COMPREHENSIVE COGNITIVE-BEHAVIOR THERAPY WITH COUPLES AND FAMILIES: A SCHEMA FOCUSED APPROACH FRANK M. DATTILIO, PH.D.

, ABPP HARVARD MEDICAL SCHOOL

2007 Frank M. Dattilio, Ph.D., ABPP

COGNITIVE-BEHAVIORAL STRATEGIES WITH COUPLES AND FAMILIES Frank M. Dattilio, Ph.D., ABPP Harvard Medical School Introduction I. Historical Development of Cognitive-Behavior Therapy II. Philosophy and theory an overview

Application of Cognitive-Behavioral Strategies with Couples and Families Cognition, affect, and behavior Combined perspectives within a systems framework Role of core beliefs and schemas and their multimodal dimensions Video clips

III.

Assessment Techniques and Case Conceptualization Conjoint, individual, and family interviews Use of surveys, questionnaires, and assessment measures Development of case conceptualization including negative automatic thoughts Assessing personality and other disorders Orient couple or family to the cognitive-behavioral model

2007 Frank M. Dattilio, Ph.D., ABPP

IV. Techniques and Procedures for Couples and Families

Identify automatic thoughts, underlying schemas, maladaptive assumptions, and cognitive distortions Draw link between emotions and negative automatic thoughts and misperceptions. Use of the Daily Dysfunctional Though Record Identify negative frame and ingrained beliefs associated with cognitive distortions Weighing evidence and challenging automatic thoughts and schemas The use of new evidence in correcting distorted thinking and ingrained schema Practice alternative (balanced) explanations and behavioral follow through Reframing through restructuring of thoughts, belief systems, and schemas Additional techniques: Quid Pro Quo behaviors, communication training, problem-solving strategies, caring days and pleasing behaviors, positive behavior change, agreements, role play, the Pad and Pencil Technique, coaching, time out, homework assignments, and bibliotherapy Family therapy intervention Integration with other modalities of treatment Integration of cognitive-behavioral strategies with other modalities of couple and family therapy

V. Videotape or Live Demonstration VI. Questions and Answers/Summary Discussion

2007 Frank M. Dattilio, Ph.D., ABPP

ABOUT THE PRESENTER

Frank M. Dattilio, Ph.D., ABPP, holds a joint faculty position with the Department of Psychiatry at Harvard Medical School and the University of Pennsylvania School of Medicine. He is a clinical psychologist in private practice in Allentown, Pennsylvania. He is a licensed psychologist, listed in the National Register of Health Service Providers in Psychology. Dr. Dattilio is board certified in both clinical psychology and behavioral psychology with the American Board of Professional Psychology and is a clinical member of the American Association of Marriage and Family therapy. He has also been a visiting faculty member at several major universities and medical schools throughout the world. Dr. Dattilio trained in behavior therapy through the Department of Psychiatry at Temple University School of Medicine under the direction of the late Joseph Wolpe, M.D., and received his postdoctoral fellowship through the Center for Cognitive Therapy, University of Pennsylvania School of Medicine under the direction of Aaron T. Beck, M.D. Dr. Dattilio is one of the originators of cognitive-behavior family therapy. He has 220 professional publications, including 15 books. He has also presented extensively throughout the United States, Canada, Africa, Europe, South America, Asia, Australia, New Zealand, Mexico, Cuba, and the West Indies on cognitive-behavior therapy. To date, his works have been translated into 25 languages and are used in 80 countries. Among his many publications, Dr. Dattilio is co-author of the books, Cognitive Therapy with Couples (1990); Panic Disorder: Assessment & Treatment through a Wide Angle Lens (2000); The Family Psychotherapy Treatment Planner (2000); and The Family Therapy Homework Planner (2001); co-editor of Comprehensive Casebook of Cognitive Therapy (1992); CognitiveBehavioral Strategies in Crisis Intervention (1994) (2nd edition (2000) (3rd edition (2007); Cognitive Therapy with Children and Adolescents: A Casebook for Clinical Practice (1995) (2nd edition, 2003); Comparative Treatments for Couple Dysfunction (2000); and editor of Case Studies in Couple and Family Therapy: Systemic and Cognitive Perspectives (1998). He has filmed several professional videotapes and audiotapes including the popular series Five Approaches to Linda (Lehigh University Media, 1996) and remains on the editorial board of a number of professional journals, nationally as well as internationally. Dr. Dattilios areas of expertise are in couple and family problems, forensic psychological evaluations, as well as the treatment of anxiety and depressive disorders. He is the recipient of numerous professional awards for his contribution to the field of psychology and psychotherapy. Dr. Dattilio can be reached at the e-mail address: frankdattilio@cs.com - Website: www.dattilio.com. 2007 Frank M. Dattilio, Ph.D., ABPP

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I. HISTORICAL DEVELOPMENT OF COGNITIVE-BEHAVIORAL THERAPY WITH COUPLES AND FAMILIES

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POPULARITY OF COGNITIVE-BEHAVIOR THERAPY

AAMFT In a recent national survey conducted by the American Association for Marriage and Family Therapy (AAMFT), MFTs were asked to report their primary treatment modality in a word or two (p. 448). Of the 27 different modalities that were identified, the most frequently identified modality was cognitive-behavioral family therapy (Northey, 2002). Psychotherapy Networker A survey that was partnered with Columbia University reported that of the 2,281 responders, 1,566 (68.7%) stated that they use CBT (mostly in combination with other methods) (Psychotherapy Networker, 2007).
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COGNITIVE PERSPECTIVE ACCEPTS THE BEHAVIORAL PERSPECTIVE In addition, FOCUS ON: 1) 2) 3) 4) 5) 6) 7) Issues of family of origin assessment Perception and distortions of thinking Automatic Thoughts, core beliefs, and schemas Attributions Expectations Standards Modification and restructuring of thoughts and beliefs

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II. APPLICATON OF COGNTIVE-BEHAVIORAL STRATEGIES WITH COUPLES AND FAMILIES

