9

COGNITIVE-BEHAVIORAL
THERAPIES FOR COUPLES
AND FAMILIES
Norman B. Epstein and Mariana K. Falconier

Couples are often adept at dealing with people outside the relationship, but
few people enter an intimate relationship with the basic understandings—
or the technical skills—that make a relationship blossom. They frequently
lack the know-how to make joint decisions, to decipher their partners’
communications. . . . Because of the strength of the feelings and expec-
tations, the deep dependency, and the crucial, often arbitrary, symbolic
meanings that they attach to each other’s actions, partners are prone to
misinterpret each other’s actions. When conflicts occur, often as a result
of miscommunication, partners are likely to blame each other rather than
to think of the conflict as a problem that can be solved.
Aaron T. Beck, MD
Love Is Never Enough: How Couples Can Overcome
Misunderstandings, Resolve Conflicts, and Solve
Relationship Problems Through Cognitive Therapy

Behavioral treatments for couple and family problems are based on the assump-
tion that dysfunctional behaviors are learned and can be reduced or replaced
with more constructive behaviors through new learning processes. Behavioral
approaches for a wide range of human problems had their roots in laboratory
research on learning processes in animals and humans. Ivan Pavlov (1932) dem-
onstrated how emotional and behavioral responses could be conditioned so that
they would be elicited by a neutral stimulus, by pairing the neutral stimulus
with an existing reflexive response. For example, a dog could be conditioned
to salivate at the sound of a bell if the bell was rung a number of times as the
dog was salivating to the smell and taste of food. John Watson’s publicized case
260 Norman B. Epstein and Mariana K. Falconier

of “Little Albert,” in which a phobia was established in a child through such

classical conditioning (Watson & Raynor, 1920), increased interest in applying
learning principles to understand a variety of human clinical disorders. However,
it was not until Joseph Wolpe (1958) developed systematic desensitization
as a treatment for phobias that therapeutic interventions based on learning
principles gained significant credibility as effective treatments. Based on the
concept that a phobia is a classically conditioned response to a stimulus that is
not dangerous, systematic desensitization involves pairing the anxiety-producing
stimulus (e.g., a mouse) with relaxation, assertiveness, or some other response
that is incompatible with anxiety. The exposure of the individual to the anxiety-
provoking stimulus is done in steps, or a hierarchy, beginning with a mildly
distressing aspect of the feared stimulus, such as looking at a caged mouse from
across a room, and eventually progressing to holding a mouse. At each step, the
individual practices the relaxation or other response that counteracts the anxiety
response, and moves to the next higher step in the hierarchy only when he or
she has deconditioned the anxiety at the current step. Wolpe’s work advanced
the field of behavior therapy and contributed to the development of effective
treatments for a variety of clinical problems, such as anxiety disorders and sexual
dysfunctions. Nevertheless, the focus of the behavioral assessment and interven-
tions tended to be on the individual, and potential application to interpersonal
problems was unclear.
B. F. Skinner’s (1953) work on operant conditioning had a more extensive
impact on the development of behavioral approaches to couple and family
problems. Skinner demonstrated that one could increase or decrease an animal’s
specific action by controlling the consequences of the action. Thus, a rat could
be taught to press down a bar in a box if pressing the bar dispensed a food
pellet (i.e., positive reinforcement). In contrast, a behavior could be decreased
by following it with conditions that are assumed to be aversive (punishment),
or by discontinuing the reinforcement. Skinner (1953, 1971) argued that all
human behavior could be explained in terms of such learning processes, and
concepts about internal processes such as emotions and thoughts as causes of
behavior are superfluous. Skinner considered all responses, including overt behav-
iors and internal responses, as acts that are controlled by consequences in the
individual’s environment, so treatment of problematic responses should involve
changing the environmental conditions. Similar to Wolpe’s work, Skinner’s theo-
retical model was in opposition to psychodynamic models (e.g., psychoanalytic
theory) that dominated the field of psychology in the first half of the 20th
century with their focus on intra-psychic causes of behavior. Unlike psychody-
namic propositions that an individual’s current problems were caused by residual
issues from childhood and other earlier life experiences, learning theories such
as Skinner’s emphasized present conditions that affect the occurrence of particular
positive and negative behaviors. Equally important for clinical intervention was
the idea that learned responses could be modified or eliminated through learning
 Cognitive-Behavioral Therapies 261

procedures. Skinner’s ideas about the impact of one’s environment (the specific
consequences received for one’s responses) had a major influence on the devel-
opment of behavioral therapies, including early versions of behavioral couple
and family therapy. Because members of a couple or family continuously provide
positive and negative consequences for each other’s behavior and influence each
other’s actions, changing those consequences could modify members’ problematic
behavior.
Even though operant conditioning principles were helpful in understanding
how animals and people learn a variety of responses, it became clear that they
had some limitations in accounting for the rapid and varied learning that takes
place in humans during childhood and beyond. Humans learn complex responses
without having to wait for reinforcement of the small acts that constitute them.
Social learning theorists such as Rotter (1954) and Bandura (1977; Bandura &
Walters, 1963) described observational learning processes in which an individual
can imitate a complex behavior demonstrated by another person, particularly if
the observer sees that the model has high status or receives reinforcement for
the behavior. Bandura and Walters’s (1963) research showed that a child who
observed an adult hitting a large toy clown was likely to imitate the behavior.
Beginning early in life, a child learns many complex skills—speaking a language,
playing sports, and so forth—by observing and imitating others. Social learning
theorists began to focus on the interpersonal context in which behaviors are
adopted and maintained, and the relevance of such learning processes for mutual
influences between members of an intimate relationship began to be noted.
The earliest behavioral conceptualizations of couple and family relationships
focused on ways in which two members of a relationship shape each other’s
behavior by providing consequences for particular responses. As two people
interact, they reinforce each other for certain responses and either ignore or
provide punishment for others. Over time, each person increases his or her
frequency of responses that were reinforced and decreases his or her frequency
of those that were ignored or punished. Goldstein (1971) and Stuart (1969)
developed somewhat different treatments for marital distress, based on this concept
of mutual influence. Goldstein worked with women whose husbands refused to
take part in marital therapy; Goldstein instructed the wives in reinforcing their
spouses for desired changes in specific behaviors without informing the husbands
about this procedure. Stuart intervened jointly with both members of a couple,
guiding them in devising behavioral “contracts” in which each person agreed
to perform particular behaviors desired by the other person in return for receiv-
ing reinforcements from the partner. The procedures were also based on social
exchange theory, developed by social psychologists (Thibaut & Kelley, 1959), in
which an individual’s satisfaction with a relationship is a function of the ratio
of benefits to costs that he or she experiences in the relationship.
Behavioral marital therapists such as Liberman (1970), Weiss, Hops, and
Patterson (1973), O’Leary and Turkewitz (1978), Jacobson and Margolin (1979),
262 Norman B. Epstein and Mariana K. Falconier

and Stuart (1980) further developed techniques for increasing couples’ mutual
exchanges of positive behavior, using social learning principles to teach com-
munication skills and set up behavioral contracts between partners. Similarly,
Patterson (1971) developed behavioral interventions for families with children
who exhibited aggressive and other problematic behavior, based on social learn-
ing principles such as operant conditioning. Behavioral family therapists com-
monly have focused on developing parents’ skill at decreasing their children’s
problematic behaviors and increasing their desirable behaviors (Barkley & Benton,
1998; Blechman, 1985; Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004;
Dishion & Patterson, 2005; Forgatch & Patterson, 2010; Kazdin, 2005; Webster-
Stratton & Herbert, 1994). By the end of the 1970s, behavioral approaches to
couple and family therapy had become established treatment modalities, with
growing evidence of their efficacy.
Even though behaviorists focused on changing family members’ overt acts in
order to establish more satisfying relationships, they increasingly acknowledged
that there is subjectivity in individuals’ experiences of what behaviors by their
family members are pleasing or displeasing. For example, marital treatments by
Margolin and Weiss (1978) and Jacobson and Margolin (1979) took into account
partners’ attributions for each other’s behavior. Thus, if an individual intends to
behave positively toward a partner, but the partner makes an inference (attribu-
tion) that the individual had negative motives for the behavior, the partner will
be upset by the actions, whether or not the attribution is accurate. Nevertheless,
publications on behavioral marital and family therapy did not provide much
information on how clinicians could assess and modify family members’ negative
cognitions that were contributing to relationship conflict and distress.
Beginning in the 1980s, behavioral couple and family therapists began to
integrate into their model concepts and methods from the rapidly developing
cognitive therapies of Ellis (1962), A. Beck (1976), and Meichenbaum (1977).
Whereas behaviorists had largely focused on family members’ overt actions,
cognitive therapists emphasized how internal thought processes that can be
distorted influence individuals’ emotional and behavioral responses. Consideration
of subjective internal experiences posed a challenge for behaviorists, who often
had rejected intrapsychic explanations of behavior offered by psychodynamic
theorists. However, findings from basic research on human cognition, research
on the effectiveness of cognitive therapy for individual problems such as depres-
sion, and evidence that strictly behavioral interventions for couples’ relationship
problems had limited effectiveness all contributed to a growing acceptance of
cognitive interventions among behaviorists (Baucom & Lester, 1986; Epstein &
Williams, 1981; O’Leary & Turkewitz, 1978).
In turn, the tradition in cognitive therapies has been to focus on assessing
and modifying individuals’ cognitive distortions and other inappropriate
thought processes. If an individual is unhappy in his or her marriage, a cogni-
tive therapist would be most likely to help the person distinguish between
 Cognitive-Behavioral Therapies 263

distorted and accurate views of the relationship. Cognitive restructuring proce-

dures could be used to change distorted cognitions, but if the individual’s views
of the relationship are accurate, the implications for treatment are less clear. A
cognitive therapist could help the individual devise alternative solutions to the
problem of living in a distressing relationship, such as requesting change from
one’s partner or perhaps ending the relationship. However, attempting to improve
the relationship by working only with one member presents significant limita-
tions. Consequently, as cognitive therapists have increasingly considered how
individuals’ interactions with significant others affect their well-being, they have
integrated behavioral interventions into their treatments (A. Beck, 1988; Epstein,
1982).
Thus, two converging trends led to integration of behavioral and cognitive
theories and clinical techniques in the field of couple and family therapy. On
the one hand, behaviorally oriented therapists have adopted concepts and methods
from cognitive therapies as a means of taking into account family members’
subjective responses to one another’s actions. On the other hand, cognitive
therapists have adopted the behaviorists’ focus on interaction processes among
family members, which influences each person’s subjective thoughts and emo-
tions. Resulting cognitive-behavioral approaches to couple and family treat-
ment attend to both the overt interactions among family members and the
internal experiences of each member.
Increasingly, cognitive-behavioral couple and family therapy models also have
focused on family members’ emotional responses to each other, not only as results
of their cognitions and behaviors, but also as causal factors. For example, Weiss
(1980) described the process of sentiment override, in which an individual’s
existing feelings about another person influence the individual’s reactions to the
person more than the other’s current actions do. Thus, a man who left the house
angry at his wife in the morning may criticize her when she attempts to express
her caring for him later in the day, because his residual anger overrides any
positive impact of her caring behavior. In addition, cognitive-behavioral therapists
(e.g., Epstein & Baucom, 2002) have drawn on concepts from emotionally
focused couple therapy (Greenberg & Goldman, 2008; Johnson, 1996) in
helping couples increase awareness of their own and each other’s underlying
emotions that contribute to negative interaction patterns. Finally, methods from
dialectical behavioral therapy (Linehan, 1993) are used to help couples regulate
potentially damaging experiences and venting of negative emotions (Fruzzetti &
Iverson, 2006; Kirby & Baucom, 2007).
Behavioral, cognitive, and cognitive-behavioral models of couple and family
therapy have been challenged by some adherents of systems theory as being
limited to linear rather than circular concepts of causality in family relation-
ships. They have argued that behaviorists’ learning concepts, such as operant
conditioning, involve linear causal thinking, in that reinforcement of a person’s
action causes an increase in that action. Similarly, systems-oriented theorists have
264 Norman B. Epstein and Mariana K. Falconier

argued that cognitive therapists see a linear causal relationship between a person’s
cognitions and his or her emotional and behavioral reactions (e.g., a parent views
a child as intentionally disobeying him or her, and this inference leads to anger
toward the child and a spanking). Although these critiques have been accurate
to some degree, they have overlooked aspects of cognitive-behavioral theory and
practice that take into account mutual, circular influences involving members of
a couple or family, which are described in this chapter. For example, Bandura’s
(1977) social learning model takes into account how individuals who are inter-
acting with one another mutually influence the probabilities that the other person
will respond in particular ways.
During the 1970s, James Alexander and his colleagues (e.g., Barton & Alexander,
1981) developed functional family therapy (FFT) as an integration of systems
and behavioral approaches, based on recognition that both models focus on inter-
action patterns among family members. Similar to other behavioral approaches,
FFT identifies sequences of behavior among family members and is intended
to modify problematic patterns (Alexander, Waldron, Robbins, & Neeb, 2013;
Sexton & Alexander, 2003). Consistent with systems theory, it is based on a premise
that understanding an individual’s behavior requires identifying its interpersonal
context—how the person influences and is influenced by his or her family mem-
bers. Functional family therapists tend to differ from other behaviorists by assuming
that a person’s behavior is intentionally designed to produce particular consequences
(e.g., aversive behavior that leads others to back off), even if the person is not fully
aware of the intent. That premise has been debated but challenged behaviorists to
identify why family members continue to engage in negative actions that seem
to be at odds with their positive goals for their relationships. Over the years, FFT
has become even more integrative, addressing cognitive, affective, and environmental
factors that place adolescents and their family members at risk for negative interac-
tions. FFT has strong empirical support, and it has contributed to the development
of cognitive-behavioral approaches that take into account interpersonal processes
and circular causality in family relationships.
This chapter describes the current state of cognitive-behavioral therapy with
couples and families. Following a summary of the model’s major concepts and
identification of major proponents of the approach, normal and dysfunctional
family processes are described. Ways of assessing and treating couple and family
problems from a cognitive-behavioral perspective are described, with illustrative
case examples, and the current status of research on the efficacy of these methods
is summarized.

