Cognitive Behavioral Therapy

Jean Galica, M.A., LMFT

Jean Galica

Licensed Marriage & Family Therapist


Behavioral/Cognitive-Behavioral Therapy

Introduction:  Behavioral approaches to therapy parallel procedures for scientific study of behavior; hence, behavioral therapy is more concerned with the here and now, what can be observed, seen, heard, smelled, touched, and tasted. Its basic belief is that behavior is determined more by consequences than by antecedents or historical fact. Consequently, its procedures must be measurable. Behavioral and cognitive therapies differ greatly from psychodynamic therapies as behavioral and cognitive therapies are concerned with how, when, where, and what versus the why. The client decides the goal while the therapist decides on the how (Becvar 1996). Behavioral and cognitive therapies can be used in several different applications, such as with individuals, couples, and families. As the field of behavioral and cognitive therapies continues to evolve, various models of therapy, such as behavioral marital therapy, behavioral parent training, functional family therapy, and conjoint sex therapy, have been built into this framework.

These approaches are also taking more and more into account the affect/mood of the individuals. In families, behavioral and cognitive approaches focus on how the members of the group view and maintain the behavior of others. The goal is to move the thinking of the family from negative thoughts to more positive and benign thoughts and help the group members to begin to take control of their lives. The move is to focus not only behavioral changes but to deal with relationships as well.

 

Behavioral Therapy:  The first known use of the term “behavior therapy” in literature was in a status report by Lindsley, Skinner, and Solomon in 1953 referring to their applications of operant conditioning research on psychotic patients (Encyclopedia of Psychology, Vol. 1, p 137). Operant conditioning is when a desired response is rewarded, then the belief is that the likelihood of the desired response reoccurring is increased. Other early investigators in behavior therapy, such as Wolpe, Watson, Jones, Eysenck, Krasner, etc., also consistently defined behavior therapy in terms of “learning theory.”

                        “In the first article devoted to ‘behavior therapy’ published in the Annual

            Review of Psychology, Krasner (1971) argued that 15 streams of development

            within the science of psychology came together during the 1950’s and 1960’s to

            form this new approach to behavior change. These streams may be briefly

            summarized as follows: (Encyclopedia of Psychology, Vol. 1, pp 137-8).

 

    1. The concept of behaviorism is experimental psychology (e.g., Kantor, 1969).
    2. The research in instrumental (operant) conditioning of E.L. Thorndike (1931) and Skinner (1938).
    3. The development of the technique of reciprocal inhibition as a ‘treatment’ procedure (Wolpe, 1958).
    4. The experimental studies of a group of investigators at Maudsley Hospital in London under the direction of H.J. Eysenck (Eysenck, Experiments in behavior therapy, 1964).
    5. The application of conditioning and learning concepts to human behavior problems in the United States, from the 1920’s through the 1950’s, by such investigators as John B. Watson, Mary Cover Jones . . .E. Lakin Phillips.
    6. Interpretation of psychoanalysis in terms of learning theory (e.g., Dollard & Miller, 1950), enhancing learning theory as a respectable base for clinical work.
    7. The concept of classical conditioning derived from Ivan Pavlov as the basis for explaining and changing both normal and deviant behavior.
    8. Theoretical concepts and research studies of social role learning and interactions in social psychology and sociology (e.g., George Homans, George H. Mead, Talcott Parsons, and Theodore Sarbin).
    9. Research in developmental and child psychology emphasizing various learning and modeling (e.g., Albert Bandura . . . John Dollard).
    10. Social influence studies of demand characteristics, experimenter bias, hypnosis, and placebo.
    11. An environmentally based social learning model as an alternative to the ‘disease’ model of human behavior (Bandura, Principles of behavior modification, 1969, Ullmann & Krasner, 1965).
    12. Dissatisfaction with psychotherapy and the psychoanalytic model, as evidenced by strong critiques (e.g., Eysenck, 1952).
    13. The development of the idea of the clinical psychologist within the scientist-practitioner model.
    14. A movement within psychiatry away from the then orthodox focus of internal dynamics and pathology, toward concepts of human interaction and environmental influence (e.g., Adolph Meyer and Harry Stack Sullivan).
    15. A utopian emphasis on the planning of social environments to elicit and maintain the best of human behavior (e.g., Skinner’s Walden Two, 1948).”         