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SCHEMA Definition: Greek Root Word XHMA (Scheen) - To have - To Shape, To plot or make a detailed plan or outline EARLY SCHEMA THEORY What disturbs human beings most is not the things themselves, but their conceptions of things. [Epictetus, M5 (undated)] Stoic Greek Philosopher
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DEVELOPMENTAL PSYCHOLOGY Piagets Theory on Accommodation and Assimilation (1950) schema formation. Intelligence progresses from a state in which accommodation to the environment is undifferentiated from the assimilation of things to the subjects schemata to a state in which the accommodation of multiple schemata is distinguished from their respective and reciprocal assimilation (Piaget, 1954) (p. 395).
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 Kellys Cognitive Constructs (1955) Cognitive structural constructs. How information is stored and organized and how it structures the processing of information. Viewed man as a scientist. Man looks at the world through transparent patterns or templates, which he creates and then attempts to fit over the realities of which the world is composed Let us give the name constructs to these patterns that are tried on for size. There are ways of construing the world (Kelly, 1955 pp. 8-9). Bowlbys Attachment Theory (1969) Based on experience with caregivers, children develop internal working models of close relationships. These models may later be used to form an internal working model of adult romantic relationships.
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FURTHER ELABORATED DEFINITIONS A structure for screening, coding and evaluating the stimuli that impinge on the organism. On the basis of the matrix of schemas, the individual is able to orient himself in relation to time and space, and to categorize and interpret experiences in a meaningful way [Beck, 1967, p. 283]. Schemas play a central role in accounting for repetition in free associations, images, and dreams.

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Template for Viewing Ourselves and the World Becks Cognitive Triad SELF

WORLD
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OTHERS

EXPANDED CONCEPTS ON SCHEMA Organized elements of past reactions and experiences that form a relatively cohesive and persistent body of knowledge capable of guiding subsequent perception and appraisals. [Segal, 1988, p. 147] Set of rules held by an individual that guides his or her attention to particular stimuli in the environment and shapes the types of inferences the person makes from unobserved characteristics. [Arias & Beach, 1987, p. 110]

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CENTRAL THEME Most definitions maintain that cognitive schemas represent highly generalized superordinate-level cognition that are resistant to change, and exert a powerful influence over thought, affect, and behavior.

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SCHEMA PARAMETERS

PHYSIOLOGY SCHEMA OF SELF & FAMILY BEHAVIOR

COGNITION

EMOTION

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FOUR LEVEL THEORY

Early maladaptive schema Beliefs about oneself and others that develop early in ones life that tend to have an enduring negative impact (i.e., You can never rely on anyone but yourself). Schema maintenance used to confirm existing schema i.e., Abandonment Schema My spouse will not be available as a stable source of support when I need him/her. [Individual looks for repeated substantiation of this] Schema avoidance Individuals block thoughts and images that are likely to trigger the schema either by distraction, or other means, in order to avoid feeling it. Schema overcompensation fighting a schema by thinking, feeling, behaving, and relating as though the opposite of the schema were true. [Young, Klosko, & Weishaar, 2003]
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Youngs Schema Theory Draws From: Psychoanalytic Theory CBT

Constructivism

Schema Theory

Attachment

Gestalt Psychology

Object Relations Theory

Youngs theory pertains primarily to psychological disturbance with individuals [personality disorders].
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SELF SCHEMAS

Self-worth & Self-esteem Trauma Childhood Experiences Rejection & Abandonment

Source: Marcus, H. (1977)
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Security Comfort

Attachment

CONSCIOUS VS. SUBCONSCIOUS AWARENESS

PHYSIOLOGY -Gastrointestinal -Cardiovascular -Respiratory -Neuromuscular EMOTIONAL -Anger -Sadness -Sorrow -Depression -Frustration
2007 Frank M. Dattilio, Ph.D., ABPP

BEHAVIOR -Withdrawn -Aggression -Passivity

COGNITIONS -Thoughts -Beliefs

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SCHEMA DEVELOPMENT Information and experiences continue to affect the development of schemas until a template forms for viewing ourselves, others, our world, and relationships. Sometimes these templates can become rigid and almost fixed and are difficult to modify.
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SCHEMA MAINTENANCE The tendency to seek and locate information that confirms existing schemata and fortifies it. Healthy maintenance New information is used to balance out old information and adjust based on substantiating evidence assimilation (i.e., first impression vs. second impression). Unhealthy Maintenance New information violates old information due to incongruity. Instead of assimilation and adjustment, maintains rigid stance and rationalizes the need to remain fixed (i.e., first impression remains only impression).

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SCHEMAS IN COUPLE AND FAMILY RELATIONSHIPS Family-ofOrigin Development of Self Schema External Influences Parent Relationships Family Relationships Self and Spouse Immediate Family
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Identification and Internalization of Parental Thoughts, Emotions, and Behaviors

ATTACHMENT STYLES

Securely

- These individuals view themselves as worthy and others as trustworthy. Comfortable with both intimacy and autonomy. Research shows that these people are typically more satisfied in relationships.

Preoccupied - Maintain negative view of self, but positive view of others. Become over involved with others and foster unhealthy relationships depend on others for sense of self-worth.
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Fearful-Avoidant - Maintains a negative view of both themselves and others. Fearful of intimacy and avoid relationships with other people. Dismissing - Maintain positive view of themselves, but have a negative view of others. May avoid relationships with others. Prefer being independent. Closeness is not important to them.

Source: Bartholomew, K. & Horowitz, L. M. (1991).

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TYPES OF BROAD RELATIONSHIP BELIEFS WITH COUPLES

Assumptions

- Beliefs about the nature of close relationships in general, as well as in specific (self and spouse) (i.e., my spouse should know how I feel in most situations and stand up or cover for me if I give him/her the eye.) - Beliefs about the way relationships should be or the way partners should behave (i.e., he shouldnt be going on vacation alone without his wife that's just not right!).

Standards

(Epstein & Baucom, 2002)

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Long-standing and strongly held assumptions and standards have an impact on emotions and behaviors and serve to organize ones perception of the world.

Conflict

Unrealistic, Too extreme, Rigid

Not being met in the relationship

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RELATIONAL SCHEMAS
Defined by Baldwin (1992) as: Cognitive structures representing regularities in patterns of interpersonal relatedness. 3 components Interpersonal Script - Key events that occur in the relationship. Self Schema Partner Schema - Attributes and traits that describe oneself. - Attributes and traits that describe ones partner.

Baldwin, M. W. (1992).