Theoretical Concepts
As described in the beginning of this chapter, cognitive-behavioral approaches to
couple and family therapy focus on the behavioral interactions and family mem-
bers’ subjective thoughts and emotional responses that contribute to relationship
 Cognitive-Behavioral Therapies 265

problems. The following sections describe the major behavioral, cognitive, and
emotional aspects of family interactions that are relevant in a cognitive-behavioral
approach to understanding and treating relationship problems.

Behavioral Factors in Couple and Family Relationships

Based on social learning principles (Bandura, 1977), it is assumed that when two
adults form a relationship they each bring a personal learning history that affects
how they relate to the other. In past relationships, especially family of origin,
each person learned skills and styles of communicating and relating to significant
others—by observing parents, siblings, and so forth and through being reinforced
for certain actions and punished for others. These learned ways of interacting
with others may differ across cultures. In addition, parents implicitly model and
explicitly teach their children skills for solving both small and large life problems.
Some parents model effective problem-solving skills, whereas others model inef-
fective and even destructive approaches. For example, a child may observe a
parent responding to conflict with extended family members and friends by
behaving aggressively, or by cutting off contact with the other people. This
observational learning may result in the child lacking constructive skills for
dealing with conflict in relationships in his or her own life. In a cognitive-
behavioral framework, it is assumed that individuals develop both positive and
negative behavioral responses through the same learning processes and that
learning procedures can be used to modify problematic responses.

Problematic Couple and Parent-Child Interaction Patterns

Given the behavioral tendencies that they bring to their relationship, members
of a couple develop patterns for interacting with each other, based on how they
react to each other over time. These patterns can vary considerably in their
effectiveness in meeting the partners’ needs. For example, if a couple develop a
pattern of mutually avoiding expression of areas of dissatisfaction, it likely will
result in chronic unresolved issues. Cognitive-behavioral couple therapists
(e.g., Baucom & Epstein, 1990; Epstein & Baucom, 2002; Jacobson & Christensen,
1996; Rathus & Sanderson, 1999) have noted that at least some conflict is inevi-
table in an intimate relationship, due to differences in partners’ needs, personalities,
temperaments, and so forth. One of the risk factors for relationship distress is
poor skill at identifying and implementing effective solutions to problems
(Gottman, 1994; Weiss & Heyman, 1990). Gottman’s research has indicated that
distressed couples tend to respond to conflicts with negative behaviors such as
criticism, defensiveness, contempt, and stonewalling (withdrawal), which are strong
predictors of dissolution of the relationship.
Couples who engage in high rates of negative behavior toward each other tend
to lack adequate skills for communicating their needs and solving relationship
266 Norman B. Epstein and Mariana K. Falconier

problems in a cooperative way. In one common pattern, partners develop an

almost “automatic” response pattern in which a perceived negative behavior by
one person results in negative reciprocity from the other person. In negative
reciprocity, a person who receives a negative from a partner reciprocates with a
negative action toward the partner. Sometimes the reciprocation is immediate,
as an argument between partners escalates with mutual insults, but at other times
an individual waits until a later time to “get even.” Distressed couples are more
likely than satisfied ones to engage in negative reciprocity (Baucom & Epstein,
1990; Weiss & Heyman, 1990). A second common problematic pattern involves
one person pursuing the other, while the other person withdraws (Christensen,
1988). This demand/withdraw pattern typically becomes a repetitive cycle.
Although family therapists can see the circular process in mutual attack and
demand/withdraw patterns, the members of such couples typically perceive linear
causality in their interactions, with the other person being at fault. For example,
an individual who keeps pursuing a partner says, “I pursue only because my
partner withdraws,” but the other person’s view is “I withdraw because my
partner keeps pursuing me.” The cognitive-behavioral therapist’s job is to help
the couple understand the circular nature of their pattern and motivate each
person to modify his or her contribution to it.
Parents’ marital conflict has been found to be associated with a variety of child
problems, including conduct disorders and depression (e.g., Kaczynski, Lindahl,
Malik, & Laurenceau, 2006; Zimet & Jacob, 2001). Research suggests that a major
way in which a couple’s conflict influences their children is through its effect on
their own parenting behavior. Thus, a parent who is upset and distracted by
couple relationship problems is less likely to guide and discipline a child in a
patient, consistent, and constructive manner, as well as less likely to provide warm
emotional support to the child. Furthermore, a couple may express conflict in
the area of parenting by openly counteracting each other’s attempts to discipline
a child and by trying to form an alliance with the child against the other parent.
Therefore, when presented with a family with child emotional and behavioral
problems, a cognitive-behavioral therapist may intervene in parental conflict to
the extent that the couple is open to doing so, but the primary interventions will
likely focus on ways that the two parents interact with the child.
Research also indicates that problem-solving skill deficits and negative interac-
tion patterns commonly exist in distressed parent-adolescent relationships (Robin
& Foster, 1989). Patterson (1982) described how aggressive children commonly
grow up in coercive family systems, in which their parents use criticism,
threats, and forms of punishment to try to control the children’s behavior, and
in turn the children use aversive behavior to influence the parents. Thus, the
parents and children engage in a pattern of negative reciprocity, in which they
exchange negative acts in a retaliatory manner.
If a child receives little attention or other reinforcement for positive behavior,
but receives attention from parents for negative actions, such as verbal and physical
 Cognitive-Behavioral Therapies 267

aggression, it is likely that the attention will reinforce and thus strengthen the
negative behavior. Based on operant conditioning principles, the reinforcement
of negative behavior is likely to produce a stronger effect if the parents provide
it to the child inconsistently. Research by learning theorists such as Skinner indi-
cated that an individual who receives intermittent reinforcement—the rein-
forcement occurs occasionally or unpredictably rather than every time—will repeat
the actions that produced the reinforcement even when there is no reinforcement
for a long time. The individual has learned that sooner or later reinforcement is
likely to occur, so he or she should keep trying to elicit it. The power of inter-
mittent reinforcement is demonstrated by the persistence of individuals who
gamble by playing slot machines.
Furthermore, parents can unwittingly teach a child to use verbal and physical
aggression through modeling, if they use those types of behavior in disciplining
the child. Although a parent may be tempted to vent frustration toward a child
by using aversive words and actions, particularly if the parent lacks more effective
parenting skills, that approach tends to backfire by contributing to more coercive
exchanges between the child and the parents. One of the tasks facing a cognitive-
behavioral family therapist is changing some parents’ beliefs that verbal and
physical aggression are useful in developing more positive behavior in their
children.
Time-out procedures are an alternative form of consequences that cognitive-
behavioral therapists advocate for negative child behavior, at least for younger
children. Time-out involves removing the child physically from all available
sources of reinforcement, such as having him or her sit in a chair in a corner—
away from TV, games, siblings, and even the attention of parents. Its power is
based on the child’s tendency to seek reinforcement and the unpleasant experi-
ence of being deprived of it. Sometimes parents report that they are familiar
with and use time-out procedures to punish a child, but the therapist discovers
that they use the procedure inconsistently. Some parents send the child to a
location where there is plenty of enjoyable activity to be found, such as the
child’s room, whereas other parents may effectively cut off the child from rein-
forcement occasionally but fail to do so consistently (perhaps yelling at the child
instead).
Effective parenting also includes reinforcement of positive behavior (Forgatch &
Patterson, 2010; Kazdin, 2005). Often a parent is so focused on a child’s negative
behavior that he or she either fails to notice instances in which the child behaves
well or fails to provide reinforcement such as praise for those acts. Ignoring posi-
tive behavior follows the operant learning principle of extinction, in which an
act that has no positive consequences will decrease. If parents want children to
behave less negatively, they need to use a combination of techniques for decreas-
ing negative acts and techniques for increasing positive acts.
As previously noted, providing reinforcement for a child’s positive behavior
requires that the parent notice those actions. Jacobson and Margolin (1979) labeled
268 Norman B. Epstein and Mariana K. Falconier

the tendency to notice another’s negative behavior and overlook positive behaviors
as negative tracking. This biased perception is one form of cognition described
in the next section. Once a parent notices a child’s positive behavior, the parent
faces a decision about how he or she should respond. Parents who believe that
children should behave well “just because it is the right thing to do” and view
reinforcement as “bribes” are unlikely to use praise and other rewards. These beliefs
are assumptions and standards, two other forms of cognition that influence
family relationships and are described in the next section. A third factor in parents’
failure to reinforce positive acts is deficits in communication skills. Some
parents are unfamiliar with ways to phrase positive feedback messages to their
children. Rather than giving a vague, general message such as “You had a better
day yesterday,” the parent may need to learn how to give the child specific behav-
ioral feedback, such as “I was very happy to see you putting your dirty clothes
in the hamper and cleaning up the dinner table.” Parent training interventions
(e.g., Forgatch & Patterson, 2010; Kazdin, 2005) help develop knowledge and
confidence to provide clear constructive feedback and instructions to children.
Inconsistency in parenting behavior may be due to various factors. Some
involve deficits in parents’ behavioral skills, and others involve ways that they
think about their parenting roles. Some parents are ambivalent about setting firm
limits on children’s behavior, because they equate strictness with harshness. In
some cases, a parent has bought into a child’s complaint that the parent is unlov-
ing or unfair in setting limits. Parents who have experienced separation or divorce
or who work long hours and have limited time to spend with their children
may feel guilty that their children have experienced these family situations. Still
others feel overwhelmed by stresses in their lives, such as trying to balance work
and family roles, and do not believe that they can tolerate the effort involved
in consistent parenting. These factors involve the parents’ cognitions about
parenting, and in cognitive-behavioral family therapy the clinician helps each
parent identify and modify thoughts that interfere with constructive interactions
with the children. A more detailed description of cognitive factors follows.

Cognitive Factors in Couple and Family Relationships

Cognitive therapies are based on the premise that a person’s emotional and
behavioral responses to life events depend on the person’s thoughts about those
events. Virtually the same event might happen to two people, but the two indi-
viduals might react differently because they interpret the event differently.

Bonnie and Fred were eating breakfast together and talking about ideas
for a family summer vacation when their 16-year-old son Mike walked
into the kitchen. When Bonnie told Mike that they were thinking about
the whole family spending 10 days at a beach resort, Mike responded, “I
don’t want to go to any resort. I want to stay home and spend time with
 Cognitive-Behavioral Therapies 269

my friends.” Bonnie’s immediate reaction was strong sadness, and she sat
quietly, but Fred became quite angry and yelled at Mike, telling him he
was “ungrateful for the nice things we do for you.” When Bonnie and
Fred discussed the incident later, Bonnie described how Mike’s comment
made her feel sad because it made her think that their days as a whole
family were ending, as their son was moving toward independence. In
contrast, Fred noted that his anger had been associated with thoughts that
Mike should be grateful that his parents were willing to spend a lot of
money to take him to a special place, and that Mike’s comment was dis-
respectful. Thus, each parent interpreted Mike’s behavior somewhat dif-
ferently, and their subjective interpretations led to different emotions and
behaviors.

Aaron Beck’s cognitive therapy (A. Beck, 1976; A. Beck, Rush, Shaw, & Emery,
1979; J. Beck, 2011; Leahy, 1996) focuses on helping individuals learn to identify
aspects of their thinking that contribute to negative emotions and behavior, test
the validity of their thoughts, and replace distorted cognitions with more realistic
ones. In Beck’s model, two major types of cognitions influence individuals’
responses to events in their lives: automatic thoughts and schemas.