 

Behavior therapy is derived from experimentally established procedures and principles. The experimentation must include the control of variables, the presentation of data, replicability, and a probabilistic view of behavior. However, the method of experimentation may vary widely. Consequently, the term “behavior therapy” was used to denote a change in maladaptive behavior. A behavior therapist, therefore, would deal directly with the maladaptive behavior versus an indirect approach with underlying factors that are causing the maladaptive behavior.

Early behavior therapists rejected the idea of cognitive influence, but within a couple of decades, the 1980’s, behavior therapy entered what has been labeled the “cognitive revolution.” This aroused considerable dispute within the ranks of behavior therapy. Some felt that cognitions were not behaviors and others believed cognitions were an integral part of behavior therapy. To this day, the relationship between cognition and behavior remains uncertain, but to a greater and lesser extent, all therapies are simultaneously cognitive and behavioral. Behavior therapy is based on empirical validation versus a derivation from a theory and sometimes rising out of the clinical experience of the practitioner.

Tenets of behavior therapy lie in classical conditioning (a form of learning in which an unconditioned stimulus leads to an unconditioned response and then the unconditioned stimulus is paired with a conditioned stimulus resulting in the same response) and operant techniques (a reward for performing certain behaviors). Behavior that is rewarding or reinforcing will be repeated and the individual will learn from experience. As a result of experience, individuals often respond in predictable ways to certain stimuli or life events.

According to Goldberg, there are ten underlying assumptions of behavioral therapy, which are as follows: (Goldberg, Family Therapy, 1996, p 254)

 

  1. All behavior, normal or abnormal, is acquired and maintained in identical ways (that is, according to the same principles of learning).
  2. Behavior disorders represent learned maladaptive patterns that need not presume some inferred underlying cause or unseen motive.
  3. Maladaptive behavior, such as symptoms, is itself the disorder, rather than it being a manifestation of a more basic underlying disorder or disease process.
  4. It is not essential to discover the exact situation or set of circumstances in which the disorder was learned; these circumstances are usually irretrievable anyway. Rather, the focus should be on assessing the current determinants that support and maintain the undesired behavior.
  5. Maladaptive behavior, having been learned, can be extinguished (that is, unlearned) and replaced by new learned behavior patterns.
  6. Treatment involves the application of the experimental findings of scientific psychology, with an emphasis on developing a methodology that is precisely specified, objectively evaluated, and easily replicated.
  7. Assessment is an ongoing part of treatment, as the effectiveness of treatment is continuously evaluated and specific intervention techniques are individually tailored to specific problems.
  8. Behavioral therapy concentrates on “here-and-now” problems, rather than uncovering or attempting to reconstruct the past. The therapist is interested in helping the client identify and change current environmental stimuli that reinforce the undesired behavior, in order to alter the client’s behavior.
  9. Treatment outcomes are evaluated in terms of measurable changes.
  10. Research on specific therapeutic techniques is continuously carried out by behavioral therapists.

 

Social Learning Theory:  As stated previously, “behavior therapy” is defined in terms of “learning theory”; thus, I would like to briefly discuss the social learning theory of Albert Bandura. One of Bandura’s famous quotes is, “Of the many cues that influence behavior, at any point in time, none is more common than the actions of others.” (Bandura, 1986, p 206).

            Originally Bandura’s social learning theory was referred to as “observational learning.” The belief is that human learning takes place by individuals observing the behaviors of others and, by these observations, the observer makes decisions about which of those behaviors they choose to adopt as their own in which they later perform.

            In constructing his theory of social learning, Bandura identified three weaknesses that he saw in behaviorism. They were as follows: (1) A limited range of behaviors can be observed for research in a laboratory; (2) these theories were unable to account for the acquisition of new responses to situations; and (3) it dealt with only one type of learning, direct learning. Direct learning is where the learner performs a response and experiences the consequences. Bandura called direct learning instantaneous matching and he referred to indirect learning as delayed matching. Indirect learning is where the learner observes reinforced behavior and then later enacts the same type of behavior.

