers of men and women) who meet for 90 minutes three times
a week.
• Sometimes the group meets once or twice a week without the
therapist to facilitate the working through of transference
relationships.
• Patients often free-associate to their feelings about other members,
report dreams, and analyze resistance and transference feelings
toward both the therapist and other group members.
PSYCHODRAMA

• Another historic approach to group therapy involved “psychodrama.” This is a form of role-
playing that was developed by Moreno. The patients act out roles much as if they were in a
play.
• The drama may involve an event from the patient’s past or an upcoming event toward
which the patient looks with anxiety.
• In general, psychodrama involves a patient, a stage on which the drama is played, a director
or therapist, “auxiliary egos” (other patients, therapeutic aides, and others), and an
audience. The director assigns the patient a role, and the supporting cast is made up of the
auxiliary egos.
• Moreno contended that acting out a situation, listening to the
responses of the auxiliary egos, and sensing the reactions of the
audience lead to a deeper kind of catharsis and self-understanding.
• He believed that this is much more effective than simply “talking”
to a therapist.
• Particularly for patients who are inhibited or lack social skills,
psychodrama can lead to improved levels of self-expression and to
the development of heightened social skills.
TRANSACTIONAL ANALYSIS

• Eric Berne (1961) was the developer of and the dynamic force behind
transactional analysis (TA). TA is essentially a process in which the
interactions among the various aspects of the people in the group are
analyzed. Analyses often focus on three chief “ego states” within each
person: the Child ego state, the Parent ego state, and the Adult ego state.
Each state is composed of positive and negative features.
• Depending on how a person was raised, he or she will manifest various
aspects of these positive and negative characteristics. A child who was
over- supervised or overregulated by the parents might develop an
inhibited or guilt-ridden ego state.
• These analyses lead the patients toward more rational, appropriate ways
of thinking.
• The units that are analyzed are transactions—the stimuli and responses
that are active between ego states in two or more people at any given
moment.
• A transactional analysis involves the determination of which ego states
are operative in a given transaction between people.
2. GESTALT GROUPS

• Gestalt therapy focuses on leading the patient to an awareness of the “now”

and an appreciation of one’s being in the world. In group therapy, this is
achieved by concentrating on one member at a time.
• The therapist focuses on the patient, while the other group members serve as
observers. This has been dubbed the “hot seat” approach. Patients are asked to
experience their feelings and behavior—to lose their minds and find their
senses. Other members of the group are not just passive observers; they may be
called on to say how they regard the person in the hot seat.
GROUP BEHAVIOR THERAPY

• Group behavior therapy, a fairly popular mode of group therapy in con-

temporary clinical psychology, seems to have grown out of considerations of
efficiency rather than a primary decision to focus on the dynamics of group
interactions.
• For example, it is possible to teach patients in a group setting how to relax,
and it is equally possible to establish common anxiety hierarchies
simultaneously with several patients.
• The therapist in group behavioral therapy often plays a very active, almost
didactic role, providing lessons, skills training, and homework assignments.
• Behavioral and cognitive-behavioral groups are usually time limited (e.g.,
12 sessions) and are comprised of patients with similar problems.
• As in most behavior therapy treatments, these group members complete a
number of assessment instruments before, during, and after treatment to
monitor progress.
• Rose (1991) provides a number of examples of how reinforcement,
modeling, problem solving, and cognitive interventions are implemented in
behavior therapy groups. Research has supported the efficacy of behavioral
and cognitive- behavioral group interventions for the treatment of
depression, social skills deficits, pain, agoraphobia, and other conditions
(Rose, 1991).
• Assertiveness training groups are usually also characterized by
such features as cooperative problem solving, honesty, and
acceptance among group members.
• Another example is cognitive-behavioral group therapy for social
phobia.
• Group therapy also is popular in working with young children and
adolescents.
• Group behavioral therapy meetings, like other time-limited
approaches, typically take place on a weekly basis for a
predetermined number of sessions (e.g., eight sessions for a group
consisting of members dealing with a life crisis).
ARRANGEMENTS