Automatic Thoughts
Automatic thoughts are stream-of-consciousness thoughts that spontaneously
run through one’s mind and seem plausible at the time, even if they are distorted.
People typically do not stop to question their automatic thoughts, so the thoughts
can control their moods and behavior. Aaron Beck (1976) originally developed
cognitive therapy based on his observation that depressed individuals had frequent
overly negative thoughts about themselves, the world, and their futures. These
negative thoughts are shaped by cognitive distortions, or errors in processing
information. For example, overgeneralization is a cognitive distortion in which
the individual observes one instance of an event and views it as representing a
general characteristic. For example, when five-year-old Amanda disobeyed Tim’s
instruction to put her toys away, he thought, “She never listens to what I tell her
to do,” and this thought made him angry. Later, Tim was able to take a broader
perspective and acknowledged that sometimes Amanda is obedient. Some other
types of cognitive distortions include personalization (assuming that events
involve you when in fact they do not), mind reading (making unwarranted
inferences about others’ thoughts and emotions), dichotomous thinking (plac-
ing experiences into distinct, opposite categories, such as “good child” versus
“bad child”), selective abstraction (biased perceptions such as negative tracking),
magnification (viewing something as more important than it is, such as seeing
a minor mistake as a catastrophe), and minimization (viewing something as
less important than it is, such as seeing one’s own or another’s improved behavior
270 Norman B. Epstein and Mariana K. Falconier

as “no big deal”). Cognitive therapists help clients become aware of upsetting
distortions in their thinking and teach them ways to challenge negative automatic
thoughts (A. Beck et al., 1979; J. Beck, 2011).
Theorists and researchers who have studied forms of cognition affecting couple
and family relationships (see reviews by Baucom & Epstein, 1990; Baucom,
Epstein, Sayers, & Sher, 1989; Epstein & Baucom, 1993, 2002; Fincham, Bradbury,
& Scott, 1990) have identified three types of cognition that can involve the
information-processing errors involved in cognitive distortions. Selective per-
ception is equivalent to the distortion of selective abstraction, in which an
individual notices only some aspects of his or her interactions with a family
member. Tim’s selective perception of his daughter Amanda’s disobedience con-
tributed to his anger. Research has indicated that couples, especially those in
distressed relationships, commonly disagree on what events occurred in their
interactions within the last 24 hours (Christensen, Sullaway, & King, 1983;
Jacobson & Moore, 1981).
Attributions are inferences that individuals make about causes of events they
observe, and these inferences may be accurate or distorted. Some attributions
concern the characteristics of a cause—that is, whether it is global versus specific,
stable versus unstable, and internal to a person or relationship versus external.

When Denise told Sam that she lost her job, he said little to her. Her
attribution that his failure to express support for her was due to “his self-
centered personality” was global, stable, and internal to Sam. It was global
because she viewed his lack of support as due to a broad personality
characteristic that is likely to influence many areas of Sam’s functioning
in relating to Denise and others. It was stable because it involved a per-
sonality characteristic that is likely to be present over a long period of
time. Finally, as part of Sam’s personality it was an internal characteristic
rather than an outside cause. In contrast, Denise might have attributed
Sam’s behavior to his being distracted by a stressful project at his job. Such
a cause is more external to Sam, is unstable to the extent that stresses at
his job tend to be temporary, and is specific to the extent that it adversely
affects his ability to listen to Denise when they are discussing their jobs.

Research has generally found that distressed couples are more likely than
satisfied couples to attribute each other’s negative behaviors to global, stable
characteristics of the partner (Baucom & Epstein, 1990; Bradbury & Fincham,
1990). These attributions concerning negative traits in the partner are associated
with individuals’ future distress and negative communication with their partners
(Bradbury & Fincham, 1992; Durtschi, Fincham, Cui, Lorenz, & Conger, 2011;
Fincham & Bradbury, 1987; Fincham, Harold, & Gano-Phillips, 2000). Barton
and Alexander (1981) note that when family members attribute relationship
problems to others’ negative traits, it reduces the chance that they will work
 Cognitive-Behavioral Therapies 271

toward improving the ways they interact with each other. Blaming problems
on another person typically leads to waiting for the other person to change
and failing to recognize ways in which one can contribute to change oneself.
Also, viewing problems as being caused by global, stable traits can result in the
individual feeling hopeless about change.
Other attributions affect relationships because of their particular content. For
example, Pretzer, Epstein, and Fleming (1991) found that individuals who attrib-
uted their couple relationship problems to a lack of love or malicious intent by
their partners were more dissatisfied in their relationships. Similarly, Morton,
Twentyman, and Azar’s (1988) clinical observations of child-abusing parents
indicated that these parents commonly believe that their children’s misbehavior
is caused by intentional efforts to be annoying and spiteful.
Expectancies are the third type of cognition that potentially involves distorted
processing of information. An expectancy is a prediction that an individual
makes about the probability that particular events will occur in the near or
distant future in particular situations.

Dave tells his son Robby that he cannot play outside before dinner, because
he has an expectancy that Robby will run off with his friends. As with
other types of inferences, expectancies can vary in their accuracy, and to
some degree a person’s expectancies about family members are shaped by
past experiences with those individuals. Dave’s expectancy may be due to
past episodes of Robby disappearing with friends at mealtimes. However,
perhaps Robby has never done that, and Dave’s expectancy is based on his
general belief that “young boys are impulsive and mostly pay attention to
having fun with their friends.”

Research studies have indicated that couples’ negative expectancies about their
abilities to solve relationship problems are associated with higher levels of rela-
tionship distress (Pretzer et al., 1991; Vanzetti, Notarius, & NeeSmith, 1992).
Cognitive-behavioral therapists help family members identify their expectancies
and test their validity.

Schemas
Whereas cognitive distortions shape the form of a person’s thoughts, cognitive-
behavioral therapists examine how the content of the thoughts is based on sche-
mas, long-standing beliefs or “knowledge structures” that the individual has
about characteristics of people, objects, relationships, and so forth. In contrast to
selective perceptions, attributions, and expectancies, which tend to focus on events
occurring at a particular moment or in a particular situation, schemas are rela-
tively stable ways in which a person understands his or her world. They include
basic beliefs about how human beings function and how they relate to one
272 Norman B. Epstein and Mariana K. Falconier

another. It is thought that many of these schemas begin to develop during

childhood, based on experiences that an individual has with people and other
aspects of the world. Later life experiences can alter an existing schema, but
research indicates that strongly established beliefs can be highly resistant to change
(Fiske & Taylor, 1991). Examples of schemas relevant to couple and family
relationships are beliefs about gender roles and characteristics of females and
males, beliefs about how love “feels,” beliefs about appropriate behavior of indi-
viduals in particular family roles such as “child,” and beliefs about the charac-
teristics of a “good marriage” (Dattilio, 2010; Epstein & Baucom, 2002). Two
major categories of schemas that affect couple and family relationships are
assumptions and standards (Baucom & Epstein, 1990; Baucom et al., 1989; Epstein
& Baucom, 1993).
Assumptions are beliefs that an individual has about typical characteristics
of people and objects. Assumptions are concepts about how aspects of the world
are and how they work. As a child observes people over a period of time, he
or she develops concepts about human thoughts, emotions, and behavior. Those
concepts vary from one person to another, depending on the particular people
the individual observed, the cultural patterns to which he or she has been exposed,
and the idiosyncratic inferences that he or she made about what was observed.
A child who is raised in a home in which parents and older siblings frequently
vent anger through sudden verbal and physical outbursts may develop a basic
assumption that the expression of strong emotions is automatic and uncontrol-
lable. Such an assumption may affect the way the child deals with his or her
own emotions in relationships with others, during childhood and adulthood.
Eidelson and Epstein identified some assumptions associated with marital distress,
including the beliefs that (1) disagreement between partners is destructive to
their relationship, (2) problems in male-female relationships are due to innate
differences between the sexes, and (3) once patterns have developed in a relation-
ship, the partners cannot change them (Eidelson & Epstein, 1982; Epstein &
Eidelson, 1981).
Standards are beliefs about ways that people, relationships, and events “should”
be. Similar to assumptions, it is likely that individuals develop standards for
themselves and relationships on the basis of life experiences and context. Those
experiences can involve family-of-origin relationships, observation of other
people’s characteristics and relationships, mass media (e.g., the Internet, television,
movies, books, popular songs), peer relationships, teachers, clergy, and more.
Standards are largely influenced by the norms established by ethnic, socioeco-
nomic, religious, and sociopolitical contexts, although members of each cultural
context typically are not aware of how the norms that seem so “natural” to
them differ from those held by members of different cultures.
Holding standards is not inherently problematic; in fact, people typically have
standards that comprise their personal moral codes (e.g., “Parents should nurture
their children and avoid abusing them”). However, standards can vary in how
 Cognitive-Behavioral Therapies 273

realistically they represent the possibilities of real life, and unrealistic beliefs may
lead to frustration and disappointment. For example, Eidelson and Epstein (1982)
found that the more individuals adhered to the standards that (1) partners should
be able to read each other’s thoughts and emotions and (2) partners’ sexual
relationships should be perfect (trouble free and highly satisfying), the more they
were unhappy in their relationships. The concept of extreme or unrealistic
beliefs is similar to the irrational beliefs that are a focus of rational-emotive
therapy (Ellis, 1962; Ellis, Sichel, Yeager, DiMattia, & DiGiuseppe, 1989), which
was renamed “rational-emotive behavior therapy” due to its increased focus on
clients’ behaviors. Ellis and his colleagues emphasized that when an individual
holds unrealistic beliefs about people and life experiences, he or she is likely to
be upset and to behave negatively when the realities of daily life fall short of
those standards.
Standards also might be problematic either when two partners’ standards are
in conflict or when a person’s standards are realistic but are not being met to
his or her satisfaction in the couple’s relationship. Baucom, Epstein, Rankin, and
Burnett (1996) developed a questionnaire to assess individuals’ standards for
couple relationships, focusing on standards about boundaries (how much auton-
omy versus togetherness partners should have), the degree of investment of
time and energy that partners should make for their relationship, and how
power/control should be distributed and used in the couple’s relationship.
Their Inventory of Specific Relationship Standards (ISRS) assesses these three
types of standards concerning 12 different areas of one’s relationship, such as
affection, sex, household tasks, finances, and the expression of positive and nega-
tive feelings. Differences in standards for boundaries, investment, and power/
control issues in each of those 12 areas may be particularly challenging for
intercultural couples in which partners come from cultures that hold opposite
standards in many of those areas. For example, Epstein, Chen, and Beyder-Kamjou
(2005) found differences in relationship standards between U.S. couples and
mainland Chinese couples, such as that Chinese couples considered it more
acceptable to exercise power in their relationships. Chinese couples also tended
to be less overtly expressive of affection verbally and nonverbally than U.S.
couples. Increasingly, couple and family therapists are describing ways in which
Western-derived therapy models that are based on particular assumptions and
standards regarding appropriate relationship qualities must be applied in culturally
sensitive ways that take different beliefs and traditions into account (Epstein et al.,
2012).
Thus, a cognitive-behavioral model of couple and family functioning takes
into account a number of types of cognitions that individuals have about them-
selves and their close relationships. The types of behavior patterns described in
the previous section are influenced by the ways that family members interpret
one another’s actions. For example, in negative reciprocity, two family members
are more likely to reciprocate each other’s negative acts if they selectively notice
274 Norman B. Epstein and Mariana K. Falconier

the negatives and overlook the positives, or if they attribute the negative behavior
to causes such as the other person having malicious intent. Similarly, an individual
may withdraw from a family member if he or she has an expectancy that any
attempt to communicate with this person will be ineffective. Concerning sche-
mas, a parent may fail to use positive reinforcement for a child’s good behavior
if the parent holds a standard that children should naturally behave well because
“they know it’s the right thing to do” and holds an assumption that rewarding
children “only spoils them.” The parent’s beliefs result in dissatisfaction with the
child’s behavior and influence how the parent responds to the child’s failure to
live up to what the parent expects. Consequently, understanding and treating
problems in couple and family relationships necessitates paying attention to both
the ways that family members interact and the family members’ cognitions that
influence those interactions.
These emphases on behavior and cognition in the literature on cognitive-
behavioral therapies sometimes create an impression that family members’ emo-
tions are neglected in these approaches. In fact, family members’ emotional
responses are central aspects of their satisfaction or distress in their relationships
and are of major concern to cognitive-behavioral therapists. The next section
describes emotional factors in couple and family relationships.

Emotional Factors in Couple and Family Relationships

Much of the literature on cognitive therapy has focused on thought processes
as causes for depression, anxiety, anger, and other emotions (e.g., A. Beck, 1988;
A. Beck et al., 1979; A. Beck & Emery, 1985; Dattilio & Padesky, 1990; Def-
fenbacher, 1996; Ellis et al., 1989) when the individual responds to life events.
Similarly, behavioral couple and family therapists have emphasized how exchanges
of positive and negative behavior between two people in a relationship affect
satisfaction with the relationship. Thus, it is easy to get the impression that
cognitive-behavioral models take a linear causal view, in which emotions are
results, but not causes, of family members’ cognitions and behaviors. However,
considerable clinical and research evidence suggests that people’s emotions about
their relationships influence their thoughts and behavior as well. Weiss (1980)
described a process of sentiment override, in which a person’s overall feelings
about a spouse determine the person’s cognitions and behavior toward the spouse
more than the spouse’s current behavior does.