            Bandura bases his theory on what he coined “reciprocal determinism” which is the interaction of behavioral, environmental (social), and cognitive influences of human learning. “The major difference between Bandura’s social-cognitive theory of learning and earlier theories is his definition of learning. He noted that persons acquire internal codes of behavior that they may or may not act upon later. Therefore, he divided learning and performance as two separate events. Learning was the acquisition on the internal symbolic representations in the form of verbal or visual codes, which could serve as guidelines for future behavior. These memory codes of observed behaviors are referred to as representational systems and divided into two types of systems, visual and verbal-conceptual. The first is concerned with abstractions of distinctive features of events instead of just mental copies. The second would be the verbal form of details for a particular procedure.” (Internet-eduction.indiana.edu/~cep/courses/p540/bandsc.html).

            Bandura went on to describe that modeled behavior, emulating others, conveys information in one of three ways: (1) A social prompt to imitate similar behavior in others; (2) to strengthen or weaken a behavior; or (3) to transmit new patterns of behavior. His three types of modeling stimuli are as follows: (1) Live models; (2) symbolic models; and (3) verbal descriptions or instructions. Bandura also identified three types of reinforcers which are as follows: (1) Direct reinforcement (directly experienced by the learner); (2) vicarious reinforcement (observed consequences of the behavior of the model); and (3) self-reinforcement (feelings of satisfaction or displeasure for behavior gauged by personal performance standards).

 

Cognitive Therapy:  Cognitive therapies stress the importance of cognitive processes as determinants of behavior. Cognitive therapists believe that behavior and emotions result largely from a person’s appraisal of the situation (not so much what the issue is but rather the person’s interpretation of the issue) and one’s appraisal is influenced by their beliefs, assumptions, images, etc., and thus these cognitions become the target of the therapy. The three common assumptions of cognitive therapies are: “(1) Behavior and emotions develop through cognitive processes; (2) procedures based on the human learning laboratory are effective in influencing cognitive processes; and (3) the therapist should serve as ‘diagnostician-educator’ to uncover maladaptive cognitive processes and arrange learning experiences for altering them.” (Encyclopedia of Psychology, Vol. 1, p 245).

            Cognitive therapies differ from psychotherapies, although they acknowledge the importance of beliefs and other cognitions influencing behaviors, in that cognitive therapies see cognitions as being more primary than emotions and behaviors. Cognitive therapists also believe that cognitions instigate behavior and trigger the emotions and believe that changing maladaptive and dysfunctional thoughts, assumptions, and beliefs should be the main concern of therapy. Consequently, cognitive therapists center their attention on the cognitions versus the affect and do not deal directly with the affect but rather cognitive material.

            Thus, cognitive therapists are less concerned with the unconscious drives and defenses than the psychoanalytical therapist. However, cognitive therapists believe consciousness does extend from the unconscious and they believe most problems can be resolved without digging up the deep unconscious. Cognitive therapies also differ from behavioral ones in that the cognitive therapist puts more importance on mental phenomena. Behaviorists for the most part ignore cognitions in favor of overt behaviors and focus on measurable behaviors. Their procedures are limited to changing the environment in order to obliterate undesirable behaviors and replace them with desirable behaviors.

            Many cognitive therapists are ex-behavioral therapists who became disillusioned with the narrowness of the behavioral position. Cognitive therapists believe that many human problems cannot be adequately treated without taking mental cognitions, such as beliefs, into account. Cognitive therapy involves helping an individual think in more effective ways.

            Central to this theory is the belief that one’s feelings are influenced by the way in which one views life events. By changing one’s thoughts/thinking processes, it is possible to change their feelings as well. As opposed to more psychodynamic or psychoanalytic theories in which feelings are viewed as primary and borne of formative experiences, cognitive therapy holds that our feelings can be modified by examining and changing our automatic thought processes.

 

Cognitive-Behavior Therapy:  Cognitive-behavior therapy is an approach designed to change mental images, thoughts, and thought patterns so as to help patients overcome emotional and behavioral problems. It is based on the theory that behaviors and emotions are caused in part by cognitions and cognitive processes which one can learn to change.

            The cognitive strategies of cognitive-behavior therapy are to uncover dysfunctional and maladaptive thinking that often accompany psychological distress and problems. These strategies are based on the belief that one’s feelings are a direct result of one’s thoughts. In other words, what and how one thinks determines how that person feels. The goal of the intervention is to challenge and, hopefully, change maladaptive cognitions, thus allowing the patient to lead a far more productive and happy life.