• most groups consist of five to ten patients who meet with the therapist at least once a
week for 90-minute to 2-hour sessions. The members are often seated in a circle so that
they can all see each other. Sometimes they are seated around a table, sometimes not.
• Some therapists feel strongly that a heterogeneous group is best— one that includes
women and men with a variety of problems, backgrounds, and personalities. Other
therapists feel that homogeneous groups are best— groups composed, for example,
exclusively of alcoholics or patients with phobias. They believe that homogeneity
makes for greater efficiency, quicker understanding, and mutual acceptance.
THE CURATIVE FACTORS

• Yalom has specified a set of curative factors that seems to define the essence of what
these group methods offer:
1. Imparting information. Group members can receive advice and guidance not just from
the therapist but also from other group members.
2. Instilling hope. Observing others who have successfully grappled with problems helps
to instill hope—a necessary ingredient for any successful therapy experience.
3. Universality. Listening to others, one discovers that he or she has the same problems,
fears, and concerns. Knowing that one is not alone can be highly rewarding.
4. Altruism. In the beginning, a group member often feels useless and
demoralized. As it becomes apparent that one can help others in the group, a
feeling of greater self-value and competence emerges. relationships, social
skills, sensitivity to others, resolution of conflicts, and so on.
5. Imitative behavior. Watching and listening to others can lead to the
modeling of more useful behaviors. Group members learn from one
another.
6.Corrective recapitulation of the primary family. The group context
can help clients understand and resolve problems related to family
members. The effects of past family experiences can be dissolved by
learning that maladaptive coping methods will not work in the present
group situation.
7. Catharsis. Learning how to express feelings about others in the
group in an honest, open way builds a capacity for mutual trust and
understanding.
8. Group cohesiveness. Group members become a tightly knit little
group that enhances self-esteem through group acceptance.
FAMILY THERAPY

• “Family therapy” often is characterized by a unique approach to treatment

involving the conceptualization of psychological symptoms as arising from
the family system.
THE DEVELOPMENT OF FAMILY THERAPY

• Fruzzetti and Jacobson (1991) trace the origins of family therapy to the 19th-
century social work movement. However, family therapy did not
immediately gain prominence. It was not until the mid-20th century that
family therapy became a popular form of treatment.
• The perspectives of behaviorism and humanism paved the way for an
alternative treatment like family therapy to become a viable option for
clinicians.
• Theodore Lidz and his research team also emphasized the family in
the etiology of schizophrenia.
• Bowen’s (1960) observation of schizophrenic patients who lived
together with their parents in a hospital ward for sustained periods led
to the conclusion that the entire family unit was pathogenic, not just
the patient.
• Satir (1967a), Haley (1971), Jackson(1957), and Bell (1961) gave
impetus and direction to the family therapy movement—a movement
rich in technique, theory, and history.
FORMS AND METHODS

• The general procedures of family therapy are carried on by psychologists,

psychiatrists, social workers, counselors, and others. Family therapists and
counselors are trained in several different programs, including clinical
psychology, counseling psychology, psychiatry, social work, family and child
development, and education. Some therapists use family therapy as only one of
several techniques; others are exclusively family therapists.
• Theoretical approaches range from the systemic, to the psychodynamic, to the
behavioral, and on to those that purport to integrate various theoretical practices.
GOALS

• Most family therapists share the primary goal of improving communication

within the family and deemphasize the problems of the individual in favor of
treating the problems of the family as a whole.
• family therapists are devoted to the philosophy that regarding the family as a
unit and working with it as such will enhance that unit. Although this may
benefit the individual members, the real focus is on the family.
SOME GENERAL CHARACTERISTICS

• Certain aspects of family therapy differentiate it from the customary

individual therapy. For example, family members have a shared frame of
reference, a common his- tory, and a shared language of connotations that
may be foreign to the therapist. The therapist has to learn the family roles and
something about the family’s idiosyncratic subculture.
• At the same time, the therapist must remain detached and not become overly
identified with one faction of the family at the expense of another.
• A history and assessment process is a typical part of family
therapy. The presenting problem must be stated and
understood.
• Laying out the entire panorama of family history—its
extended members and their goals, aspirations, fears, and
frailties—can lead to deeper understanding, empathy, and
tolerance.
CONJOINT FAMILY THERAPY