Ken had built up strong resentment toward Sarah based on a number of

incidents over the past two years in which she made personal choices that
seemed selfish to him. Sarah was aware of Ken’s upset about those events,
and she was committed to improving their relationship. She had begun to
make special efforts to ask Ken about his preferences about decisions she
was considering. However, each time Sarah asked to talk to Ken about
 Cognitive-Behavioral Therapies 275

such a decision, even when she began the discussion by emphasizing that
she wanted to consider his input, Ken quickly reacted with anger and
criticized her for being selfish. His strong emotion interfered with his
ability to listen to her and led to his negative behavior toward her.
Similarly, Nikki had become depressed about her relationship with
James, because their work shifts and child-rearing activities left them very
little time as a couple. Unfortunately, whenever they did have an oppor-
tunity to do something together, her depressed mood made it difficult for
her to enjoy herself. James would notice her lack of enthusiasm and
comment on it. Nikki would react defensively, and they would have an
argument.

Cognitive therapists also have noted how an individual’s emotional states can
influence his or her perceptions and behavior. They have described how an
individual may engage in emotional reasoning, relying on cues of his or her
emotions as signs of some “truth.” For example, depressed individuals commonly
experience symptoms of low energy, inertia, and low motivation to engage in
basic daily activities such as getting out of bed and getting dressed. If a person
concludes, “I don’t feel that I can do anything,” it is likely that he or she will
become inactive, which tends to worsen the depression. A cognitive therapist
would help this person understand that it is important not to trust the physical
and emotional cues, and that it is possible to engage in activities even when one
feels that way. Similarly, people who experience panic attacks often interpret the
symptoms (e.g., rapid heart rate, sweating, shortness of breath) as signs of a seri-
ous physical problem such as a heart attack or signs of “going crazy.” Cognitive-
behavioral treatment of panic disorder includes teaching the individual that those
symptoms are uncomfortable but not dangerous (Barlow, 2002).
Difficulty regulating one’s anger commonly contributes to verbally and physi-
cally aggressive behavior toward others, so interventions to improve anger man-
agement are a key component of cognitive-behavioral couple therapy (CBCT)
treatments for intimate partner violence (Heyman & Neidig, 1997; LaTaillade,
Epstein, & Werlinich, 2006). In order to reduce intense anger that fuels aggres-
sion, therapists teach couples a variety of strategies, such as self-soothing methods
(e.g., muscle relaxation, going for a walk, taking a warm shower), nonaggressive
self-talk (e.g., “Even if he’s trying to provoke me, I can stay calm”), and effective
use of “time-outs” in which partners agree to physically distance themselves
from each other temporarily in order to calm down. Similar techniques are
taught to parents who have difficulty regulating anger toward their children
(Nicholson, Anderson, Fox, & Brenner, 2002; Sanders, Cann, & Markie-Dadds,
2003).
Thus, emotion has a crucial role in cognitive-behavioral approaches to couple
and family relationships, and therapists typically gather a lot of information about
the emotions that each family member experiences during their interactions. It
276 Norman B. Epstein and Mariana K. Falconier

is important to differentiate various types of emotions, rather than asking family

members how happy versus unhappy they are. Individuals’ negative emotions
regarding their relationships can include anger, sadness, depression, and anxiety,
and each type of emotion may require a different form of intervention. For
example, an individual’s anxiety may be associated with negative expectancies
that communicating directly with his or her partner will lead to criticism by
the partner and tension between them. The individual may find anxiety symp-
toms so unpleasant that he or she generally avoids expressing important thoughts
and emotions to the partner. Intervention is likely to include exploration of how
valid the negative expectancies are. To the extent that communicating with the
partner appears to be tension-provoking but otherwise safe, and direct com-
munication would help meet the person’s needs in the relationship, therapy may
focus on reducing the person’s avoidant behavior.
In contrast, another individual may primarily experience anger, associated
with sentiment override from past unpleasant experiences with the partner.
Rather than avoiding the partner, this person quickly becomes upset whenever
the partner discusses their relationship, and the anger leads him or her to attack
the partner verbally. In this case, therapy is likely to focus on moderating the
individual’s strong, global anger response and helping him or her practice listen-
ing to the partner. The past events that contributed to the pervasive anger also
would be explored, with a goal of seeing whether those conditions have changed
or could be changed.

Proponents of the Model

As described previously, current forms of cognitive-behavioral therapy (CBT)
for couples and families represent an integration of behavior therapy and cogni-
tive therapy traditions, along with systems theory concepts. The model has grown
rapidly over the past two decades, and the number of its proponents has increased
markedly. Many proponents (e.g., Donald Baucom, Steven Beach, Gary Birchler,
Guy Bodenmann, Thomas Bradbury, Andrew Christensen, Frank Fincham, Alan
Fruzzetti, John Gottman, Kurt Hahlweg, Amy Holtzworth-Munroe, Neil
Jacobson, Howard Markman, Michael Metz, Clifford Notarius, Timothy O’Farrell,
K. Daniel O’Leary, Jill Rathus, Galena Rhoades, Ronald Rogge, Lorelei Simpson
Rowe, William Sanderson, Keith Sanford, Steven Sayers, Tamara Sher, Scott Stanley,
Gregory Stuart, Richard Stuart, Kieran Sullivan, Robert Weiss, Mark Whisman)
have focused predominantly on couples, whereas others (e.g., James Alexander,
Iliana Arias, Ian Falloon, Frank Floyd, Rex Forehand, Marion Forgatch, Sharon
Foster, Alan Kazdin, Kristin Lindahl, David Miklowitz, Kim Mueser, Susan O’Leary,
Gerald Patterson, Arthur Robin, Matthew Sanders, Stephen Schlesinger, Andrew
Schwebel) have focused more on families, although a number of individuals
(e.g., Frank Dattilio, Norman Epstein, Gayla Margolin) have addressed both couple
and family relationships extensively, and proponents vary in the relative degrees
 Cognitive-Behavioral Therapies 277

to which they attend to behavioral, cognitive, and emotional factors in the overall
CBT model. Sometimes authors’ publications describe cognitive interventions as
adjunctive interventions to their primary focus on behavioral interactions.
For example, if the members of a couple are resistant to practicing constructive
communication skills because they attribute each other’s past negative commu-
nication to a lack of caring about their relationship, the therapist might shift
from the behavioral intervention to challenging the negative attributions. At
other times, therapists whose background was primarily behavioral have shifted
toward giving cognition and emotions relatively equal weight as behavior in
their approaches. On the other hand, therapists whose background focused on
cognitive processes have embraced concepts and clinical methods involving
behavioral interactions and systems theory. Sometimes they use behavioral inter-
ventions primarily as a means of producing cognitive changes, such as when
training in constructive communication is used to modify partners’ lack of hope
that their relationship can improve or to increase their ability to give each other
feedback that can challenge other negative cognitions about each other.
As behavior and cognition have been integrated in cognitive-behavioral clini-
cal training programs, more therapists are entering their clinical careers with a
view that treatment of relationship problems necessarily involves attention to
complex relations between behavior and cognition, as well as family members’
emotional responses. As noted earlier, the increased attention to emotions has
been stimulated by cognitive-behavioral therapists who have focused on emotion
regulation problems (e.g., Fruzzetti & Iverson, 2006; Kirby & Baucom, 2007;
Linehan, 1993), as well as by the empirically supported emotion-focused
approaches (Greenberg & Goldman, 2008; Johnson, 1996). Publications by
Alexander et al. (2013); Baucom and Epstein (1990); Dattilio (1998a, 1998b,
2010); Epstein and Baucom (2002), Epstein, Schlesinger, and Dryden (1988);
Rathus and Sanderson (1999); Robin and Foster (1989); and Schwebel and Fine
(1994) reflect the trend toward integrative cognitive-behavioral approaches to
couple and family therapy. Throughout this chapter we have cited the work of
many cognitive-behavioral couple and family therapists as we have described the
history of CBT approaches, their increasing sophistication, and their applications
with special populations and presenting problems (e.g., depression, child behavior
problems, substance abuse, major mental disorders, family violence).

Normal Family Development

Within a cognitive-behavioral model, normal couple and family development
depends on the fulfillment of each member’s personal needs, as well as core
functions of the relationship. Among the major needs of individual members
are those involving connection with significant others (e.g., intimacy, nurturance,
altruism) and those involving individual functioning (e.g., autonomy, achievement,
power) (see Prager, 1995, for an excellent discussion of these communal needs
278 Norman B. Epstein and Mariana K. Falconier

and agentic or individual-oriented needs, respectively). Major relationship

functions include those that provide for the physical and economic security of
the couple or family, as well as those that allow the family to interact success-
fully with aspects of the outside world, such as schools. Needs and relationship
functions are likely to be fulfilled to the extent to which the members of a
couple or family

(1) are aware of those needs and types of actions involved in meeting them,
(2) communicate in clear, constructive ways that facilitate those actions,
(3) engage in effective problem solving when their current interactions are
inadequate for meeting their needs, and
(4) have cognitions that facilitate all of these processes.

In normal family development, the members are relatively free of distortions in

their appraisals of the events that occur in their relationship, have realistic stan-
dards for the ways in which they interact, approach each other in a spirit of
collaboration and mutual support (rather than as adversaries), and have good skill
at communicating and working together to resolve problems.
Communal and individual-oriented needs may vary depending on socioeco-
nomic circumstances, cultural background, age, and so forth. Sometimes those
needs conflict with each other, either within an individual or between family
members (Baucom & Epstein, 1999; Epstein & Baucom, 2002). For example,
Janice, a Caucasian middle-class female, valued close relationships with her
husband and children but also was highly motivated to achieve in her career.
Although those needs were not incompatible in principle, Janice experienced
internal conflict and stress when time demands of family and career pulled her
in different directions. In addition, her husband, Pablo, who came from a low-
income Latino family, experienced internal conflict about her working. He
valued Janice’s financial contributions to their family, but due to his more
traditional view of gender roles that emphasized the male role of breadwinner,
he felt uncomfortable with her time investment outside of the home and peri-
odically pressed her to decrease her work hours. This led to conflict between
the two.
Similarly, adolescents commonly experience a need for increasing autonomy
from their parents, which often is expressed through preferences to make their
own decisions, as well as desires to spend time with friends rather than with
family. This can create some parent-adolescent conflict, because the parents may
be unprepared for the change in the relationship. The adolescent may experience
inner conflict between the emotional attachment that he or she still has to the
parents and his or her need for autonomy. However, the adolescent may express
the desire for autonomy more, leading the parents to infer that their child no
longer cares about them. Such intrapersonal and interpersonal conflicts over
normal human needs commonly pose challenges for couples and families.
 Cognitive-Behavioral Therapies 279

In normal family development, the individuals realistically understand their

own needs and those of their family members, and they have flexible ways
of thinking about and relating to one another in order to solve problems.
Their cognitive flexibility and rationality allow them to engage in creative
problem solving. Thus, the parents of an adolescent who has become argu-
mentative and less interested in family activities may be able to interpret
(i.e., make attributions about) the child’s behavior in nonthreatening ways
and experiment with new ways of letting him or her balance increased
autonomy and family connectedness. Consistent with social exchange theory
(Thibaut & Kelley, 1959), if a relationship becomes less satisfying over time
because the ratio of positives to negatives exchanged has decreased, normal
family development involves identifying the shift and interpreting it in a
benign way rather than as a sign that the relationship is ruined. Family mem-
bers’ ability to communicate clearly and collaborate in problem solving allows
them to increase positive behaviors and decrease negative behaviors, restoring
a more satisfying balance.

Pathology and Behavior Disorders

In contrast to normal couple and family development, dysfunction develops when
the behaviors that meet the members’ needs and fulfill the relationship’s basic
functions decrease, become less effective, or are outweighed by behaviors that
interfere with fulfillment of needs. In a cognitive-behavioral model, these changes
may be influenced by the family members’ cognitions as well as the specific
behaviors that occur. For example, a husband may exhibit fewer affectionate and
caring actions toward his wife because he has become busier and distracted by
his job. However, the husband may be behaving similarly as in the past, but his
wife's response to his behavior may have changed, in that she now finds his
“predictable” behaviors less meaningful than she did years ago. Consistent with
family systems concepts, dysfunction occurs when patterns in a relationship fail
to help the members adapt to changing life circumstances (Carter & McGoldrick,
1999). Thus, if parents have rigid standards about how an adolescent should
relate to the family, attribute the adolescent’s autonomous behavior to disrespect
toward them, experience strong negative emotions (anxiety, anger), and respond
in an authoritarian manner to the adolescent’s violations of their rules, parent-
adolescent conflict is likely to escalate. Research on distressed couples and families
has indicated high levels of unrealistic assumptions and standards, negative attri-
butions regarding one another’s motives, and aversive control strategies such
as threats and punishment. As members of a relationship rely on aversive control
to try to change each other’s behavior (and often each other’s “bad attitude”),
that approach typically backfires, contributing to escalation of negative behavior
exchanges or a demand/withdraw pattern. Gottman’s (1994, 1999) research
identified behavior sequences or cascades, in which attacking, defensive, and
280 Norman B. Epstein and Mariana K. Falconier

withdrawing behaviors increase partners’ distress and increase the probability that
they will end their relationship.
A combination of negative cognitions, emotions, and behaviors in a relation-
ship results in either a relatively chronic level of dissatisfaction or a deterioration
over time. Even when an individual attempts to behave positively toward his or
her family members, they are unlikely to notice or appreciate it, due to their
overall negative sentiment toward him or her. Thus, each individual’s negative
behavior tends to be reinforced in the family interactional system, and his or
her positive behaviors are ignored or even punished. In the absence of good
communication skills, as well as problem-solving skills and emotion regulation
skills, the family is unable to disengage itself from these destructive patterns.
When a member of a family experiences personal difficulties such as psy-
chopathology symptoms, those symptoms can place stress on family relationships
and, in return, family stress and conflict can exacerbate an individual’s personal
adjustment problems (Halford & Bouma, 1997; Miklowitz, 1995; Monson &
Fredman, 2012; Mueser & Gingrich, 2006; Whisman & Beach, 2012). This
bidirectional causality necessitates that therapists assess the degree to which an
individual’s development of psychological disorders affects the development of
relationship problems, and vice versa. A cognitive-behavioral model focuses on
both processes, and decisions about combining individual therapy with couple
or family therapy depend on the evidence concerning the causal processes in a
particular family.