            However, behavioral techniques also play a central part of the cognitive-behavior therapy. The premise taken from the behaviorists is that maladaptive behaviors are learned and so, therefore, they can be unlearned.

            Consequently, cognitive-behavior therapy has its roots in both behaviorism and cognitive therapy. Most modern cognitive-behavior therapists integrate principles from both schools of thought. Together they create a balanced approach to understanding and treating problems. This approach examines not only the manner in which an individual views themselves and their environment (cognitions), but also the way they act on that environment (behavior). The goal is to effect positive and lasting change by working with the patient to modify their maladaptive thoughts and/or behaviors. It is a popular but false assumption that cognitive-behavior therapists are unconcerned about an individual’s life history. They do recognize and acknowledge that historical events and relationships can represent essential information in understanding a patient’s present level of functioning.

            In reading about the cognitive-behavior therapy, I came across this paragraph that I found very interesting and, in my opinion, reveals one of the reasons cognitions are so important. It separates the human psyche from the animals.

“Cognitions are never considered in research with lower animals. It is assumed that rats can learn relationships between cues and events through conditioning, but that they do not make interpretations or judgments, or develop distorted thinking about their environment. Hence a rat’s behavior is easy to predict, if one knows what has happened to it. Human life is so complex, and so much of the information we receive comes through language, that it is possible for cognitions and cognitive processes to develop which do not reflect accurately the reality of a person’s environment; these cognitions can cause inappropriate and undesirable behaviors and/or emotions. In rats, certain conditions usually produce the same behaviors for all rats. In humans, similar conditions might produce fear or depression in some, and no reaction in others.” (Encyclopedia

            of Psychology, Vol. 1 p 231).

            Cognitive-behavior therapy involves identifying and bringing forth change to specific cognitive processes as they relate to the problems of the individual’s emotions and behaviors. The emphasis is to deal with the “here-and-now” cognitions using such social learning principles as modeling (an individual, such as the therapist, provides an example for the observer to imitate and hopefully the imitation will eventually become part of the observer’s own behavior repertoire) and rehearsal (where the individual does the desired new behavior in therapy and receives feedback regarding their performance from the therapist), and relaxation training.

            Since the first goal of any therapy is to develop an expectation that help is available and that the treatment will be effective, cognitive-behavior therapy achieves this by helping the patient develop an awareness of maladaptive cognition-behavior-emotion patterns.

            Thus cognitive-behavior therapy is directed toward the learning through practice of specific skills which will have a direct relevance to the presenting problem. With the emphasis on learning skills and on self-responsibility in the application of these skills, the patient receives a greater sense of self-mastery and coping ability.

            In behavioral-cognitive family therapy, treatment approaches are tailored to fit the specific needs of the family. The four specific areas that will be discussed will be marital behavior therapy (MBT), behavioral parent training (BPT), functional family therapy (FFT), and conjoint sex therapy.

 

Behavioral Marital Therapy (BMT):  Not too long after the behavioral approach in psychology began to be applied to clinical problems in individuals, interest grew in making application to marital discord. The two main pioneers in BMT were Robert Libermann and Richard Stuart. Libermann saw marital therapy as an opportunity to bring about changes in both partners by restructuring their interpersonal environments and communication. According to Stuart, he believed that successful marriages are different from unsuccessful ones by the frequency or level of reciprocal positive reinforcements that the partners exchange.

            The techniques are directed at four main areas: (1) Increasing the couple’s recognition, initiation, acknowledgement, and the ability to participate in pleasing interactions; (2) decreasing the couple’s aversive interactions; (3) training the partners in the use of effective problem-solving and communication skills; and (4) teaching them to use contingency contracting in order to negotiate the resolution of persistent problems. (Goldberg 1996, p261, 1993 Gerry Grossman Seminars). Contingency contracting will be discussed in a separate section.

            Harold Markman (1992) concluded that it is not so much the differences between people that matters, but rather how the couple handles those differences. In problem solving, the couple needs to discuss one problem at a time, paraphrase to help each spouse listen to the other so each one feels understood, the couples needs to avoid mind reading, state a problem in the positive versus the negative, problems need to be defined in specific terms and yet their definitions need to be brief, feelings need to be expressed, and each partner needs to understand and acknowledge the reciprocal role that is involved in maintaining the problem.

