Cognitive-Behavioral Therapy with Couples and Families a Comprehensive Guide for Clinicians

Cognitive-Behavioral Therapy with Couples and Families A Comprehensive Guide for Clinicians

Fr a n k M. Da t t i l i o

Foreword by Aaron T. Beck

No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Dattilio, Frank M. Cognitive-behavioral therapy with couples and families : a comprehensive guide for clinicians / Frank M. Dattilio. p. cm. Includes bibliographical references and index. ISBN 978-1-60623-453-2 (hardcover : alk. paper) 1. Family psychotherapy. 2. Marital psychotherapy. 3. Cognitive therapy. I. Title. RC488.5.D34 2010 616.89′156—dc22 2009030662 About the Author

Frank M. Dattilio, PhD, ABPP, is one of the leading figures in cognitive- behavioral therapy (CBT) in the world. He holds faculty positions with the Department of Psychiatry at Harvard Medical School and the University of Pennsylvania School of Medicine. He is also in the private practice of clinical and forensic psychology and marital and family therapy in Allentown, Pennsylvania. Dr. Dattilio is listed in the National Register of Health Service Providers in Psychology; is board certified in both clinical psychology and behavioral psychology with the American Board of Professional Psychol- ogy; and is a clinical member of the American Association for Marriage and Family Therapy. He has also served as a visiting faculty member at several major universities throughout the world. Dr. Dattilio trained in behavior therapy through the Department of Psychiatry at Temple University School of Medicine under the supervision of the late Joseph Wolpe, MD, and was awarded a postdoctoral fellowship through the Center for Cognitive Therapy at the University of Pennsylva- nia School of Medicine, where he worked closely under the supervision of Aaron T. Beck, MD. Dr. Dattilio has more than 250 professional publications in the areas of couple and family problems, anxiety and behavioral disorders, and forensic and clinical psychology. He has presented extensively on CBT throughout the United States, Canada, Africa, Asia, Europe, South America, Australia, New Zealand, Mexico, the West Indies, and Cuba. His works have been translated into more than 27 languages and are used in more than 80 coun- tries. Among his many publications, Dr. Dattilio is coauthor of the books Cognitive Therapy with Couples, The Family Psychotherapy Treatment

vii viii About the Author

Planner, and The Family Therapy Homework Planner; coeditor of the Com- prehensive Casebook of Cognitive Therapy, Cognitive-Behavioral Strategies in Crisis Intervention, Cognitive Therapy with Children and Adolescents: A Casebook for Clinical Practice, and Comparative Treatments for Couple Dysfunction; and editor of Case Studies in Couple and Family Therapy: Systemic and Cognitive Perspectives. He has filmed several professional vid- eotapes and audiotapes, including the popular series “Five Approaches to Linda,” and serves on the editorial boards of a number of professional jour- nals, nationally as well as internationally, including the Journal of Marital and Family Therapy and Contemporary Family Therapy. Dr. Dattilio is the recipient of several professional awards for outstanding achievement in the fields of psychology and psychotherapy. He resides in Allentown, Pennsyl- vania, with his wife, Maryann, and regularly visits his three adult children and eight grandchildren. Foreword

I am delighted that Frank Dattilio has embarked on the challenge of produc- ing a truly comprehensive text on cognitive-behavioral therapy with couples and families. As we rapidly approach the fifth decade of cognitive therapy’s introduction into the psychotherapeutic arena, it is evident that the modality has grown exponentially throughout the world as one of the most popular and effective approaches in contemporary mental health treatment. Since the development of cognitive therapy’s application with couples, which took root in the 1980s, there has been a proliferation of research on relationship discord and the role of cognitive processes as they affect emotion and behavior. In the late 1980s and throughout the 1990s, the application of cognitive therapy was expanded to encompass family dynamics, as well as the role that schema plays in the process of change. In Love Is Never Enough (Beck, 1988), I made the practical application of the cognitive therapy approach available to the general public, which helped to increase the general awareness of the power of cognitive therapy in the course of treating relationship distress. Frank Dattilio, who is a for- mer student of mine and a major proponent of the application of cognitive therapy with couples and families, has been instrumental, along with a number of other colleagues, in promoting cognitive therapy’s acceptance in the field of family therapy. His well-received book Case Studies in Couple and Family Therapy: Systemic and Cognitive Perspectives (Dattilio, 1998a) has helped to integrate cognitive therapy into the mainstream of contemporary family therapy and to bolster its acceptance among couple and family therapists around the world. The widespread adoption of the cognitive therapy approach may be