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RELATIONSHIP STANDARDS
- Boundaries within the relationship the degree of independence vs. interdependence that each spouse should maintain. i.e.: Amount of time spent together Degree of which thoughts and feelings are shared - Power and Control Acceptable standards within the process of decision making and compromise. - Degree of Investment in the Relationship behaviors that show caring and affection, commitment, willingness to communicate, etc.
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III. ASSESSMENT TECHNIQUES AND CASE CONCEPTUALIZATION

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ASSESSMENT AND CASE CONCEPTUALIZATION

I Initial Conjoint Interview
Gather background information Define presenting problem/conflict areas Compare and contrast spouses individual perception of the problem(s) Listen for any distortion or ingrained beliefs about themselves and their spouses Explore previous therapeutic interventions and/or self-help strategies what has worked and what has failed Learn their dance and the roles that their schemas play Early formulation of road map about how the function and where conflict occurs Distribute and explain the use of questionnaires/inventories and how these will be used to identify thoughts and beliefs

II

Individual Session with Spouse

Score inventories and review feedback Focus in on highlighted areas of automatic thoughts, ingrained beliefs, schemas and maladaptive behavior patterns Probe for the need for personality testing Assess the amenability to change Ascertain collaboration

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III Second Conjoint Interview

Provide feedback on conceptualization of the problem Discuss any roadblocks to change Review realistic vs. unrealistic expectations Ascertain collaborative set Orient couple to the cognitive-behavioral model Establish an initial plan of action (e.g., communication, addressing rigid belief systems, problem solving, etc.)

Family Interviews
Members are all interviewed at the same time Depending on situation, individual interviews may be held, but are rare The use of questionnaires and inventories may be used, particularly with older children (age 12 and older) who are not very verbal Assess individual and family perceptions and schemas

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QUESTIONNAIRES AND INVENTORIES FOR COUPLES

Marital Attitude Questionnaire Revised. Pretzer, Epstein and Fleming, 1991. Dyadic Adjustment Scale (DAS). Spainer, 1976. Marital Happiness Scale (MHS). Azrin, Master, & Jones, 1973. Marital Satisfaction Inventory (MSI). Snyder, 1981. Spouse Observation Checklist (SOC). Weiss, 1973. Areas of Change Questionnaire (ACQ). Weiss, 1970. Marital Communication Inventory. Bienvenu, 1970. Abbreviated Barrett-Lennard Relationship Inventory. Schumm, Bollman, & Jurich, 1981. Primary Communication Inventory. Navran, 1967. Communication Patterns Questionnaire (CPQ). Christensen, 1988.
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QUESTIONNAIRES AND INVENTORIES FOR FAMILIES

The Adolescent-Family Inventory of Life Events and Change. McCubbin and Thompson, 1991. The Conflict Tactics Scales (CT). Straus and Gelles, 1990. The Family Adaptability and Cohesion Evaluation Scale (FACES-III). Olson, Portner, and Lavee, 1985. The Family Beliefs Inventory (FBI). Roehling and Robin, 1986. Family of Origin Scale (FOS). Hovestact, Anderson, Piercey, Cochran, and Fine, 1985. Family Assessment Device (FAD). Epstein, Baldwin & Bishop, 1983. The Family Awareness Scale (FAS). Green, Kolevzon and Vosler, 1985. The Family Coping Inventory (FCI). McCubbin and Thompson, 1991. The Family Functioning Scale (FFS). Tavitian, Lubiner, Green, Grebstein and Velicer, 1987. Family Sense of Coherence (FSOC) and Family Adaptation Scales (FAS). Antonovsky and Sourani, 1988. Kansas Family Life Satisfaction Scale (KFLS). Schumm, Jurich and Bollman, 1986. Parent-Child Relationship Survey (PCRS). Fine and Schwebel, 1983. Self-Report Family Instrument (SFI). Beavers, Hampson and Hughs, 1985.

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FAMILY CONSTITUTION1
1. 2. 3. Standards for interrelationships among family members - the manner in which behavior and emotion is expressed - the maintenance of power and control in the family Standards for the division of labor - how chores are assigned - who does what in the household Standards for dealing with conflict - what is tolerated and what is not - how resolution is sought - how balance is restored Standards for boundaries and privacy - how and where the lines are drawn - who can do what, and when Standards for individuals outside of the family unit - procedures to be used with extended family members - procedures with friends

4. 5.

1Adapted

from Schwebel and Fine (1994).

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IV. TECHNIQUES AND PROCEDURES FOR COUPLES AND FAMILIES

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BEHAVIOR

EMOTION

Automatic Thought

Cognitive Distortions

Life Experiences + -

Schemas Self Family Life Spouse Marriage

Cognitive Techniques Socratic Questioning Downward Arrow Miracle Question Before/After Framing Imagery Techniques
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AUTOMATIC THOUGHTS

Thoughts or Images that occur to the spouse(s) simultaneously and are usually associated with negative affect. e.g.: Its too late to save our marriage, its over.

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MALADAPTIVE ASSUMPTIONS

A set of rules that a spouse or family member follows to guide and evaluate their own and others behavior. e.g.: I should never let anyone get too close to me its dangerous!

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SCHEMA ASSESSMENT
Identifying: Automatic Thoughts Maladaptive Assumptions Cognitive Distortions Underlying Beliefs and Schemas Behavior Emotion Questionnaires/Inventories Socratic Questioning Downward Arrow Miracle Question Image Technology Reframing Techniques