            Cognitive therapists maintain that behavior change alone is insufficient to maintain a permanent resolution of conflict between partners, particularly if the conflict is intense and ongoing. Cognitive restructuring is called for to ensure a happier and more fulfilling relationship. This is done by helping each partner modify unrealistic expectations about what they should expect from the relationship, teaching them as a couple how to decrease destructive interactions, and helping each partner to accept his/her responsibility for the distress they are experiencing. Restructuring distorted beliefs has a pivotal impact on changing the dysfunctional behaviors of the couple.

            In summary, BMT blends principles of social learning theory and the social exchange theory, which postulates that ongoing behavior exchanges influence long-range outcomes in relationships, and by teaching couples how to achieve more positive reciprocity so that their relationship will be more pleasing to both partners. Interventions emphasize examining the thought processes and belief systems of the couple while also recognizing the need for and, hopefully, implementing behavioral changes.

 

Behavioral Parent Training (BPT):  BPT advocates differ from system therapists in that they accept the parents’ view that the child is the person with the problem and the therapy is focused on changing the parents’ response to the child and, in effect, this will change the child’s behavior. Psychologists at the Oregon Social Learning Center, under the direction of Gerald Patterson and John Reid, led the way in developing a series of treatment programs which were based on social learning principles, teaching parents how to reduce and control disruptive behavior in their children.

            The practical features of parent skills training are as follows: (1) It is cost effective because less time is needed for assessing and developing a specific intervention procedure because the treatment plan is standardized, focuses on family empowerment, and it minimizes the reliance on therapists; (2) skills learned with one child may be applicable to siblings if similar conditions arise; (3) training process, if successful, builds confidence and competence in the parents; (4) intervention usually begins early; (5) parents possess the greatest potential for generating behavior change in their children as they have the greatest control over the child’s natural environment; and (6) the use of parents as trainers makes it easier for the children as they do not have to transfer new learned behaviors from the therapist’s office to home.

            It is not important whether the training takes place in a therapy session or in a workshop setting, but it is extremely important that the therapist be very precise in their procedures. The therapist is training parents in behavioral principles and in the use of contingency management procedures in the hopes of altering and/or modifying their children’s behaviors.

            Specific parent training procedures may include verbal and/or performance methods. Verbal methods involve didactic instructions as well as written materials. Performance training methods may involve role playing, modeling, behavioral rehearsal, and prompting. Also, videotaping is becoming a popular vehicle used as a performance-based model.

            The therapist needs to assess four factors before implementing parent skills training which are: (1) Assess the degree to which environmental control is possible; (2) assess if there are interpersonal problems between parents which would preclude their working together in a collaborative set; (3) assess for intrapersonal interference factors with either parent, such as depression or anxiety, which would preclude success; and (4) the assessment of the resources and motivation of the child as different forms of intervention may be suggested.

            A typical training process would follow the following steps: (1) The therapist would explain the social learning theory principles the parents need to know; (2) the problem behavior needs to be precisely defined; (3) the antecedent and consequent behaviors around the problem needs to be analyzed (analyze what elicits it, reinforces it, how it is maintained, and how family members interactions reflect their effort to deal with it); (4) monitoring of the frequency of the targeted behavior and establishing a baseline, which is a stable, reliable performance level against which changes can be compared; and (5) training parents in the specific procedures for changing the problem behaviors. This would involve precisely defining rules for and the expectations of the child (parents may need help in defining realistic and age-appropriate expectations), changing the conditions antecedent to the occurrence of the problem behavior, setting up exact procedures by which to reward the child (type of timing of reward needs to be specified), and setting up exact procedures for discipline. Parents are taught and encouraged to use natural consequences as much as possible.

            Assessment is very important. During assessment the therapist needs to be alert to problems in other family dyads that might just preclude successful parent training. It must be remembered that a misbehaving child does not necessarily represent marital discord. Continuous assessment and monitoring are very important to BPT. Continuously monitoring charts, etc., indicates that progress is being made and this is an important reward for parents. The data obtained from the monitoring will also provide information as to whether the procedures are being correctly applied, appropriate for the situation, and there may even be an indication that the therapy needs to be redesigned.