Techniques
Cognitive-behavioral techniques for couple and family therapy tend to emphasize
cognitive restructuring, modification of problematic emotional responses, and
changes in behavior. Cognitive restructuring techniques are designed to help
family members increase their awareness of their cognitions that are contributing
to distress and conflict and to test their validity or appropriateness (Dattilio, 2010;
Epstein & Baucom, 2002). Behavior change techniques focus on increasing
family members’ positive actions toward one another, decreasing negative actions,
and developing their skill at effective communication and problem solving.
Interventions for emotion include techniques for improving family members’
awareness of their emotions, their skill at expressing their emotions in clear
and constructive ways, and their ability to regulate their emotional responses
(Epstein & Baucom, 2002; Fruzzetti & Iverson, 2006). Emotional regulation
involves an individual’s ability to control the strength of his or her emotions—for
example, using relaxation techniques so that the person feels moderate anger
rather than rage. In clinical practice, interventions for cognitions, behaviors, and
emotions commonly are combined during treatment sessions, as well as for home-
work assignments between sessions, but for clarity they are described separately in
the following sections.
 Cognitive-Behavioral Therapies 281

It is important to note that cognitive-behavioral therapists are not restricted

to any particular interventions and can use any approach that is designed to
modify problematic family interactions, is objectively measurable, and has been
subjected to empirical evaluation of its effectiveness (Wetchler & Piercy, 1996).
The therapist’s role is one of teacher/consultant, in which he or she provides
didactic information, instructions, modeling of constructive responses, and coach-
ing as family members try new skills and responses with one another. Treatment
is designed to teach families skills that they can use long after therapy has ended.

Cognitive Assessment and Interventions

Cognitive restructuring begins with assessment of family members’ selective
perceptions, attributions, expectancies, assumptions, and standards concerning
their relationships. The major approaches are

(1) interviews with the family,

(2) observation of thoughts they spontaneously express as they speak to one
another,
(3) probes for cognitions associated with family members’ emotional and behav-
ioral responses during sessions, and
(4) use of questionnaires.

Interviews Concerning Cognitions

A therapist can assess an individual’s selective perceptions of his or her family
members’ behavior by asking what specific acts he or she observes, when they
occur, in what circumstances, and how often (Dattilio, 2010; Epstein & Baucom,
2002). Sometimes it becomes clear that the individual is leaving out important
information because he or she has failed to notice it. For example, a parent
initially may report that a child “fails to obey directions.” When asked for
examples, the parent describes instances when the child was told to “clean his
room” and in which he was instructed to “stop interrupting adults when they
are talking.” When the therapist asks the parent to describe any instances in
which the child did obey a directive, the parent replies, “I can’t think of any.
He’s a very willful child.” However, the therapist then asks, “When you send
him to clean his room, are there any things he does to clean up?” The parent
hesitates and then replies, “He puts some toys away in his closet, but he leaves
dirty clothes on his bed and books on the floor.” The therapist begins to under-
stand that the parent selectively fails to notice, or discounts, instances when the
child exhibited obedient behaviors that the parent could praise in order to
encourage the child. Noticing that the parent uses the negative trait label
“willful child,” the therapist asks questions to determine the degree to which
282 Norman B. Epstein and Mariana K. Falconier

the parent assumes that “willfulness” is a broad characteristic affecting many

areas of the child’s life.
Often parents in distressed families attribute their children’s negative behavior
to such traits rather than to situational conditions. For example, given wide-
spread publicity concerning attention deficit/hyperactivity disorder (ADHD),
many parents attribute their children’s distracted, active, or disobedient behavior
to that disorder and fail to consider ways in which the child’s environment may
be eliciting and reinforcing the undesirable behavior. Differentiating between
ADHD and a behavior problem that developed primarily through learning
experiences requires careful observation of a child’s behavior in a variety of situ-
ations, as well as assessment of specific cognitive deficits (Gupta & Bhoomika,
2010). A therapist can interview each family member about attributions for
others’ behavior by asking questions such as “When you see her behaving like
that, what do you think causes that behavior?”
Similarly, the therapist can tap into individuals’ expectancies about events in
their relationships by asking questions such as, “When you think about [behav-
ing in a particular way], how do you think [particular family members] will
react?” It is important to identify how the person anticipates that others will
respond in the short term and in the long term, because the expectancies may
be different. For example, when Susan was asked how she believed her partner,
Michele, would react if Susan said she wanted to discuss possible changes in
their responsibilities for household tasks, she replied, “She would listen quietly
and would agree to do some chores more often.” However, when asked what
Michele might do later, Susan said, “She’d probably make me pay for it later by
turning me down when I want to go out to do something I enjoy.”
Assessing family members’ assumptions about each other and their relation-
ships involves asking questions about the characteristics that they believe certain
types of people have and questions about how they believe relationships function
(Dattilio, 2010; Epstein & Baucom, 2002). For example, some parents assume
that young children are incapable of depression, anxiety, and other strong emo-
tions that adults feel, so they do not consider that their children’s behavior
problems or academic difficulties may be influenced by such emotional responses
to life events. A therapist can ask a parent about his or her assumptions by using
questions such as “Your family recently moved here, leaving relatives and friends
behind. You mentioned that your son’s school problems started soon after you
moved. How do you think he has coped with the big changes in his life?”
Perhaps the parent would reply, “He complained about moving, but within a
couple days he was playing outside with the boy next door. Kids make new
friends easily, and they just move on with their lives.” The therapist might con-
tinue the inquiry into the parent’s assumption about the son’s emotional life by
saying, “You described how you have felt sad about leaving your friends. How
do you think your son’s experience of leaving his friends might compare with
yours?”
 Cognitive-Behavioral Therapies 283

An individual’s relationship standards can be assessed with questions in the

form of “How do you believe [some aspect of oneself, the partner, or the rela-
tionship] should be? If things could be just the way you want them to be, what
would it be like?” Alternatively, when an individual describes a characteristic of
his or her self, partner, or relationship, the therapist can ask, “How does that
compare with the way you want it to be?” (Dattilio, 2010; Epstein & Baucom,
2002). Inquiring about relationship standards is especially important when thera-
pists are working with couples and families with different cultural norms, sexual
and/or gender orientation, and/or spiritual beliefs from theirs, because this
assessment can inform therapists about their clients’ diverse standards. These
questions are also crucial when assessing relationships of partners or of parents
and children who differ in their cultural identity, sexual and/or gender orienta-
tion, or religiosity/spirituality.

Observation of Spontaneously Expressed Cognitions

Family members often spontaneously express some of their cognitions as they speak
to the therapist and one another. For example, clues to selective perception include
language such as “You always . . . ” and “You never . . . .” Attributions are com-
monly expressed with trait labels such as “You’re so selfish!” and descriptions of
others’ motives such as “You want to control my life.” Concerning expectancies,
an individual might spontaneously voice a prediction such as “If I count on you
to pick up after yourself, in a few days I won’t be able to see the floor of your
bedroom.” Assumptions tend to be expressed with statements about the ways that
things are (e.g., “Men are . . . ”), whereas standards tend to be expressed as condi-
tions that should exist (e.g., “You should want to do your fair share of the chores”).
However, a therapist must ask questions to pin down the individual’s specific mean-
ing rather than assume that he or she knows exactly what cognitions an individual’s
comments reflect.

Probing for Cognitions Associated with Emotional

and Behavioral Responses
During a couple or family therapy session, the therapist often will notice cues
that an individual is reacting to something that another person has said or done.
Sometimes there are verbal or nonverbal signs of an emotional response (e.g., a
pained facial expression), and sometimes the individual’s actions (e.g., turning
away) suggest that he or she is interpreting the other’s behavior in a negative
way. At such times, a therapist can gently interrupt the interaction, point out
the person’s response, and ask what the person was just thinking (Dattilio, 2010;
Epstein & Baucom, 2002). This “here and now” probing for cognitions is valu-
able, in that it gives the therapist opportunities to identify specific thoughts that
occur as family members interact. Catching cognitions as they occur often is
284 Norman B. Epstein and Mariana K. Falconier

preferable to asking family members to try to recall what they were thinking
during past upsetting experiences.
Meichenbaum’s (1977) work with self-statements (similar to automatic
thoughts) that influence individuals’ abilities to cope with stressful situations is
relevant for assessing and treating spontaneously occurring cognitions in family
interaction. Meichenbaum noted that the content of some cognitions interferes
with coping ability by fueling negative emotion and eliciting problematic behav-
ior. For example, when Barbara told Luke that she wanted to discuss a problem
in their relationship, Luke replied that he was too busy and began to walk out
of the room. As Barbara thought, “He can’t get away with ignoring me! He’s
not getting out of here!” she felt her anger rise and moved quickly to block
Luke’s path to the door. It is important to help family members identify their
internal dialogue, to see how it contributes to negative responses and to help
them practice more constructive self-statements.

Questionnaires
A number of self-report questionnaires have been developed to assess particular
types of relationship cognitions; for example, Eidelson and Epstein’s (1982)
Relationship Belief Inventory that assesses assumptions and standards, Roehling
and Robin’s (1986) Family Beliefs Inventory that assesses parents’ and adolescents’
unrealistic beliefs about their relationships, Pretzer et al.’s (1991) Marital Attitude
Survey that assesses attributions and expectancies, Fincham and Bradbury’s (1992)
Relationship Attribution Measure, and Baucom et al.’s (1996) Inventory of Specific
Relationship Standards. These scales have been used primarily in research, but
therapists can administer them to family members as a way of surveying particular
types of cognitions, which can be explored further during interviews.

Cognitive Restructuring Techniques

The overall goal of cognitive restructuring is to broaden each person’s ways of
thinking about his or her close relationships. Particular interventions tend to be
most useful for intervening with each type of cognition described previously.
Reducing selective perception. When the assessment indicates that an individual
is selectively attending to particular aspects of family interaction and overlooking
others, the therapist can ask the person, as a homework assignment, to keep a
daily written log of specific acts. This will influence the person to pay closer
attention to his or her family members’ behavior.

Brenda claimed that Carl rarely participated in child-care activities such

as dressing, feeding, and reading to their two young children. When she
was asked to monitor his specific child-care behavior each day for the
next week, she returned with a log that indicated some days with few
 Cognitive-Behavioral Therapies 285

such behaviors but other days in which Carl had engaged in several of
them. Of course, because Carl was aware that Brenda was keeping track
of his behavior, he may have increased his involvement, and Brenda told
the therapist that she attributed his child-care activity to “being on the
spot” and wanting to impress the therapist. Nevertheless, the therapist
emphasized that Carl did engage in child-care activities, he chose to do
so, and it would be helpful if Brenda could let him know that she appreci-
ated it rather than criticizing him about his motives. Similarly, therapists
can ask family members to monitor one another’s behaviors during therapy
sessions in order to counteract selective perceptions.

Modifying biased attributions. When it appears that an individual is making a

biased attribution about the cause of another’s responses, the therapist can ask
him or her to think of other possible explanations for the person’s actions.

When Brenda attributed Carl’s child-care behavior to his wanting to

impress the therapist, the therapist said that Brenda might be correct, but
that it was important not to jump to conclusions and to consider other
possible causes for his behavior. The therapist coached Brenda as she listed
a few other explanations, including the idea that the therapy had opened
Carl’s eyes to how overburdened she felt and that he was trying to improve
their parenting relationship. Direct feedback from the family member in
question also can help challenge an individual’s negative attribution. Carl
told Brenda that he had increased his child-care behavior primarily because
their discussions during therapy sessions made him think about how he
was missing out on time with their children, who would be growing up
quickly.

Modifying inaccurate expectancies. An individual who makes a negative prediction

about one or more family members can be asked to think back systematically to
similar past situations and whether those events unfolded as he or she now expects.
A second technique is to ask the person to keep a log of events during the next
week and to focus on the degree to which his or her predictions come true.
Finally, the therapist can coach the person in setting up a “behavioral experiment”
in which he or she intentionally tests the negative expectancy.