Familyof-Origin Life Experiences

2007 Frank M. Dattilio, Ph.D., AB

Traumatic Events

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COMMON COGNITIVE DISTORTIONS WITH COUPLES AND FAMILIES

Arbitrary Inference. Conclusions are made in the absence of supporting substantiating evidence. For example, a man whose wife arrives home a half-hour late from work concludes, She must be having an affair; or parents whose child comes home late, he/she must be up to no good. Selective Abstractions. Information is taken out of context and certain details are highlighted while other important information is ignored. For example, a woman whose husband fails to answer her greeting the first thing in the morning concludes, He must be angry at me again; or a child who is in a bad mood may be perceived by his/her siblings to be ignoring them. Overgeneralization. An isolated incident or two is allowed to serve as a representation of similar situations everywhere, related or unrelated. For example, after being turned down for an initial date, a young man concludes, All women are alike, Ill always be rejected; or a son whose parents deny him a night out concludes, "They never let me do anything. Magnification and Minimization. A case or circumstance is perceived in greater or lesser light than is appropriate. For example, an angry husband blows his top upon discovering that the checkbook is unreconciled and states to his wife, Were financially doomed; or if a daughter cant use her parents car to attend a dance concludes, My social life is ruined. Personalization. External events are attributed to oneself when insufficient evidence exists to render a conclusion. For example, a woman finds her husband re-ironing an already pressed shirt and assumes, He is dissatisfied with my preparation of his clothing; or a father whose daughter would rather go out with her friends than go shopping with him concludes, She doesnt like my company anymore.
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Dichotomous Thinking. Experiences are codified as either black or white, a complete success or total failure. This is otherwise known as polarized thinking. For example, upon soliciting his wifes opinion on a paperhanging job underway in the recreation room, the wife questions the seams, and the husband thinks to himself, Shes never happy with anything; or children of parents who frequently find them at fault state, Were damned if we do and damned if we dont. Labeling and Mislabeling. Ones identity if portrayed on the basis of imperfections and mistakes made in the past, and these are allowed to define oneself. For example, subsequent to continual mistakes in meal preparation, a spouse or child states, I am worthless, as opposed to recognizing her error as being human. Tunnel Vision. Sometimes spouses and family members only see what they want to see or what fits their current state of mind. A gentleman who believes that his wife does whatever she wants anyway may accuse her of making a choice based purely on selfish reasons; or a parent who tells her daughter that she is not up for driving her somewhere may conclude, Shes only concerned about herself. Biased Explanations. This is almost a suspicious type of thinking that partners develop during times of distress and automatically assume that their spouse holds a negative alternative motive behind their intent. For example, a woman states to herself, Hes acting real lovey-dovey because hell later probably want me to do something that he knows I dont enjoy; or children who believe that when their parent is being nice to them it is because they want them to do an extra chore. Mind Reader. This is the magical gift of being able to know what the other is thinking without the aid of verbal communication. Spouses and family members end up ascribing unworthy intentions onto each other. For example, a gentleman thinks to himself, I know what is going through her mind, she thinks that I am nave to her motives. Children also may often believe that their parents know what is bothering them without them having to fully express themselves.

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AUTOMATIC THOUGHT - My partner is incapable of change

MALADAPTIVE ASSUMPTION - Shes not going to change even though she acts as though she wants to. - She only cares about herself.

UNDERLYING SCHEMA - People are basically selfish and remain the way they are A leopard never changes its spots.

COGNITIVE DISTORTION - All or nothing thinking - Arbitrary inference

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SOCRATIC QUESTIONING
Therapist: John, I see that on the Beliefs About Change Inventory under Defeatist Beliefs, you placed a checkmark next to the statement, My partner is incapable of change. What immediate thoughts come to your mind when you say that statement? Spouse: Well, you see, it was a mutual decision for both of us to come here for counseling; however, I really do not believe that my wife is capable of changing her ways, even though she may act motivated to do so when in your presence of the presence of others.

Therapist: Then your thought is that while she appears motivated, there is little likelihood that she will change. Spouse: Yes, its almost a waste of time.

Therapist: Any other thoughts or beliefs about it? Spouse: Yes, I also think that I will be placed in a position of expending a lot of energy toward making the marriage work, and then the joke will be on me when we still end up in divorce. So, I view it to some degree as a trap.

Therapist: So, you believe that going ahead in marital therapy will only result in making a fool of you. Spouse: Yes, I do and, therefore, I am reluctant to believe my wife when she says that she wants to try.
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2007 Frank M. Dattilio, Ph.D., ABPP

Therapist: What is your belief about change in general? Spouse: Well, basically, if you want to know the truth, I truly feel that people basically remain the way they are and are impervious to change, even though they might state that they wish to change. I believe in the old adage, A leopard never changes its spots.

Therapist: Does that include yourself as well John? Spouse: Yea, I guess so. Were all pretty much set in our ways.

Therapist: I see. Then your underlying belief is that change is futile. Therefore, nothing can improve your relationship.

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DOWNWARD ARROW I need to scream because Harry doesnt always listen to me.

If I dont scream, Ill never be heard.

If I am not heard, I am nobody.

If I am nobody, I am helpless.

If I am helpless, people will run over me.

Harry will run over me and this will give him complete control.

Ref. Dattilio, F. M. (1993). Cognitive Therapy with Couples and Families. The Family Journal, 1(1), 51-65.
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MIRACLE QUESTION

If you went to sleep tonight and by some chance, or by a miracle, the problem vanished overnight so that upon awakening the next morning, the problem would be gone.

How would you know that the problem was gone? [deShazer, 1988]

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BEFORE JEFFS VIEW OF MARGE WONDERFUL CHARMING CAREFREE SPONTANEOUS LIVELY PLAYFUL MARGES VIEW OF JEFF STEADY RELIABLE SELF-CONFIDENT DECISIVE LOGICAL INTELLECTUAL

AFTER JEFFS VIEW OF MARGE FRIVOLOUS SUPERFICIAL IRRESPONSIBLE IMPULSIVE EMOTIONAL AIRHEAD MARGES VIEW OF JEFF RIGID UNYIELDING COMPULSIVE CONTROLLING OPPRESSIVE STUFFY

Ref: Beck, A. T. (1988). Love is Never Enough. New York: Harper & Row. 2007 Frank M. Dattilio, Ph.D., ABPP - 56 -

LISTING AUTOMATIC THOUGHTS AND LABELING COGNITIVE DISTORTIONS

Automatic Thought My wife should know when I am grouchy, I am not always angry with her.

Cognitive Distortion Mind Reading

Its too late to do anything about this marriage. Its dead on arrival.

Magnification

Things are either on or off with us its an emotional roller coaster.

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Dichotomous Thinking

DYSFUNCTIONAL THOUGHT RECORD

DIRECTIONS: WHEN YOU NOTICE YOUR MOOD GETTING WORSE, ASK YOURSELF, WHATS GOING THROUGH MY MIND RIGHT NOW? AND AS SOON AS POSSIBLE JOT DOWN THE THOUGHT OR MENTAL IMAGE IN THE AUTOMATIC THOUGHT COLUMN. D SITUATION THOUGHTS A T E DESCRIBE: 1. Write automatic 1. Actual event leading to thought(s) that T unpleasant emotion, or preceded emotion(s). I 2. Stream of thoughts, day 2. Rate belief in M dreams, or recollection, automatic thought(s) E leading to an unpleasant 0 - 100% emotion, or 3. Distressing physical sensations.