            There are several methods that can be used in BPT which include contingency contracting (which will be discussed in a separate section of its own), modeling, shaping, which was devised by Skinner and involves the reinforcement of successive approximations of a targeted behavior until the desired behavior is obtained, e.g., achieving the desired behavior by gradually reinforcing small steps along the way instead of reserving reinforcement for the final achieved behavior, time out, use of tokens, just to name a few.

            In summary, BPT is based on social learning theory and represents an effort to train parents in behavioral principles of child management. Intervention attempts to help families develop a new set of reinforcement contingencies in order to begin to learn and implement new behaviors.

 

Contingency Contracts:  Contingency contracts are therapeutic agreements in which all the parties agree to place a problem behavior under a contingency control. One person agrees to do one thing (implementing a more positive behavior) in return for some type of reward or reinforcement, the “give to get” concept/technique. Behavioral therapists believe that a person will exchange their maladaptive behavior for adaptive behavior to gain the desired change in the behavior of the other person.

            It is a simple, straightforward technique, either written or oral, widely used with marital issues and parent-adolescent conflict. The goal is to acknowledge the power of each set of participants to reverse the negative exchange by means of a mutual exchange of positive and cooperative giving of pleasurable behavior. Typically, a contingency contract is assessed after a period of time.

            A contract is negotiated wherein each party specifies who is to do what for whom under which circumstances, times, and places. The terms are to be spelled out in clear, concise statements and they are to be free from coercion. All parties of the contract agree on the contingency in advance. The critical element is the contingent relationship between behavior and consequences. (Encyclopedia of Psychology, Vol. 1; Becvar; and Goldberg).

            Contingency contracts are used widely in marital therapy. All interpersonal relationships are governed by reciprocity. Good marriages have healthy exchanges of positive reinforcers (e.g., spouses cooperate and assist each other and find satisfaction because of the frequent exchange of positive reinforcers, such as favors, affection, etc.). Distressed marriages, however, are marked by a high level of negative reinforcers and very few positive ones. Control is usually maintained by threat and coercion. As a result, many couples need to learn to communicate more effectively and directly, develop problem solving skills, and learn to compromise. Contingency contracting is a great vehicle for helping to implement this exchange of positive reinforcers. Gradually behaviors are brought under control and the exchange of positive reinforcers becomes natural. In marital therapy, there are two basic types of contracts: (1) Quid pro quo (“if-then”) contracts and (2) good faith contracts.

            In quid pro quo agreements, both spouses agree to change behaviors that are sources of conflict for the couple. Usually there is an exchange initiated by each spouse. An example might be that (1) the husband will give the wife a free night out and will babysit the children if he can have the guys over for the big football game on TV and the wife will cook pizzas for them, and (2) the wife will cook his favorite meal and they will have a candlelight dinner once a week if he, the husband, will do the grocery shopping for her. The key is that the two exchanges are independent, meaning that either can be implemented even if the other one breaks down. Each spouse has the capacity to get what they want by doing something that other one wants.

            In good faith contracts, the spouses simply agree to reinforce each other in a specified manner for desired responses. The partners are not assured that the other will change critical behaviors, but they will have their own changes reinforced.

            In either one of these contracts, the terms are specified, so there is no confusion on the interpretation of whether or not the agreement was fulfilled. The emphasis is always on the performance of positive reinforcers versus the reduction of negative behaviors.

            Research shows that negative behaviors generally tend to decrease after positive exchanges increase, but positive responses do not necessarily increase when negative responses decrease. (Encyclopedia of Psychology, Vol. 1, p 120).

            Contingency contracts are also frequently used with families and adolescents and delinquents. As with marital therapy, the contracting teaches problem solving, negotiations, and compromise. The contract specifies behavioral goals, which must be realistic and within the grasp of the adolescent, and the consequences (positive and negative) to be implemented by the parents.

            It defines the privileges and restrictions on the adolescent which are fair to both the parents and the adolescent. The focus is on reducing overt conflict versus establishing love and affection.

 

Functional Family Therapy (FFT):  FFT is designed to bring about both cognitive and behavioral changes in individuals and their families. The model is different from most behavioral models in that it attempts to do more than just change overt behavior, but it also helps patients first to understand the function the behavior plays in regulating relationships. FFT aims at creating non-blaming relationship focus by providing explanations for the causes of members’ behaviors without imputing motive.