During a session with his wife, Lois, Ted predicted that their adolescent
daughter would talk excessively on the phone with her friends if he and
Lois stopped reminding her to keep her calls brief and gave her the
responsibility for monitoring her phone use. The couple agreed to try it,
however, and when they returned the next week, they reported that Karen
had surprised them by talking only a little more than they would have
preferred.
286 Norman B. Epstein and Mariana K. Falconier

Challenging unrealistic or extreme assumptions and standards. Because core beliefs

tend to be long-standing aspects of a person’s worldview, it likely will take time
and persistence to modify them (Dattilio, 2010). For example, an individual may
hold a standard that in an intimate couple relationship the partners should spend
virtually all of their free time together, and they should share all of their thoughts
and emotions with each other. This person may have become involved with a
partner who initially seemed to value togetherness just as much (early in their
relationship they were inseparable), but in fact who holds a standard that members
of a couple should have opportunities to develop some autonomous activities.
When the partner’s desire for some autonomy became clear, the individual
responded with great disappointment, anger, and attempts to coerce the partner
to spend more time together. A therapist might ask each member of this couple
to describe his or her standard about togetherness versus autonomy, how well
the standard was met in their relationship, and what specific behavior changes
would be needed to meet the standard adequately. As described earlier, differ-
ences in two partners’ standards for their relationship are not necessarily prob-
lematic as long as both people can accept some deviation from what they desire
most (Baucom et al., 1996).
The potential for meeting each person’s standards depends on whether the
standard is realistic and flexible or whether it is extreme and inflexible. Thus, if
the individual who wants a very high level of togetherness and open communica-
tion is unwilling to accept that the partner wants some degree of autonomy, the
couple will likely have great difficulty finding a mutually acceptable solution. As
Jacobson and Christensen (1996) have noted, resolving conflicts in a relationship
depends in part on each person’s acceptance of differences between their needs,
personalities, and so forth. Cognitive-behavioral therapists explore with each
person the advantages and disadvantages of clinging to a standard versus trying
to live by a “softened” version of the standard (Epstein & Baucom, 2002). Thus,
the individual who demands togetherness with the partner could be coached in
considering a standard such as “I greatly enjoy togetherness and open commu-
nication with my partner, but I realize that we can have a close relationship even
when my partner wants to have some independent activities and thoughts. The
key is that we are still the most important people in each other’s lives.”
As with other types of cognitions, one must often have direct experience
with living according to a revised standard before he or she finds it acceptable.
In the case we just described, when the therapist coached the individual in try-
ing intentional planning of independent as well as shared activities, the partner
was relieved by the reduced pressure and was in a better mood whenever the
couple spent time together. The pleasant times together also felt more intimate
to the person with the strong togetherness standard, which made the revised
standard easier to accept.
These have been examples of cognitive interventions, but no standard set of
techniques is used routinely. The therapist can be creative in helping family
 Cognitive-Behavioral Therapies 287

members consider the validity and appropriateness of their cognitions. The next
section describes behavioral interventions.

Behavioral Techniques
Based on social learning and social exchange theoretical principles, as well as
research findings described earlier, the major types of behavioral interventions
focus on (1) increasing exchanges of positive behavior and decreasing exchanges
of negative behavior among family members, (2) training in communication
skills, and (3) training in problem-solving skills. Each of these major types of
intervention is summarized in this section.
Therapists assess the behaviors that are in need of modification in each family
by observing the family members interacting during sessions, as well as by asking
the members to describe specific examples of the interactions that they find
distressing. A functional analysis involves observing sequences of behaviors in
family interaction and identifying both what behaviors of other family members
precede (tend to elicit) another’s problematic behavior and what behaviors of
other family members follow it (tend to reinforce or punish it).

Zhang Wei (age 30), his wife, Wang Xiu Ying (age 28), and their daughter,
Zhang Li (age 5), a Chinese family, had been living in the United States
for six months so that both parents could attend graduate school. They
were referred to a family therapist by Li’s school because her kindergarten
teacher had considerable difficulty managing her behavior. Both parents
were very embarrassed by the attention that Li’s behavior had drawn and
were frustrated about her increasing tantrums, which were occurring more
often in public places such as stores, as well as in school and at home. The
family therapist interviewed the parents in detail about the events that
typically occurred just before Li began a tantrum and after she started one.
The parents were visibly uncomfortable when describing their daughter’s
problematic behavior, stressing that she got a lot of positive attention from
both parents and from her paternal grandparents who lived with them,
but they detailed how typically a tantrum began after they told Li to stop
doing something that she was enjoying (e.g., playing with a toy, taking
packages of candy from store shelves). They explained that Li’s teacher
also described a pattern in which she became very upset and disobedient
when instructed to stop play activities in class. Wei and Xiu Ying also
noted that they usually tried to explain to Li why they wanted her to stop
what she was doing, and that sometimes they gave in (e.g., bought her
the candy) in order to end her embarrassing public display. To observe the
family interaction directly, the therapist asked the parents to instruct Li to
stop playing with a toy in the therapy room and to sit in a chair. After
the parents looked at each other for a few moments, Xiu Ying asked her
288 Norman B. Epstein and Mariana K. Falconier

daughter to please put the toy down and sit in the chair. Li resisted Xiu
Ying’s instructions and began whining. The mother tried talking to her
more, looked at her husband, and then stared at the therapist helplessly.
This assessment gave the therapist crucial information about the behavioral
patterns that needed to be changed to improve the family’s problem.

Changing frequencies of positive and negative behavior. The most widely used
technique for increasing positive exchanges and decreasing negative ones involves
setting up behavioral contracts among family members. Typically this is a
formal agreement, commonly written, that each person will enact particular
behaviors that another family member desires. Some contracts involve quid pro
quo agreements, in which a person commits to behaving in particular ways
that another person requests, with the understanding that in return the other
person will behave in ways that the first person requests. A limitation of this
approach is that one person’s failure to carry out his or her side of the contract
may lead the other person to void the agreement. Alternatively, couples can
be coached in forming good-faith agreements in which each person agrees
to change particular behaviors, whether or not the other person reciprocates
(Baucom & Epstein, 1990; Jacobson & Margolin, 1979).
In parenting training (e.g., Forgatch & Patterson, 2010; Kazdin, 2005;
Webster-Stratton & Herbert, 1994), parents are coached in setting up contracts
with their children, in which the child is expected to behave in particular ways
the parents desire, and to avoid behaving in particular negative ways, in return
for specified types of reinforcement. However, contracts of this type may not be
welcome in more collectivist cultures, in which it is expected that children and
other family members should be motivated to act in the best interest of the
family, rather than their own (Epstein et al., 2012). These parents initially may
be opposed to the suggestion that they provide a child rewards for behavior that
they view as the child’s obligation to the family. In such cases, therapists must
be culturally sensitive, discussing the parents’ beliefs with them and perhaps
reframing the contract as an initial means of establishing more cooperative
behavior in children who are not yet mature enough to understand the impor-
tance of contributing to the well-being of the family group.
A contract in which the parents have the authority to decide on the types
of behavior to be changed, as well as the types of reinforcement to be earned,
differs from an agreement between two adults, who may have equal power in
their relationship. Therapists generally encourage parents to use reinforcements
such as praise, time playing with the child, and other rewards that do not involve
spending money, although reinforcements involving small expenses (e.g., renting
a movie the child wants to see) can be effective. A contract can be formalized
by creating a behavior chart that lists the specific behaviors to be monitored
by the parents and includes spaces in which the parents indicate the frequency
with which the child exhibited each behavior during each day of the week.
 Cognitive-Behavioral Therapies 289

Parents can use a system in which occurrences of positive behaviors and days
without particular negative behaviors earn points toward a large reward. Punish-
ment for negative behavior can consist of temporary removal of particular
privileges or a time-out for younger children.
Communication skill training. Couples and families are coached in clear, con-
structive communication, involving both expressive skills and listening skills,
based on an assumption that good communication requires effective sending as
well as receiving of messages (Epstein & Baucom, 2002; Mueser & Gingrich,
2006). Guerney’s (1977) guidelines are among the most widely used for com-
munication training. In Guerney’s approach, two individuals practice taking
turns as the person expressing his or her thoughts and emotions and the person
listening empathically in order to understand the expresser’s experience. The
person in each role is coached in following guidelines for good communication.
For example, the expresser is supposed to describe his or her thoughts briefly,
using specific descriptive language. The expresser is to describe his or her
thoughts and emotions as subjective rather than as “the truth,” conveying that
the listener has the right to have other views. When describing dissatisfaction
with the listener’s behavior, the expresser should convey empathy for the listener’s
personal experiences. In turn, the listener’s job is to try to understand the
thoughts and emotions of the expresser (i.e., imagine how it feels to be in his
or her position). The listener is to avoid interrupting the expresser, criticizing
him or her, offering advice, and so forth. After the expresser has briefly described
his or her personal experience, the listener’s task is to “reflect” back what he
or she has heard. The expresser gives the listener feedback about the accuracy
of the reflecting, and they repeat the process until the communication has been
effective.
In addition to providing coaching in expressive and listening skills, therapists
observe each family and identify other specific verbal and nonverbal behaviors
to target for change. For example, if members of a family make little eye contact
with one another as they talk, the therapist will coach them in increasing it.
Therapists teach families these communication skills by describing them briefly,
demonstrating the skills, and coaching family members as they practice them
during therapy sessions. Family members continue to practice the skills as home-
work between sessions. Communication training is widely used in cognitive-
behavioral couple and family therapy (Epstein et al., 1988; Markman, Stanley, &
Blumberg, 2010; Mueser & Gingrich, 2006; Robin & Foster, 1989).
Problem-solving training. Whereas communication training focuses on messages
about each family member’s thoughts and emotions, problem-solving training
deals with steps that family members need to take in order to find mutually
acceptable solutions to problems they face together. Some problems involve
people or circumstances outside the family (e.g., a member’s job demands), whereas
others involve issues within the family (e.g., partners’ different approaches to
handling family finances). Cognitive-behavioral therapists (e.g., Epstein & Baucom,
290 Norman B. Epstein and Mariana K. Falconier

2002; Jacobson & Christensen, 1996; Mueser & Gingrich, 2006; Robin & Foster,
1989) teach couples and families a series of steps, including

(1) defining the nature of the problem clearly and specifically, in behavioral terms
(the “who, what, when, and where”),
(2) brainstorming a variety of possible solutions to the problem (without evaluat-
ing them at this point),
(3) discussing advantages and disadvantages of each potential solution, in terms of
costs and benefits to all parties involved,
(4) choosing a solution (or combination of two or more solutions) acceptable to
all, based on the cost-benefit analysis (step 3),
(5) implementing the solution between sessions, and
(6) evaluating its effectiveness. Solutions that turn out to be inadequate are
reconsidered and revised as needed.

In addition, increasing attention has been paid to helping couples develop

more effective dyadic coping strategies for dealing with stressors in their life
together (Bodenmann, 2005). In contrast to problem-focused coping styles (e.g.,
looking for a new job when one has lost a job) and emotion-focused coping
styles (e.g., exercising to reduce emotional distress) that each individual may use,
forms of dyadic coping include the partners assisting each other or working
cooperatively to reduce or overcome a stressor (Bodenmann, 2005). The forms
of dyadic coping that are acceptable and used by couples can be influenced by
cultural beliefs regarding gender roles in intimate relationships (e.g., whether it
is considered acceptable for a wife to give her husband suggestions for coping
with his job stresses) (Falconier, 2013).

Techniques Focused on Emotions

When a therapist determines that an individual is failing to monitor his or her
emotional states, and thus cannot communicate about them to family members,
the therapist coaches the person in paying attention to cues that he or she is
having emotional experiences. For example, the therapist noticed that Alan
sometimes showed nonverbal signs of sadness when his teenage children criticized
his life philosophy and personal habits. When the therapist asked him how he
was feeling, Alan replied that he was disappointed in them but did not feel any
emotions about it. The therapist gave him feedback about his facial expressions
and his slumped posture at such times, asking him to pay attention to how his body
felt. Alan began to notice a “heavy feeling” in his body and a tightness in his
throat. The therapist continued to coach him in noticing his bodily cues and
thinking about the thoughts and emotions associated with them.
As described earlier, some people have difficulty with emotion regulation, or
the ability to keep emotional arousal from reaching a level so high that it
 Cognitive-Behavioral Therapies 291

interferes with constructive thinking and behavior. For some individuals, deficits
in emotion regulation constitute a lifelong trait that probably calls for individual
therapy, whereas for others it may result from faulty learning of skills that can
be practiced in family therapy. For example, some family members who engage
in angry outbursts characterized by verbal aggression but who pose no danger
of physical violence to one another may be treated jointly with interventions
focused on anger management (e.g., relaxation training, anger control self-
statements, use of “time-outs” in which partners temporarily go to separate
locations and “cool off,” and communication training) (e.g., Heyman & Neidig,
1997; LaTaillade et al., 2006). Meichenbaum (1977) and Deffenbacher (1996)
use a stress inoculation approach in which individuals rehearse self-statements
that calm them (e.g., “Stay calm. You don’t have to react to his provocative
behavior”) and that direct their behavior (e.g., “Speak slowly and don’t raise
your voice”), and those techniques can be used in conjoint couple and family
therapy sessions as well.