AUTOMATIC

EMOTION(S) DISTORTION
DESCRIBE: 1. Specify sad, anxious/angry, etc. 2. Rate degree of emotion 0 - 100%
1. ALL OR NOTHING THINKING 2. OVERGENERALIZATION 3. MENTAL FILTER 4. DISQUALIFYING THE POSITIVE 5. JUMPING TO CONCLUSIONS 6. MAGNIFICATION OR MINIMIZATION 7. EMOTIONAL REASONING 8. SHOULD STATEMENTS 9. LABELING AND MISLABELING 10. PERSONALIZATION

ALTERNATIVE RESPONSE
1. Write rational response to automatic thought(s). 2. Rate belief in alternative response 0 - 100%

OUTCOME
1. Re-rate belief in automatic thought(s) 0 -100% 2. Specify and rate subsequent emotions 0 - 100%

Questions to help formulate the ALTERNATIVE RESPONSE: (1) What is the evidence that the automatic thought is true? Not true? (2) Is there an alternative explanation? (3) Whats the worst that could happen? Could I live through it? Whats the best that could happen? Whats the most realistic outcome? (4) What should I do about it? (5) Whats the effect of my believing the automatic thought? What could be the was in this situation and had this thought, effect of changing my thinking? (6) If what would I tell him/her? (persons name) - 58 -

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CASE EXAMPLE
FAMILY PROBLEM FATHER - History of over controlling mother, passive, detached father. - Resented his own mother - Formed coalitions with his own siblings against his mother to deal with her overbearingness Conflict over mother MOTHER History/Family-of-Origin - Parents Holocaust survivors - Her mother attempted suicide and blamed her (daughter) Schema - To keep my family strong and healthy, I must remain firm no room for softness. Now daughter, a mother herself, overreacts Intolerant and resentful of weakness in her family members (dichotomous thinking)

SCHEMA - We have to stick together in dealing with Mom. Downward Arrow

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FAMILY MEMBERS Automatic Thoughts - Our mother/my wife is unstable/ill and needs to be treated gently. - She is unreasonable and unfair due to her own upbringing. - Dont rock the boat. - We must walk on egg shells and placate mother so that she doesnt experience an emotional breakdown - we must be cautious. - People are like a welded piece of metal, if there is too much pressure on them, they will crack. This is how the maternal grandmother cracked. - Avoidance, acquiescing, hide emotions. - Resentment, anger, flatness - Dont discuss emotions it is a dangerous topic - Protect each other dont rock the boat.
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SCHEMA

Behavior Emotion JOINT FAMILY SCHEMA

2007 Frank M. Dattilio, Ph.D., ABPP

Beliefs and Schemas Developed From Family-Of-Origin Mother (Behavior) Is vigilant and intolerant of any expressions of weakness in self or other family members. (Automatic Thought) There is no room for weakness in life. I must be firm. My husband is soft. (Schema) As a loving wife and mother, I must ensure that the family avoids falling prey to weakness. Childrens Reaction (Behavior) Children act-out the dissension between parents, demonize mother. Idolize father. Polarization occurs. (Automatic Thought) I have to choose sides, either my father or my mother. (Schema) You have to be careful what you say and do with some people youll always be in the middle.

Beliefs and Schemas Developed From Family-Of-Origin Father (Behavior) Placates mother because he understands her upbringing, but subtly undermines her. (Automatic Thought) My wife is unreasonable. I dont blame the kids shes being too rigid. (Schema) Its okay to show some vulnerability in life. Ill just play it safe, but pull the children aside and tell them to ignore mothers tirades. (Action) Father plays both sides in order to avoid conflict.

(Action) Mother is intolerant of any signs of weakness and/or passivity and scolds father for siding with others against her.

(Action) Avoid conflict at all costs. Try to keep everyone happy. Additional Conflict [Action] Mother is alienated - 70 -

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Family Schema Analysis and Intervention Step 1: Uncover and identify shared family schemas and highlight those areas of conflict and dysfunction that are fueled by the schemas. Schemas can be uncovered by probing automatic thoughts and using techniques, such as Downward Arrow, as was done with the mother in this case (Dattilio, 1998a; Dattilio & Padesky, 1990). Once schemas are identified, verification should be made by obtaining some measure of agreement from family members. Step 2: Trace the origin of family schemas and how they have evolved to become an ingrained mechanism in the family process. This is done by probing into the parents backgrounds and the parenting styles that their parents used during their upbringing. Similarities and differences should be delineated between parents backgrounds and their individual schemas in order to clarify how they have contributed to their immediate family schemas.

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Step 3: Point out the need for change, indicating how the restructuring of a schema may facilitate more adaptive functioning and harmonious family interaction. At this stage, it is essential to point out to the family that modification of schemas may ease the tension and lower the level of conflict in the family. For example, one of the areas to address with the mother who feared weakness was the burden involved in her belief that she has to be emotionally responsible for anyone elses ability to withstand stress. Step 4: Elicit acknowledgment and encourage cooperation from the family as a whole for the need to change or modify existing dysfunctional schemas. This is imperative for change to actually occur, and it paves the way for a collaborative effort between the therapist and the family members. For family members who have different or incompatible goals for treatment, finding a common ground between family members becomes a major objective for the therapist. Using newly gathered information may aid in the modification of goals.

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Step 5: Assess the familys ability to make changes and plan strategies for facilitating them. It is important to determine how capable a family is of making significant changes in their basic beliefs. Potential limiting factors include limited ability levels and resistance to acquiring effective coping skills. For example, if a family is functioning on a lower intellectual level, their coping skills may be less sophisticated and the intervention may need to be more concrete, and the process may be slower. Also, it is essential to assess the amount of resistance that exists within the family that can maintain a level of homeostasis. Step 6: Implement change. The familys therapist functions as an instrument to facilitate change, encouraging family members to consider modified versions of their basic beliefs. This is done through the use of collaborative experiences (such as is referred to in Step 5), brainstorming ideas for modifying beliefs, and weighing the effects that modifications to existing beliefs are likely to have on family interactions. The key in the change process is identifying how family members actually will behave differently toward each other if they are living according to the modified schema.
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Step 7: Enacting new behaviors. This involves trying out the changes and feeling the fit. The use of family exercises and homework assignments is imperative in enacting permanent change (Dattilio, 2002). Step 8: Solidifying the changes. This stage involves establishing the changed schema and associated family behaviors as a permanent pattern in the family through repeated practice, while family members also remain flexible to future modifications.

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CHALLENGING AND RESTRUCTURING SCHEMAS

MOTHER Challenged Belief What evidence supports the idea that all signs of weakness lead to a threat to ones welfare? Might this be a distortion due to my childhood exposure? Experiment Take the risk with myself to see if a display of negative emotion is necessarily deadly. Allow my-self to cry on one occasion in front of my family. Action Cries briefly during an argument with husband. Result Family members appear relieved. I didnt fall apart. Restructured Belief Maybe its not so terrible to show some negative emotion at times. In fact, it felt kind of good. 2007 Frank M. Dattilio, Ph.D., ABPP FATHER Challenged Belief It I encourage my wife to express some negative emotion, would that be so terrible? Whats the evidence that supports the notion that she would fall apart? CHILD Challenged Belief Why cant I just express to my parents that I dont want to be placed in the middle of their arguments? Will they hate me if I do?