            Functional family therapists see all behavior as adaptive, not in terms of “good” or “bad.” Each individual’s behavior serves a function to create a specific outcome in interpersonal relationships. They may take a variety of forms, but they are seen as efforts to achieve one of the three interpersonal states: (1) Merging (contact/closeness); (2) separating (distance/independence); and (3) midpointing (a combination of one and two). The therapist needs to comprehend why the behavior exists and how and why it is maintained by others within the family.

            Once the therapist understands what interpersonal functions are served for whom by the problem behavior, they can then offer help to the family in finding more effective ways to accomplish the same end result. The therapist does not try to change the functions but rather only the specific behaviors used to maintain those functions.

            The three stages of FFT are as follows: (1) The initial assessment stage (the therapist determines the functions served by the behaviors of the various family members); (2) instituting change in the family system (the aim is to modify attitudes, expectations, cognitive sets, and affective reactions) in which the therapist would need to use some familiar behavior principles in their interventions, such a relabeling; and (3) education, which is very important because it provides a context in which to learn specific skills needed to maintain positive changes.

            Positive change is more likely to be produced and/or maintained if the techniques used by the therapist are fitted to the values and functions of the family members.

 

Conjoint Sex Therapy:  Sex therapists tend to make the assumption that some marriages flounder due to sexual difficulties or incompatibilities and tend to focus their interventions specifically on the couple’s sex problems. Different types of dysfunctions are desire, arousal, orgasmic, pain, and the frequency of sex.

            However, the basic assumption in the Masters and Johnson (1970) approach is that there is no such thing as an uninvolved partner in a relationship in which there is some form of sexual inadequacy. Masters, a physician, and Johnson, a psychologist, treated patients conjointly to emphasize that any dysfunction is in part a relationship problem rather than one that belongs to only one partner.

            One of the main contributions of Masters and Johnson was sensate focus, which is learning to touch and explore each other’s bodies and to discover more about each other’s sensate areas without any pressure for sexual performance or orgasm. Sensate focus exercises are designed to offer each partner pleasure in place of the anxiety they were feeling previously in demand for sexual arousal and intercourse.

            Masters and Johnson believe that most sexual dysfunction is anxiety produced over performance versus each partner abandoning themselves into the giving and receiving of erotic pleasure with their partner.

            Kaplan (1974) followed up on Masters and Johnson by suggesting more reasons for sexual dysfunction, such as personal and interpersonal causes (sexual ignorance, fear of failure, etc.) or intrapsychic conflicts (early sexual trauma, guilt, shame, repressed sexual thoughts, and feelings) or psychological determinants of sexual dysfunction (marital discord, power struggles, lack of trust, etc.).

            Cognitive therapists today employ a number of techniques. Some of the more common ones are sensate focus, systemic desensitization (the therapist constructs a stimulus hierarchy in which different situations that the clients fears are ordered on a continuum from mildly stressful to very threatening) (1993 Gerry Grossman Seminars), relaxing techniques, communication training in initiating and refusing sexual invitations, and communication during sexual exchanges. Cognitive-behavior therapists tend to suggest specific exercises for each partner with the goal of overcoming negative, self-defeating feelings and images regarding sexual experiences.

            Sex therapy is only considered successful if the presenting symptom is eliminated or at least improved. However, improved sex is no panacea for a marriage that has already failed.

 

References

 

Becvar, Dorothy Stroh, Becvar, Raphael J. (1996). Family Therapy, a Systemic Integration. (3rd edition). Boston: Allyn

                and Bacon.

 

Encyclopedia of Psychology, Volume I. New York: John Wiley & Sons.

 

Goldberg, Herbert, Goldberg, Irene. (1996). Family Therapy, An Overview. (4th edition). Pacific Grove: Brooks/Cole    

                Publishing Company.

 

Internet: (4 articles): Bandura’s Biography; Cognitive Behavioral Therapy; Overview of Bandura’s Theory; and Social     

                Learning Theory of Albert Bandura, chapter 31.

 

Persons, Jacqueline B. (1989). Cognitive Therapy in Practice. New York: W.W. Norton & Company.

 




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