Cognitive-Behavioral Couple and Family Therapy

for a Diverse Population
Couple and family therapists are likely to treat clients who are diverse in terms
of race, ethnicity, income, education, age, sexual orientation, gender identification,
and level of physical/intellectual functioning. This cultural diversity requires that
therapists be culturally competent (Sue, 2006) by (a) being aware of their own
cultural values, beliefs, and biases that are based on their own and their clients’
cultural backgrounds, (b) understanding the worldviews of the cultures that
clients identify with, and (c) applying interventions that are consistent and
respectful of the cultural beliefs and traditions that clients want to uphold.

Awareness of One’s Own Cultural Values, Beliefs, and Biases

Identifying their own cultural values and beliefs as well as their biases about
other cultural groups is the first step for therapists in preventing those cognitions
from affecting the therapeutic process. For example, a therapist may inadvertently
treat clients differently who are affiliated with a religion toward which he or
she is negatively biased. Similarly, a middle-class therapist who grew up in a
social context that portrayed individuals from lower socioeconomic groups as
dangerous or unreliable may maintain distance from clients belonging to that
group, which may be expressed even in the way he or she greets these clients.
When therapists raise their awareness about their own biases and beliefs, they
can challenge them and prevent them from affecting the therapeutic process.
CBT with couples and families provides a theoretical framework for understand-
ing therapists’ schemas, as well as tools with which therapists may challenge their
own cognitive distortions. Our biases about other cultural groups, both positive
292 Norman B. Epstein and Mariana K. Falconier

and negative, stem from distorted cognitions such as selective perceptions, over-
generalizations, inaccurate attributions, and unfounded assumptions. Cognitive
restructuring procedures may help therapists challenge their own schemas about
other cultural groups, which is likely to modify their habitual responses to indi-
viduals in those groups. A therapist who becomes aware of his or her learned
responses and the cognitive schemas accompanying them might be in a better
position to assist clients.

Understanding Clients’ Worldviews

As noted earlier, therapists can learn about their clients’ values, beliefs, and tradi-
tions by asking about them. Therapists also can learn by observing clients’
behaviors. For example, in some cultures physical contact in public is avoided,
and clients would not be comfortable shaking hands with a therapist, whereas
in other cultures physical expressions of affection are favored, and clients may
try to hug or kiss the therapist good-bye. It is also important that couple and
family therapists try to learn about the particular cultural groups their clients
belong to by educating themselves through reading, watching videos, or immers-
ing themselves in a cultural activity (e.g., attending a ritual ceremony, a school,
a family meeting, or a community fair). These experiences will increase the
therapist’s knowledge about norms and traditions in the clients’ culture, which
must be taken into account in assessing whether family patterns that may be
considered abnormal in the therapist’s culture are normative within the clients’
worldviews. For example, in the case of the Chinese family described previously,
it was important for the therapist to be aware that Chinese families typically are
reluctant to expose family problems to outsiders, try to avoid loss of face, and
focus considerable positive attention on children (Epstein et al., 2012).

Applying Culturally Sensitive Intervention

Cognitive-behavioral therapy interventions have been applied to diverse popu-
lations, including Latino (Aguilera, Garza, & Muñoz, 2010; Duarte-Vélez,
Bernal, & Bonilla, 2010; Gelman, López, & Foster, 2005), African American
(Gore & Carter, 2003; LaTaillade, 2006), and Asian clients (Dattilio & Bahadur,
2005; Epstein et al., 2012) (for a review of CBT applied across all ethnic minori-
ties, see Voss Horrell, 2008), LGBT clients (e.g., Martell, Safren, & Prince, 2004;
Safren & Rogers, 2001), and clients with intellectual disabilities (for a review, see
Nicoll, Beail, & Saxon, 2013). Cognitive-behavioral couple therapists who work
with minority populations focus on the cultural sensitivity of their interventions
by evaluating whether they are consistent with their clients’ values, beliefs, tradi-
tions, and worldviews. For example, when working with clients from societies
with more traditional gender roles and more hierarchical family structures,
therapists might discuss with parents (and often a father) the possibility of using
 Cognitive-Behavioral Therapies 293

behavioral contracts or engaging the whole family in joint problem solving

before assuming that the family will welcome a democratic approach that involves
negotiations. Similarly, interventions that prioritize an individual’s needs and
desires might not be welcomed by clients from more collectivistic groups, for
whom communal goals may be prioritized.

Research on Cognitive-Behavioral Couple

and Family Therapy
Because behavioral therapies had their roots in laboratory research on animal
and human learning, with a focus on objectively measurable changes in specific
behaviors, behaviorists have a tradition of emphasizing that therapy procedures
should be based on sound evidence showing that they are effective. A similar
strong record of research on the role of cognition in individual and relationship
problems has strengthened the foundations of cognitive therapies. Consequently,
there has been more empirical research on the effectiveness of behavioral and
cognitive-behavioral couple and family treatments than on any other approach,
with the notable exception of the well-researched emotion-focused therapy (EFT)
approach (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Dunn & Schwebel,
1995; Gurman, 2013; Lebow, Chambers, Christensen, & Johnson, 2012; Shadish
& Baldwin, 2003, 2005). In addition to studies of treatments clearly labeled as
“behavioral” or “cognitive-behavioral,” Alexander and his colleagues have com-
piled research support for their functional family therapy approach, which in
practice is to a great extent a cognitive-behavioral approach involving commu-
nication training and behavioral contracting (Alexander et al., 2013).

Research on Cognitive-Behavioral Couple Therapy

for Relationship Distress
The vast majority of the studies demonstrating that CBCT is more effective in
improving self-reported relationship satisfaction than a no-treatment “waiting
list” control condition and placebo or “nonspecific” treatments (e.g., having
couples discuss their issues without intervening actively) have included primarily
behavioral interventions including some form of behavioral contracting, com-
munication training, and problem-solving training (Baucom et al., 1998; Dunn &
Schwebel, 1995; Lebow et al., 2012; Shadish & Baldwin, 2003, 2005). When
studies have compared the effectiveness of the major components of behavioral
marital therapy (communication training, problem-solving training, behavioral
contracts), they have been found to be equally effective, although small sample
sizes in these studies may have limited their ability to detect treatment differences
(Baucom et al., 1998; Hahlweg & Markman, 1988; Shadish et al., 1993). The
positive effects of behavioral interventions tend to last through one-year follow-
up assessments, but approximately one-third of the improved couples relapse over
294 Norman B. Epstein and Mariana K. Falconier

the next few years. When researchers have assessed not only statistically significant
change but also how many treated individuals score in the non-distressed range
on marital adjustment questionnaires, studies have shown that between approxi-
mately one-third and one-half met the latter criterion. It is important to note
that the studies involved an average of 11 therapy sessions (based on research
design considerations), which may not be adequate treatment for many distressed
couples.
Those couple therapy protocols included little or no cognitive restructuring
or interventions intended to address inhibited or unregulated emotional responses
that are important foci in the more recent Enhanced Cognitive-Behavioral
Couple Therapy (ECBCT; Baucom, Epstein, LaTaillade, & Kirby, 2008; Epstein &
Baucom, 2002). However, a few studies examined outcomes for cognitive
restructuring interventions. Huber and Milstein’s (1985) study compared a cog-
nitive intervention focused on reducing partners’ unrealistic relationship beliefs
(assumptions and standards) with a wait-list control condition, and the findings
indicated that the cognitive intervention produced more realistic beliefs and
higher relationship satisfaction than the control condition did. Halford, Sanders,
and Behrens (1993) compared twelve to fifteen 90-minute sessions of traditional
behavioral marital therapy with an enhanced behavioral intervention that included
cognitive restructuring, exploration of partners’ emotional responses associated
with negative couple interactions, and treatment generalization enhancement.
The cognitive restructuring involved identifying each partner’s maladaptive rela-
tionship beliefs and attributions and then using cognitive therapy Socratic ques-
tioning to challenging those negative cognitions, as well as some self-instructional
training. The amount of each type of intervention in the integrative treatment
varied according to the therapists’ assessment of each couple’s needs. Both the
traditional behavioral marital therapy and the integrative treatment condition
decreased couples’ negative behavior and cognitions, but those changes were not
significantly correlated with increases in their relationship satisfaction. The amount
of cognitive restructuring was not specified, and the study’s design does not allow
conclusions about the degree to which cognitive restructuring contributed to
improvement in the couples’ relationships.
Two studies by Baucom and colleagues (Baucom & Lester, 1986; Baucom,
Sayers, & Sher, 1990) have been cited frequently as demonstrations of the degree
to which cognitive restructuring can contribute to effectiveness of couple therapy.
Baucom and colleagues investigated whether adding cognitive restructuring
modules to the behavioral components of contracting, communication training,
and problem-solving training would increase positive effects of behavioral marital
therapy. The cognitive restructuring that they used involved sessions meant to
educate partners about attributions and guide them in identifying negative
attributions they made about causes of problems in their own relationships, plus
sessions meant to teach couples about unrealistic relationship beliefs that might
be affecting their relationship and guide them in identifying their own unrealistic
 Cognitive-Behavioral Therapies 295

beliefs. The study design involved comparison of different combinations of

behavioral and cognitive interventions, to determine whether a combination
treatment would be more effective than solely behavioral couple sessions. In
order to keep the total number of sessions constant across treatment conditions,
the researchers replaced some sessions of behavioral interventions with sessions
of cognitive restructuring. Baucom et al. (1990) provided couples in all treatment
conditions with 12 weekly sessions. The behavioral marital therapy alone condition
included 12 sessions of communication skills training, problem-solving, and quid
pro quo contracts, whereas the cognitive restructuring plus behavioral marital therapy
condition included six sessions of cognitive restructuring (three on attributions,
two on unrealistic relationship standards, and a final session integrating cognitive
restructuring concepts) followed by six sessions of the behavioral interventions.
Finally, the cognitive restructuring plus behavioral marital therapy plus emotional expres-
siveness training (skills for expressing emotions and listening empathically) condition
included three sessions of each of the three components.
Overall, findings from the studies by Baucom and colleagues indicated that
cognitive interventions tended to produce more cognitive change, whereas behav-
ioral interventions produced more behavioral change, but all of the active treat-
ment conditions increased relationship satisfaction more than the wait-list control
condition, and all the active treatment conditions were equally effective. Some
writers concluded that such findings indicate that cognitive restructuring does
not enhance the effects of behavioral interventions (Baucom et al., 1998; Halford
et al., 1993), but it is important to note that substituting cognitive restructuring
sessions for behavioral intervention sessions produced equal overall effectiveness.
Furthermore, the very small number of sessions of each type of intervention that
were allowed in the combination treatment conditions may have weakened the
effectiveness of each component. Epstein (2001) noted that research is needed
on a truly integrated CBCT that provides adequate intervention for each couple’s
particular cognitive, behavioral, and affective problems. Furthermore, Whisman
and Snyder (1997) pointed out that tests of cognitive interventions have been
limited by a failure to assess the variety of problematic cognitions (selective
attention, expectancies, attributions, assumptions, and standards) that Baucom
et al. (1989) identified as influencing relationship quality. The few existing studies
examining effects of cognitive interventions also have been limited to samples
of predominantly White middle-class couples, so their effectiveness with other
racial and socioeconomic groups is unknown, an issue of concern for examining
cultural sensitivity of the treatment.
A survey of the practice characteristics of clinical members of the American
Association for Marriage and Family Therapy (Northey, 2002) indicated that
cognitive-behavioral interventions were the treatments most commonly used.
Nevertheless, in spite of the widespread enthusiasm for cognitive-behavioral therapy,
the strong body of empirical support for behavioral interventions, and the encour-
aging findings from the existing outcome studies examining cognitive interventions,
296 Norman B. Epstein and Mariana K. Falconier

there is a need for more outcome research, especially investigating the effects of
integrative approaches that address behavior, cognition, and emotion.