Experiment Try saying nothing if she experiences negative emotions, especially to the children, and keep in mind that it doesnt mean that Im a bad husband.

Experiment Try to express my desire to remain neutral and that I love them both and dont want to have to choose.

Action Avoids interfering to protect mother.

Action Remains neutral.

Result Wife cries, children support mother in expressing her emotion. Restructured Belief Nothing terrible happened.

Result No serious rejection. Parents dont hate me. Restructured Belief I can be myself without always worrying about negative repercussions.

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BEHAVIOR INTERVENTIONS TECHNIQUES Communication training Problem solving strategies Behavioral change agreements Assertiveness training Paradoxical intention Behavioral rehearsal Bibliotherapy Homework
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BEHAVIORAL TECHNIQUES PARADOXICAL TECHNIQUES AND INTENTIONS PRESCRIBING THE PROBLEM These techniques are best used when couples of families are legitimately stuck in a gridlock or are resistant to other therapeutic interventions. i.e.: Problem: Daughter is acting-out and is attempting to take charge in a single parent family. Prescription: Daughter is instructed to exaggerate her taking charge of mother. Mother is instructed to assume the paradoxical role of the child and to give up her position of authority and to be a helpless child.

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QUID PRO QUO CONTRACT BASED ON SOCIAL EXCHANGE THEORY

ContingencyContracting - Contract in which the behavior of one spouse is contingent on that of another. e.g., husband agrees to do the dishes on two evenings in exchange for the wife taking out the garbage or doing some other task
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CARING DAYS AND PLEASING BEHAVIORS (LOVE DAYS)

-Developed by Richard Stuart. Each spouse identifies various behaviors that their partner finds enjoyable and commits him or herself to increasing these behaviors. Both keep a daily record of their observations. - Ratio to Reward -

BEHAVIOR CHANGE AGREEMENTS AND CONTRACTING

- Agreement to engage in shared activities or specific behavioral change or modifications.

ROLE PLAY OR MODELING

- The use of modeling or role playing may help to show couples or family members what the behavior change might look like.

COACHING

-The therapist actually structures the interaction between couples or family members as a guide to facilitate change. This is often combined with role play (e.g., use of assertiveness training, etc.).

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HOMEWORK ASSIGNMENTS

- Usually germaine to the topic discussed during weekly sessions, but may involve communication, problem solving, behavior change, etc.

BIBLIOTHERAPY OR VIDEOTHERAPY

- Designed to supplement techniques and theories promoted in treatment; e.g., Love is Never Enough and Fighting for Your Marriage.

TIME OUT

- Typically implemented with couples or family members who have anger problems or who are prone to acting-out physically. Individuals are instructed to T for time out and extricate themselves from situation. Also combined with other cognitive techniques (e.g., thought stopping, deep breathing, imagery, etc.).

THE PAD AND PENCIL TECHNIQUE

- Used for helping spouses and family members refrain from interrupting each other.

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COMMUNICATION TRAINING

Techniques used to increase spouses or family members skills in: Expressing thoughts and emotions clearly Listening to others messages Filtering out the extraneous Sending constructive rather than destructive messages
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RULES FOR THE SPEAKER When speaking to your spouse, try to emphatically identify the needs of the listener so that he or she can understand your message. The following guidelines are helpful when expressing yourself. 1. Speak attentively: Just as one listens attentively, one should also speak in the same manner, maintaining appropriate and direct eye contact and looking for body signals (facial or posture) which indicate that your partner is listening. Phrase meaningful questions: One way to keep a conversation short (and unproductive) is to ask a question that can be answered by either a yes or a no. Instead, try to ask questions that lead to more of a response from you partner that will help you understand him or her better. Dont over talk: Speak to the point and avoid drawn-out statements that over tell a story or reaction. This will give your spouse a chance to clarify and reflect on what he or she hears from you. Accept silence: Sometimes one of the best ways to make a point is to pause or use a period of silence after speaking. This allows you and your listener to digest what is being said. Dont cross-examine: Avoid firing questions at your spouse when attempting to learn something during a conversation. The use of tact and diplomacy express respect and may serve as a far better means of learning what you need to know.

2.

3.

4.

5.

Adapted from Dattilio, F. M. (1989). A guide to cognitive marital therapy. Innovations in clinical practice: A source book. Professional Resource Exchange, Sarasota, FL, and Beck, A. T. (1988). Love is never enough. Harper & Row, New York. 2007 Frank M. Dattilio, Ph.D., ABPP - 82 -

RULES FOR THE LISTENER Many couples listen to each other, but only in the strict behavioral sense. They do not actually hear what each other is saying. Good listening skills involve a clear understanding of what is being said. Here the therapist may want to instruct the partners how to listen and hear what is being said by following several guidelines. 1. Listen attentively: Keep good eye contact with your spouse and acknowledge that you are hearing him or her. 2. Dont interrupt: Its difficult to hear when you are talking yourself.

3. Clarify what you hear: Sum up or make clear with your spouse your understanding of what is being said at the end of a statement or phrase. This will aid you in getting the correct message. It is also important to admit you dont understand something. 4. Reflect on what you hear: This is different than clarification. Reflection involves showing your spouse that you are aware or understand what her or she feels. In essence, you hold up a mirror so your spouse can see what he or she is saying. 5. Summarizing: Both spouses should always attempt to summarize their conversation so that no loose ends are remaining and both have a clear understanding of what has been discussed. A summary also allows a couple to set a direction for constructive follow-up.
Adapted from Dattilio, F. M. (1989). A guide to cognitive marital therapy. Innovations in clinical practice: A source book. Professional Resource Exchange, Sarasota, FL, and Beck, A. T. (1988). Love is never enough. Harper & Row, New York.
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STEPS FOR COUPLES AND FAMILY PROBLEM SOLVING EXPERIENCES

Define the problems in specific behavioral terms Compare perceptions and arrive at some agreeable description of the problem. Generate a possible set of solutions. Evaluate the advantages and disadvantages of each solution then select a feasible solution. Implement the chosen solution and evaluate its effectiveness.