ix x Foreword attributed to many factors, foremost of which is that cognitive therapy has been subjected to more controlled outcome studies than any other therapeutic modality. The research evidence supporting its efficacy is encourag- ing to all those working in the field of couple and family therapy, particu- larly given the increasing demand for evidence-based treatments. Cognitive therapy also tends to appeal to clients who value a pragmatic and proactive approach to solving problems and building the skills that are vital to reduc- ing relationship dysfunction. Further, the approach emphasizes a collabora- tive relationship between therapist and client(s), which is a posture that has become more and more appealing to contemporary couple and family therapists. The current volume provides an updated review of the development of cognitive therapy as applied to couples and families. There is important new emphasis on how one’s family of origin influences belief systems in relationships, as well as on schema in relationships and the restructuring of dysfunctional belief systems. Ample case material and the inclusion of special populations make this book highly readable and broadly relevant. Specific sections on methods of clinical assessment and interventions provide read- ers with a hands-on approach for dealing effectively with various types of dysfunction in relationships. In sum, this book is an excellent resource for mental health professionals of all therapeutic modalities.

AARON T. BECK, MD University Professor of Psychiatry University of Pennsylvania School of Medicine and The Beck Institute, Philadelphia Preface

Recent data suggest that 43% of couples will divorce within the first 15 years of marriage, with second marriages having an even higher likelihood of fail- ure (Bramlett & Mosher, 2002). Couple and family problems account for approximately half of all visits to psychotherapists’ offices. Recent surveys tell us that most therapists who specialize in family therapy work primarily with couples (Harvard Health Publications, 2007). Unfortunately, the track record for success in professional couple therapy has not been impressive (Gottman, 1999). More than 30% of couples completing conjoint therapy fail to show long-term improvement (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). Nowhere has this finding been underscored more than in the ambitious Consumer Reports Survey undertaken in the mid-1990s, which indicated that, among consumers of psychotherapy, those who participated in family therapy were the least satisfied (Seligman, 1995). In contrast, other research comparing couple therapy with no treatment at all concluded that couple therapy unequivocally increased satisfaction more than no treatment (Christensen & Heavey, 1999). So, with all of the fine contemporary modalities of couple and family therapy available to us, along with the current thrust of evidence-based therapies, why is there still so much discontent among consumers? There are a number of likely explanations for this discouraging outcome. One may be that spouses or family members hold rigid beliefs about their partners or relatives and the potential for change in the relationship. Much of couple and family therapy involves the members coming in each week and describing their fights and disagreements. The therapist calms them down and helps them to spell out their feelings and listen to each