• In conjoint family therapy, the entire family is seen at the same time by one
therapist. In some varieties of this approach, the therapist plays a rather
passive, nondirective role. In other varieties, the therapist is an active force,
directing the conversation, assign- ing tasks to various family members,
imparting direct instruction regarding human relations, and so on.
• Satir viewed the therapist as a teacher, a resource person, and a communica-
tor. Such a therapist illustrates to family members how they can communicate
better and thereby bring about more satisfying relationships.
• In conjoint and other forms of family therapy, there are five basic modes
of communication (Satir, 1975): placating (always agreeing, no matter
what is going on); blaming (a person’s way of showing how much he or
she can criticize another and thus throw his or her weight around);
super-reasonable (especially characteristic of teachers, whose words
may come out “super-reasonable” but may bear no relationship to how
they feel); irrelevant (the words are completely unrelated to what is
going on); congruent (the words relate to what is real)
OTHER VARIETIES OF FAMILY THERAPY

• 1. Concurrent Family Therapy. In concurrent family therapy, one therapist

sees all family members, but in individual sessions. The overall goals are the
same as those in conjoint therapy. In some instances, the therapist may conduct
traditional psychotherapy with the principal patient but also occasionally see
other members of the family.
• An individual patient’s problems can be understood better and dealt with better
in collaboration with significant others in the patient’s life, the use of such
arrangements should facilitate the therapeutic process.
2. COLLABORATIVE FAMILY THERAPY.

• In collaborative family therapy, each family member sees a different

therapist. The therapists then get together to discuss their patients and the
family as a whole. In a variation of this general approach, co therapists are
sometimes assigned to work with the same family.
3. BEHAVIORAL APPROACHES TO FAMILY
THERAPY.

• Some clinicians have viewed family relations in terms of reinforcement

contingencies and skills training. The role of the therapist is to generate a
behavioral analysis of family problems. This analysis helps identify the
behaviors whose frequency should be increased or decreased as well as the
rewards that are maintaining undesirable behaviors or that will enhance
desired behaviors. Behavioral family therapy then becomes a process of
inducing family members to dispense the appropriate social reinforcements
to one another for the desired behaviors.
4. MULTISYSTEMIC THERAPY.

• A more recent mode of family therapy, multisystemic therapy (MST) was

developed as an intervention for juvenile offenders and their families. The
model behind MST assumes that clinical problems are determined by multiple
factors, including the individual, the family, the school environment, and the
neighborhood. These influences are viewed as “systems” of influence within
which each person operates. MST sees the family as the most important link in
changing problematic behavior, and this approach is characterized by several
key components: (a) treatment is delivered in the person
home, school, or other community locations;
• (b) MST therapists are available for consultation 24 hours a day, 7
days a week; (c) the caseloads of MST therapists are kept
intentionally low (4 to 6 families) in order to provide intensive
services to each family; (d) MST therapists serve on a team in order
to provide continuity of services and to be available for back-up
should the need arise (Henggeler, 2011).
• Finally, MST has been modified to address other clinical problems as
well, including youth emotional disturbance, youth substance use
disorder, family abuse and neglect, and child/youth health problems
WHEN TO CONDUCT FAMILY THERAPY?

• There are no hard-and-fast rules as to when family therapy is appropriate and

when it is not. Most often, family therapy is begun with an adolescent as the
principal patient. Perhaps the patient’s problems are so tied up with the
family that family therapy is really the only sensible course.
• Sometimes, family crises, such as the death of a family member, propel the
entire family unit into pathology almost as one. In some families, there are
conflicts over values.
• Finally, significant marital or sexual problems may be resolved best
by a form of family therapy.
• Family therapy or couples counseling would seem appropriate when
the problems do not seem to stem from deep-seated emotional
conflicts but from matters that can be dealt with educationally,
including misguided attitudes, poor knowledge about sexuality, or
lack of communication.
• However, family therapy is not a cure-all, and it is not always
appropriate. Sometimes a family is so disrupted that such intervention
would clearly be doomed to fail. It is also possible that one or more
family members will refuse to cooperate.
LIMITATION

• Like individual patients, some families do not possess the psychological

strength or resources to cope with the threatening material that may come out
in family therapy sessions. Deciding when to use family therapy is often a
difficult matter that requires careful assessment and a great deal of clinical
sensitivity.