Adapted from Epstein, N. & Schlesinger, S. E. (1994). In A. Freeman & F. M. Dattilio (Eds.) Cognitive-behavioral therapy in crisis intervention. New York: Guilford.

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V. INTEGRATION OF COGNITIVE-BEHAVIORAL STRATEGIES WITH OTHER MODALITIES OF COUPLE AND FAMILY THERAPY

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STRATEGIC FAMILY THERAPY

Similarities - Utilizes problem solving strategies and collaborative reframing - Regard family as a system - Therapist has a direct role in facilitating change

Dissimilarities - Defines terminology with different language - Explains actions in more indirect terms

Level of Integratability High

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CONTEXTUAL APPROACH
Similarities Oriented toward behavioral change Focus on clients considering rejunctive alternatives Focus of some degree on schemas Role of therapist is direct Emphasis on legacy or family of origin Dissimilarities More focus on reciprocal efforts at enhancing and understanding emotional acceptance More emphasis on the restoration of reciprocal trust rather than a shift in behavioral interaction pattern More focus on loyalty framing, balanced siding and holding accountable Level of integratability High

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SOLUTION-FOCUSED APPROACH

Similarities Therapist active role Focus on how clients construe their psychological realities Assists clients in developing new perspectives Here and now orientation

Dissimilarities Therapist uses a more indirect role of influencing the client to find solutions More mutually collaborative More future focused Less focus on negative affect and assessing deficits in thinking More aligned with the Constructivist view

Level of Integratability High

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INTEGRATIVE COUPLES THERAPY IMAGO RELATIONSHIP THERAPY TRANSGENERATIONAL APPROACH

Similarities Adhere to a social learning model Respect the role of schema in family and relationship dysfunction

Dissimilarities Role of therapist is more of a coach Less technique oriented and more emphasis on the process of therapy

Level of Integratability High

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MODERATELY COMPATIBLE INTERNAL FAMILY SYSTEMS NARRATIVE SOLUTIONS APPROACH FEMINIST COUPLE THERAPY
Similarities Espouse to a problem centered approach Contends that feelings emerge from thoughts and beliefs Focus on altering family members internal systems Concerned about how pattern of thinking and behavior affect and maintain relationships Dissimilarities Integration of more psychodynamic principles Focus more on elaborate aspects of schemas (e.g.: internal parts) Utilizes internal resources of the client in a way that facilitates more independence More concern over the clients perception of the therapists role as intrusive Level of Integratability Moderate
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EMOTIONALLY FOCUSED APPROACH

Similarities Explores all beliefs in the process of exploring specific emotions Attempts are made to modify certain beliefs, but in a more indirect manner

Dissimilarities Much like the structural family therapists, increases the affective component to evoke change Do not recognize certain beliefs as distortions, but views them from a perspective of emotional disengagement Do not use homework assignment Do not see changing thoughts as sufficient to create lasting change

Level of Integratability Minimal

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PSYCHOANALYTIC

Similarities Both view behavior and cognition as having histories learned largely in past relationships Use same prescription of behavior change

Dissimilarities View unconscious factors as playing an important role in human behavior Listen and interpret unconscious wishes in a more open-ended setting Look more at deeper layers of the distant past

Level of Integratability Minimal

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SOCIAL CONSTRUCTIVE APPROACHS

Similarities Uses language as a major means of co-constructing change Recognizes the importance of clients to distinguish the importance of their own contribution in change Dissimilarities Places more emphasis on the interpersonal process Therapist uses a less directive role in treatment Places less emphasis on surface phenomena and more on deeper experiences Level of Integratability Minimal

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SYMBOLIC EXPERIENTIAL APPROACHES

Similarities Believes that experiences produce change Some interest in cognition, with less direct involvement in the restructuring process

Dissimilarities Takes the therapeutic process beneath the surface of the familys limited experience into the realm of myth Uses a more non-rational, intuitive style Greatest emphasis is placed on observation

Level of Integratability Minimal

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BEHAVIORAL

Similarities Focus on behavioral techniques to shape the course of change Follow a structured regime of guiding the client toward behavioral change Believes that behavioral changes will lead to a change in emotion

Dissimilarities Place more emphasis on the power of behavioral change alone to be sufficient Believes that delving into thought content and memories will actually slow down therapy

Level of Integratability Minimal

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STRUCTURAL FAMILY THERAPY

Similarities Uses some direct cognitive strategies at times (e.g.: when enactments break down) Facilitates awareness to enable people to change Dissimilarities Focus of responsibilities for change rests almost entirely on the individuals and families Techniques are more tacitly implied Therapists serve as a self-reflective instrument toward change Level of Integratability Low