xi xii Preface other. They feel better and go home, and then function well until they have their next fight. Couples and families are not easy to change. The individual personalities of the family members are often quite complex and can involve behavioral patterns that interlock poorly. Many come to therapy wanting not to change, but to be vindicated and perhaps have their partners or other family members change. They often avoid taking a hard look at themselves and committing to what they need to change in themselves, such as in the case of those maintaining unrealistic expectations about their relationships. Unless family members can be helped to see their own roles in the problems that plague them, they will have no motivation to change. In addition, many couples and families drag their feet when it comes to entering into treatment. In studies undertaken with couples seeking divorce, less than one- fourth reported that they sought help from a marriage counselor before initiating divorce proceedings (Albrecht, Bahr, & Goodman, 1983; Wolcott, 1986). When those who failed to seek treatment were questioned about the reason, they frequently cited the unwillingness of the spouse (33%), their disbelief that anything was wrong, or their conviction that it was simply too late for any type of intervention (17%) (Wolcott, 1986). This book presents a comprehensive model of cognitive-behavioral therapy (CBT) with couples and families. It addresses areas of neurobiology, attachment, and emotional regulation, placing specific emphasis on schema restructuring against the backdrop of a systems approach. In addition, this book gets into the nitty-gritty aspects of working with difficult families who are stuck in rigid thought and behavioral patterns that clinicians often find arduous to treat. Over the years, cognitive-behavioral couple and family therapy has evolved into a precisely focused and integrative approach. It is nicely adapt- able by practitioners of differing modalities. In fact, in recent surveys, more than half of all practitioners said that they most often use CBT in combina- tion with other methods (Psychotherapy Networker, 2007). The concept of schema has been expanded greatly beyond traditional CBT with couples and families and, in many ways, has been one of the cornerstones in facilitating change. CBT places a heavy emphasis on the importance of belief systems and those elements that so profoundly influence emotion and behavior. When I began using cognitive-behavioral strategies with couples and families more than 30 years ago, I encountered considerable opposition from family therapists who espoused the more traditional models in the field. They often criticized the CBT approach as being “too linear” or “superfi- cial” and failing to address the concept of “circularity, or some of the underlying dynamics,” found with relationship dysfunction (Nichols & Schwartz, 2001; Dattilio, 1998a). Many of my colleagues also felt that CBT ignored the emotional component of family members and was concerned only with thoughts and behavior. Eventually, I realized that there was some merit to Preface xiii my colleagues’ criticism. Their feedback encouraged me to rethink how the CBT approach could be refined to embrace these important components during the course of treatment. The manner in which CBT with couples and families had initially been portrayed, unfortunately, left many with the impression of a wooden and inflexible approach, despite the fact that the majority of the interventions were very effective and integratable with other modalities. Some of the earlier work with couples and families, for example, failed to consider the systemic dimension of treatment or to highlight how a person’s belief system was influenced by his or her family of origin (Dat- tilio, 1989; Dattilio & Padesky, 1990). However, since that time I have been strongly influenced by my colleagues Norman Epstein and Donald Baucom, who enhanced the CBT approach in working with couples so as to include a greater focus on emotion. They have both contributed a great deal to the empirical literature. Their work has also influenced my development and the expansion of my approach in applying CBT to families. Some of the more recent scholarly work in this area has also embraced an expanded model against the backdrop of a systems perspective and the highlighting of the emotional component of treatment. This revised model offers the flexibility to integrate other modalities of treatment (Dattilio, 1998a, 2005a, 2006a), which serves to broaden the scope of the approach. The impetus for writing this book was twofold—to provide a more contemporary version of CBT with couples and families and to enhance its effectiveness through a specific emphasis on schema. Since the early 1990s there has been a substantial amount of empirical as well as clinical/case literature published on CBT with couples and families that has changed the land- scape of what was once considered traditional CBT. This text offers some of the basic components of CBT, yet applies them with a greater emphasis on schema identification and restructuring. Some of the content of this book is based on the fine work of Jeffrey Young and colleagues (Young, Klosko, & Weishaar, 2003), but is greatly expanded in order to reflect an appreciation for relationship dynamics and systemic interaction that are found in clinical work with individuals. This book was a challenge to write for several reasons. First, there has been a burgeoning of professional literature in the past 20 years on various aspects of couple and family therapy, much of which, although important, exceeds what can fit into a single text. Hence, synthesizing what is essential and what is not became a major endeavor. This book is therefore designed to offer the reader a comprehensive guide to the practice of CBT with families without listing study after study, but using a greater focus on clinical practice. Second, the field of psychotherapy in general has gravitated toward evidence-based practice (Sue & Sue, 2008). Hence, documentation is required to be much more empirical than previously—when practitioners could sim- xiv Preface ply write about what they themselves found to be effective in treatment without having to provide rigorous scientific evidence. Anecdotal writing no longer carries the same weight in the field that it once did. However, a major problem with reporting on empirical evidence is that the text often becomes so bogged down with references that the emphasis on clinical practice is lost. It became a juggling act for me to attempt to remain scientific while crafting a text that is interesting and shows the details of clinical practice. I hope this book offers you an expanded and contemporary version of CBT with couples and families that is useful to clinicians, yet fills a much needed void in the cognitive-behavioral literature, as well as in the field of couple and family therapy in general.

Author’s Note Throughout this book, the term couple is used for any partnership (married or unmarried) and family for any partnership with children. Acknowledgments

With the passage of time, I have come to realize how fortunate I have been to study under some of the greatest minds in the history of our field. As a neophyte, I had the distinct honor of coming under the tutelage of the late Joseph Wolpe, who, in addition to imparting his own clinical wisdom, exposed me to many eminent guest lecturers at his Philadelphia training center in the late 1970s. Among these esteemed guests were the late Viktor Frankl and Anna Freud. It was during my training with Wolpe that Aaron T. Beck expressed an interest in my work and offered me a postdoctoral fellowship through the Center for Cognitive Therapy and the University of Pennsylvania School of Medicine in the early 1980s. My years of training in traditional behavior therapy and, later, in cognitive therapy prepared me well for what would eventually become a fruitful career in the field of couple and family therapy. I subsequently had the wonderful opportunity to share many collegial teaching and writing experiences with such prominent figures as Arthur Freeman, Donald Meichenbaum, Norman Epstein, Harry Aponte, James Framo, Cloé Madanes, Arnold Lazarus, William Glasser, and Peggy Papp, to name a few. My experiences with these colleagues helped to shape my clinical acumen as a cognitive-behavioral therapist, as well as a couple and family therapist, and for that I thank them immensely. I also thank the thousands of couples and families with whom I have worked throughout the world who have helped me to shape my clinical skills to what they are today. Without them, my clinical expertise and theoretical beliefs would be insular. Compiling a major text such as this is not possible without the aid of many talented assistants. I owe a tremendous debt of gratitude to my col-