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REFERENCES AND SUGGESTED READINGS Alexander, P. (1988). The therapeutic implications of family cognitions and constructs. Journal of Cognitive Psychotherapy, 2(4), 219-236. Arias, I. & Beach, S.R.H. (1987). The assessment in social cognition in the context of marriage. In K.D. OLeary (Ed.), Assessment of marital discord (pp. 109-137). Hillsdale, NJ: Erlbaum. Baldwin, M. W. (1992). Relational schemas and the processing of social information. Psychological Bulletin, 112, 461-282. Bartholomew, K. & Horowitz, L. M. (1991). Attachment styles among young adults: A test of the four category model. Journal of Personality and Social Psychology, 61, 226-244. Beach, S. R. A., Sandeen, E.E., & OLeary, K. D. (1990) Depression in marriage. New York: Guilford. Beck, A. T. (1967). Depression: Clinical, Experimental and Theoretical Aspects. New York: Hoeber. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Beck, A. T. (1988). Love is never enough. New York: Harper & Row. Beck, A. T., Rush, J. A., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Bevilacqua, L. J. & Dattilio, F. M. (2001). Brief family therapy homework planner. New York: John Wiley & Sons, Inc.
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Burns, D. (1980). Feeling good: The new mood therapy. New York: William Morrow and Company, Inc. Bowlby, J. (1969). Attachment and loss: Vol. I attachment. New York: Basic Books. Dattilio, F. M. (1993a). Cognitive techniques with couples and families. The Family Journal, 1(1), 51-65. Dattilio, F.M. (1994). Videotape. Cognitive therapy with couples: The initial phase of treatment, (56 minutes). Sarasota, FL: Professional Resource Press Dattilio, F. M. (1998) (Ed.). Case studies in couple and family therapy: Systemic and cognitive perspectives. New York: Guilford. Dattilio, F. M. (2001). Cognitive-behavioral family therapy: Contemporary myths and misconceptions. Contemporary Family Therapy, 23(1), 3-18. Dattilio, F. M. (2002). Homework assignments in couple and family therapy. Journal of Clinical Psychology, 58(5), 83-88. Dattilio, F. M. (2003). Family therapy. In R. E. Leahy (Ed.) (236-252), Overcoming roadblocks in cognitive therapy. New York: Guilford. Dattilio, F. M. (2004). Cognitive-behavioral family therapy: A coming-of-age story. In R. E. Leahy (Ed.), Contemporary cognitive therapy (389-404). New York: Guilford. Dattilio, F. M. (2005). Restructuring family schemas: A cognitive-behavioral perspective. Journal of Marital and Family Therapy, 31(1), 15-30. Dattilio, F. M. (2005). Cognitive-behavioral couple therapy (pp. 21-33). In G. Gabbard, J. Beck, & J. Holmes (Eds.), Concise Oxford textbook of psychotherapy. Oxford, UK: Oxford University Press.
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Dattilio, F. M. (2005). Clinical perspectives on involving the family in treatment. In J. L. Hudson & R. M. Rapee (Eds.) Psychopathology and the family (301-321). London: Elsevier. Dattilio, F. M. (2006). Restructuring schemata from family-of-origin in couple therapy. Journal of Cognitive Psychotherapy, 20(4), 359-373. Dattilio, F. M. (2007). Families in crisis. In F. M. Dattilio and A. Freeman (Eds.) Cognitive-behavioral strategies in crisis intervention (3rd ed.) p. 327-351. New York: Guilford. Dattilio, F. M. (2009). Comprehensive cognitive-behavior therapy with couples and families. New York: Guilford Publications. Dattilio, F. M. & Bahadur, M. (2005). Cognitive-behavioral family therapy with East Indian populations. Contemporary Family Therapy, 27(3), 367-382. Dattilio, F. M & Bevilacqua, L. J. (2000). Comparative treatments for relationship dysfunction. New York: Springer. Dattilio, F. M. & Epstein, N. B. (2003). Cognitive-behavioral couple and family therapy. In T. L. Sexton, G. R. Weekes & M. S. Robbins (Eds.) (147-175), The family therapy handbook. New York: Routledge. Dattilio, F. M. & Epstein, N. B. (2005). The role of cognitive-behavioral interventions in couple and family therapy. Edited special section, Journal of Marital and Family Therapy, 31(1), 7-13. Dattilio, F. M. & Jongsma, A. E. (2000). The family therapy treatment planner. New York: John Wiley & Sons, Inc. Dattilio, F. M. & Padesky, C. A. (1990). Cognitive therapy with couples: A practitioners guide. Sarasota, Florida: Professional Resource press.

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Dattilio, F. M., LAbate, L., & Deane, F. (2005). Homework for families. In N. Kazantzis, F. P. Deane, K. R. Ronan, & L. LAbate (Eds.), Using homework assignments in cognitive-behavior therapy. New York: Brunner-Routledge. deShazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton. Ellis, A. (1977). The nature of disturbed marital interactions. In A. Ellis and R. Greiger (Eds.) Handbook of rational-emotive therapy, p. 77-92. New York: Springer-Verlag. Ellis, A. (1978). Family Therapy: A phenomenalogical and active-directive approach. Journal of Marriage and Family Counseling, 4(2), 43-50. Ellis, A. (1986). Rational-emotive therapy applied to relationship therapy. Journal of Rational-Emotive Therapy, 12, 4-21. Ellis, A. (1991). Rational-emotive family therapy. In A. M. Horne and M. M. Ohlsen (Eds.) Family counseling and therapy, p. 302-328, Itasca, IL: Peacock. Ellis, A., Sichel, J. L., Yeager, R. J., DiMattia, D.J. & DiGiuseppe, R. (1989). Rational-emotive couples therapy, Boston: Allyn & Bacon. Epstein, N. & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Faloon, I. R. H. (1991). Behavioral family therapy. In A.S. Gurman and D.P. Kniskern (Eds.) Handbook of family therapy p. 65-95. New York: Brunner/Mazel. Fischer, J. & Corcoran, K. (2007). Measures for clinical practice: A sourcebook Vol. 1 & 2 couples, families & children (4th ed.) New York: Oxford University Press.

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Jacobson, N.S. & Addis, M.E. (1993). Research on couples and couples therapy: What do we know? Where are we going? Journal of Consulting and Clinical Psychology, 61(1), 85-93. Jacobson, N. S. & Christensen, A. (1996). Integrated couple therapy: Promoting acceptance and change. New York: W. W. Norton & Company. Jacobson, N.S. & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel. Kelly, G. A. (1955). The psychology of personal constructs. New York: Norton. Marcus, H. (1977). Self-schemas and processing information about the self. Journal of Personality and Social Psychology, 35, 63-78. Northey, W. F. (2002). Characteristics and clinical practices of marriage and family therapists: A national survey. Journal of marital and family therapy, 28, 487-494. Piaget, J. (1954). The construction of reality in the child. New York: Ballantine Books. Psychotherapy Networker (2007). The top 10: The most influential therapists of the past quarter-century, 31(2), 24-68. Schwebel, A.I. & Fine, M.A. (1994). Understanding and helping families: A cognitive- behavioral approach. Hillsdaye, NJ: Lawrence Erlbaum Associates, Inc. Segal, Z. V. (1988). Appraisal of the self-schema construct in cognitive models of depression. Psychological Bulletin, 103, 147162. Young, J. E., Klosko, J. S., & Weishaar, M. (2003). Schema therapy: A practitioners guide. New York: Guilford.

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SUGGESTED PATIENT READINGS Abrams-Spring, J. (1997). After the affair: healing the pain and rebuilding trust when a partner has been unfaithful. New York: Harper/Collins. Alberti, R. E. & Emmons, M. (1986). Your perfect right (5th ed.). San Luis Obispo, CA: Impact Publishers. Beck, A. T. (1988). Love is never enough, New York: Harper & Row. Gottman, J. (1995). Why marriages succeed or fail. New York: Fireside Books. Guerney, B.G. Jr. (1977). Relationship enhancement. San Francisco: Jossey-Bass. Markman, H., Stanley, S., & Blumberg, S. L. (19940. Fighting for your marriage. San Francisco, CA: JosseyBass. McKay, M., Fanning, P., & Paleg, K. (1994). Couple skills: Making your relationship work. Oakland, CA: New Harbinger Publications, Inc.

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