xv xvi Acknowledgments league Michael P. Nichols, whose tireless effort and superb editorial guidance has helped to shape this text into its present form. Jim Nageotte and Jane Keislar at The Guilford Press also deserve acknowledgment for their guidance on the project from beginning to end. Suzi Tucker has also been immensely helpful in providing feedback and guidance on my writing style. I must also thank Seymour Weingarten, Guilford’s Editor-in-Chief, who has always been extremely supportive and patient with my ideas over the past two decades. It is because of Seymour’s open-mindedness and flexibility that this and many other projects in the past have become a reality. A hearty thanks is also extended to my research assistants, Kate Adams and Katy Tresco, and more recently, Amanda Carr, who spent many hours conducting endless literature searches and collecting reprints. I also thank my personal secretaries, Carol Jaskolka and Roseanne Miller, for their long hours of typing and their excellent computer skills. Their expertise in coor- dinating all of the details with this book is appreciated more than they will ever know. Finally, I owe the greatest acknowledgment to my loving wife, Mary- ann, and my children and grandchildren, who endured my many absences during the preparation of this book. They have all taught me the true mean- ing and beauty of being a husband, father, and grandfather. Contents

1 introduction 1 Overview of Contemporary Cognitive-Behavioral Therapy with Couples and Families 1 Learning Theory Principles 2 Cognitive Therapy Principles 5 The Integrative Potential of Cognitive-Behavioral Therapy 6

2 the Mechanics of Change with Couples and Families 10 Cognitive Processes 10 Attachment and Affect 25 The Role of Behavioral Change 48

3 the Schema Component in Cognitive-Behavioral Therapy 54 The Concept of Schema 54 Automatic Thoughts and Schemas 57 Underlying Schemas and Cognitive Distortions 60 Identifying Schemas from the Family of Origin and Their Impact on Couple and Family Relationships 61 Cognitions and Transgenerational Schemas 67

4 the Role of Neurobiological Processes 77 The Role of the Amygdala 81 Cognition versus Emotion 85

xvii xviii Contents

5 methods of Clinical Assessment 88 Initial Joint Interviews 89 Consultation with Previous Therapists and Other Mental health Providers 91 Inventories and Questionnaires 93 Additional Psychological Testing and Appraisals 96 Genograms 97 Ongoing Assessment and Case Conceptualization throughout the Course of Therapy 98 SpecificD ifficulties with theA ssessment Process 99 Behavioral Observations and Change 101 Structured Family Interaction 102 Assessment of Cognitions 103 Individual Interviews 105 Identification of Macro-Level Patterns and Core relationship Issues 106 Assessing Motivation to Change 107 Feedback on the Assessment 108 Identifying Automatic Thoughts and Core Beliefs 108 Differentiating Core Beliefs from Schemas 111 Negative Framing and How to Identify It 112 Identifying and Labeling Cognitive Distortions 113 Translating Thoughts, Emotions, and Behaviors in the Process of Conceptualization 114 Attribution and Standards and Their Role in Assessment 114 Targeting Maladaptive Behavioral Patterns 115 Testing and Reinterpreting Automatic Thoughts 115 Formulating a Plan of Treatment 116

6 Cognitive-Behavioral Techniques 118 Educating and Socializing Couples and Family Members about the Cognitive-Behavioral Model 118 Identifying Automatic Thoughts and Associated Emotions and Behavior 119 Addressing Schemas and Schema Restructuring 120 Instituting Enactment through Reframing and Rehearsal 122 Behavioral Techniques 123 Addressing the Potential for Relapse 156 Handling Roadblocks and Resistance to Change 158 Partners’ Negativity and Hopelessness about Change 158 Differences in Agendas 159 Anxiety about Changing Existing Patterns in the Relationship 160 Relinquishing Perceived Power and Control 161 Contents xix

Issues of Taking Responsibility for Change 161 Roadblocks 163

7 special Topics 173 Divorce 173 Cultural Sensitivity 178 Depression, Personality Disorder, and Other Mental Illnesses 186 Extramarital Affairs 187 Substance Abuse 189 Domestic Abuse 191 Contraindications and Limitations of the Cognitive-Behavioral Approach 196 Couples and Families in Crisis 198 Same-Sex Couples and Their Children 199 Atypical Couple and Family Consultations 200 Cotherapy with Couples and Families 203 Multilevel Treatment 203

8 enhancements to Cognitive-Behavioral Therapy 208 Acceptance-Based Techniques 208 Mindfulness 209

9 Case Examples 212 The Retirement Trap 212 Family of Gluttons 225

10 epilogue 246

Appendix A Questionnaires and Inventories for Couples and Families 249

Appendix B dysfunctional Thought Record 251

References 253

Index 273