Research on Cognitive-Behavioral Couple Therapy

for Specific Clinical Problems
CBCT also has been evaluated as either a sole treatment or an adjunctive treat-
ment component for a number of clinical problems, involving both relational
issues and disorders of individual functioning. The following is a brief overview
of that research.
As noted previously, CBCT has been used to treat couples who exhibit psy-
chological and mild to moderate physical aggression (Heyman & Neidig, 1997;
LaTaillade et al., 2006). Partners are provided psychoeducation about partner
aggression and its negative consequences, taught strategies for anger management
(e.g., self-soothing practices, nonaggressive self-talk, and use of “time-outs” to
de-escalate aggressive interactions), and coached in skills for constructive com-
munication, problem solving, and modifying aggression-eliciting cognitions. The
Couples Abuse Prevention Program interventions conducted by Epstein and
colleagues (Hrapczynski, Epstein, Werlinich, & LaTaillade, 2011; LaTaillade et al.,
2006) in a racially and socioeconomically diverse community clinic sample
produced improvements in relationship satisfaction, negative attributions, trust,
self-reported partner aggression, and observed negative communication behavior.
Change in negative attributions was associated with decreases in aggression, but
the study did not identify the relative contributions of the treatment components
to those outcomes, and further research is needed to identify the degree to which
modification of cognitions helps.
Another application of CBCT for relational problems has been Baucom,
Snyder, and Gordon’s (2009) empirically supported, largely CBT-based program
for couples experiencing infidelity. The interventions help partners cope with
traumatic aspects of the experiences, gain insight into factors that led to the
affair, make good decisions regarding the future of the relationship, and develop
strategies and skills for reducing risk factors if they choose to continue the
relationship.
CBCT also has been used to address forms of individual psychopathology. For
example, studies by Beach and O’Leary (1992) and Jacobson, Fruzzetti, Dobson,
Whisman, and Hops (1993) indicated that behavioral marital therapy improved
both the depression symptoms and marital distress of women who presented with
both problems and whose marital problems appeared to be a major factor in their
depression. The CBCT interventions are designed to decrease negative couple
interactions and enhance mutual emotional support (Beach, Dreifuss, Franklin,
Kamen, & Gabriel, 2008; Whisman & Beach, 2012). Similarly, CBCT approaches
have been used as an adjunctive intervention with standard individual or group
CBT treatments for anxiety disorders. For example, Chambless (2012) uses couple
 Cognitive-Behavioral Therapies 297

therapy that includes psychoeducation about the partner’s anxiety disorder and
how anxiety symptoms affect and are commonly affected by couple interactions.
The couple therapy also includes communication skills training, problem-solving
training, preparation for coping with symptoms, and reduction of patterns in
which the couple have accommodated their daily interactions to the individual’s
anxiety symptoms. Monson and Fredman’s (2012) empirically supported cognitive-
behavioral conjoint therapy for post-traumatic stress disorder (PTSD) also includes
psychoeducation regarding mutual influences between an individual’s symptoms
and the couple’s interactions, building positives in the relationship, improving
emotion regulation, using communication skills to reduce the individual’s emo-
tional numbing and avoidance, improving the couple’s problem-solving skills, and
cognitive restructuring to reduce beliefs that maintain PTSD symptoms and
relationship problems. Another application of CBCT with individual psychopa-
thology is Bulik, Baucom, Kirby, and Pisetsky’s (2011) program for anorexia
nervosa that combines interventions specific to the eating disorder (e.g., the partner
provides emotional support to the individual specifically to reinforce appropriate
eating and other healthy behaviors) with traditional CBCT procedures of problem-
solving and communication skill training. Finally, Birchler, Fals-Stewart, and
O’Farrell (2008) developed an empirically supported program that integrates
behavioral couple therapy (increasing exchanges of pleasing and caring behavior,
increasing sharing of activities that are rewarding to both partners, improving
communication and problem-solving skills, avoiding threats of separation, focusing
on the present, avoiding physical aggression) with interventions focused on a
partner’s substance use (e.g., self-help meetings, medication, behavioral contracts
between partners to promote the individual’s abstinence).
Another important application of CBCT to stressors in couples’ lives is its
use in assisting couples who are dealing with severe physical illness. For example,
Baucom, Porter, et al. (2009) developed a CBT-based relationship-enhancement
program for women who are being treated for breast cancer and their male
partners. Couples are taught expressive and listening communication skills that
are applied to cancer-related topics (e.g., fear of mortality, medical decisions).
They also are taught problem-solving skills relevant to making medical treatment
decisions. Furthermore, they are given psychoeducation regarding the psychologi-
cal and physical effects of cancer treatments on sexual functioning and are helped
to find meaning and growth in their experiences with cancer. Thus, CBCT is
an adaptive, integrative approach to treating a wide variety of stressors that
couples experience both within and outside their relationships.

Research on Cognitive-Behavioral Family Therapy

In contrast to couple therapy, which often is motivated by partners’ overall
unhappiness and conflict within their relationship due to differences in their
needs, preferences, and communication styles, cognitive-behavioral family therapy
298 Norman B. Epstein and Mariana K. Falconier

(CBFT) approaches more commonly have focused on the treatment of particular

problems or disorders in individual family members—in particular, children and
adolescents. There has been strong empirical support for the efficacy of training
parents in behavioral interventions for children’s conduct disorders (Forgatch &
Patterson, 2010; Kazdin, 2005), based on the social learning principles described
earlier in this chapter, including Patterson and colleagues’ concept of the “coercive
family system.” Functional family therapy also has been demonstrated to be
effective in reducing adolescents’ aggression and substance abuse (Alexander et
al., 2013; Henggeler & Sheidow, 2012). Because Estrada and Pinsof (1995) noted
a high attrition rate among families in studies of this approach, it appears that
clinicians need to be careful to establish positive therapeutic connections with
parents who enter therapy feeling inadequate and who may easily feel threatened
if they perceive their parenting skills are being criticized.
Research also has provided evidence for positive effects of behavioral family
therapy for childhood attention deficit/hyperactivity disorder (ADHD) (Kaslow,
Broth, Smith, & Collins, 2012). Typically the family-oriented interventions of
training parents in dealing with the child’s symptoms of inattention, impulsivity,
hyperactivity and noncompliance are used in combination with interventions
that focus on those symptoms (e.g., medication and self-control training) (Barkley,
1998). CBFT also has been found to be effective in treating childhood anxiety
disorders (Kaslow et al., 2012). Finally, the behavioral couple therapy approach
that O’Farrell and his colleagues use to treat alcohol abuse also has been applied
to family treatment of substance abuse (O’Farrell, Murphy, Alter, & Fals-Stewart,
2010).
Behavioral family therapy has been empirically supported for major mental
disorders in adolescents and adults, including schizophrenia and bipolar disorder
(Miklowitz & Goldstein, 1997; Mueser & Gingrich, 2006). It typically includes
CBFT-derived

(a) psychoeducation concerning etiology, symptoms, risk factors for symp-

tom exacerbation (e.g., life stresses, including family conflict), and evidence
regarding effective treatments;
(b) communication skill training;
(c) problem-solving skill training; and
(d) management of relapses and crises.

Studies in several countries with racially and socioeconomically diverse families

have demonstrated that this approach is effective in reducing family stress and
patient relapse (Baucom et al., 1998; Lucksted, McFarlane, Downing, Dixon, &
Adams, 2012).
CBFT has been applied to the treatment of a variety of problems, and research
has demonstrated its effectiveness. More research is needed to examine the effects
of CBFT on families’ difficulties in adapting to developmental life-stage changes
 Cognitive-Behavioral Therapies 299

(e.g., children reaching adolescence; formation of stepfamily relationships) and

in coping with external stressors such as parental unemployment. Furthermore,
more attention is needed to developing methods for assessing family members’
cognitions about each other and to testing the effectiveness of interventions for
modifying cognitions that contribute to family conflict.

Case Study
Earlier, the case of Wei, Xiu Ying, and their five-year-old daughter Li was
described briefly as an example of how a therapist uses a functional
analysis to identify how an individual’s problematic behavior may be
influenced by both the behaviors of family members that precede it and
those that are consequences of it. Li’s tantrums in school, public places,
and at home tended to occur after her teacher or parents instructed her
to stop doing something that she was enjoying, such as playing with a
toy or handling packages of candy in a store. When the therapist asked
Wei and Xiu Ying how they typically responded to Li’s initial refusal to
follow their directions, Wei sat quietly and Xiu Ying reported that she
tried to explain to Li why she wanted her to stop her behavior (for
example, “Li, put the candy back. We already have a lot of candy at
home, so you don’t need any more”). Xiu Ying noted that both she and
Wei spent many hours at the university working, and Wei’s parents pro-
vided a lot of the child care during the day. She looked at Wei and uneasily
stated that Li’s grandparents often spoiled Li (their only grandchild), letting
her do what she pleased. In addition, when Li continued her misbehavior
in public, Xiu Ying and Wei were embarrassed and could not think of
anything more effective to stop her, so they sometimes bought Li what
she wanted. The therapist took note of the associations between the
parents’ responses and the child’s negative behavior and formed a hypoth-
esis that among the factors operating in this family’s problem were (1) the
grandparents had developed Li’s expectancy that she would receive things
that she desired (with minimal limits set on rewards), (2) the parents had
no effective means of punishing Li for tantrum behavior, and (3) the
parents were unwittingly reinforcing Li’s tantrums by giving her things
that she wanted whenever she behaved sufficiently aversively. In fact, it
appeared that the parents were providing intermittent reinforcement for
Li’s whining and tantrum behavior by trying to ignore it for a while and
then providing the rewards.
As noted earlier, the therapist also conducted a functional analysis by
observing the family interaction after instructing Wei and Xiu Ying to get
Li to stop playing with a toy in the therapy room and sit still. Consistent
300 Norman B. Epstein and Mariana K. Falconier

with the parents’ reports of what occurred at home, at school, and in

public, Xiu Ying began by saying, “Li, please put the toy down and come
sit in this chair next to me. It’s very important for us to all talk together.”
When Li ignored her, Xiu Ying repeated herself twice, each time looking
over at the therapist and Wei and showing more discomfort. “Li, listen
to me now! Will you please put the toy down and come over here?” As
Li continued to ignore Xiu Ying, the therapist turned to Wei, asking him
how Li tends to respond to his directions, and Wei responded that he
usually leaves it to Xiu Ying as the child’s mother to manage her behavior.
At this point, both parents looked embarrassed as they glanced in the
therapist’s direction. The therapist also asked the parents whether they
had suggested to Wei’s parents that they establish firmer limits with Li.
Wei was silent, and Xiu Ying stated, “My husband’s parents do so much
for us. They take care of our home and child while we are at the university.
We appreciate that very much.”
Thus, in this behavioral assessment, the therapist gathered detailed
information about the family interaction patterns associated with Li’s
problematic behavior, using both self-reports from the parents and direct
observation of parent-child interactions. The data suggested that the child
had learned that she could do much as she pleased, because on the one
hand her grandparents were overly giving and implemented no conse-
quences for negative behavior, and on the other hand Xiu Ying was for
the most part the only parent trying to set limits and was also using
ineffective techniques. When the adults gave in to the child’s tantrum
behavior, they experienced relief when the tantrum stopped (negative
reinforcement for them), and Li received positive reinforcement (e.g., more
time to play with a toy) for her negative behavior. In other words, there
was a circular causal pattern in which the parents and the child were
influencing each other’s behavior. Xiu Ying and Wei might have benefited
from some parenting training in the use of time-outs and other forms of
nonaggressive punishment for Li’s negative behavior, as well as the use of
positive reinforcement whenever she behaved in desirable ways. However,
as long as Wei remained uninvolved in setting limits for Li and left that
responsibility to Xiu Ying, Xiu Ying’s effectiveness could be compromised.
Furthermore, as long as the grandparents continued to set no limits on
Li, that would limit the overall effectiveness of changes in Wei and Xiu
Ying’s parenting behavior.
Although the therapist might have intervened directly with a couple
from a Western cultural background to coach Wei in becoming a parent-
ing partner with Xiu Ying and might have encouraged the couple to put
pressure on Wei’s parents to cooperate with the new child management
 Cognitive-Behavioral Therapies 301

plans, the therapist was aware of traditional Chinese family roles and
patterns that still often are male-dominated and in which grandparents
have significant status in helping couples raise young children. Rather
than risk an uncomfortable confrontation with the couple and possibly
damage the therapeutic alliance, the therapist decided to use a more
indirect approach by appealing to the couple’s cultural values.
The therapist inquired about the parents’ assumptions and standards
concerning appropriate child behavior and how they wanted Li to behave
in school and as a member of society. Both parents noted how important
education is for success in life, adding that they wanted Li to grow up
to be a cooperative member of society and a very successful student. The
therapist commented that an individual’s contribution to harmony in
relationships is important, reflecting a core Chinese value (Epstein et al.,
2012), and the parents agreed. The therapist also noted that being a
successful student involves paying good attention to teachers and doing
one’s work, and children begin to learn those skills in kindergarten. Parents
can help young children prepare for good classroom performance and
eventual good performance in adult life roles by shaping their ability to
respond to authority figures’ requests. Wei and Xiu Ying seemed to be
“on board” with this line of thinking, so the therapist continued by pre-
senting psychoeducation about parenting strategies that have been found
to be appropriate for children at Li’s developmental stage. The therapist
focused on scientific knowledge about parenting, in order to appeal to
the couple’s respect for education and professional expertise. This discus-
sion also touched on both parents’ assumption that children of Li’s age
are able to understand and appreciate logical explanations for behavioral
rules, which had resulted in their repeated ineffective attempts to reason
with her about proper behavior. They also held a standard that “loving
parents try to protect their children from experiencing frustration and
emotional distress,” so they easily felt guilty or ashamed about disciplining
Li if it appeared that it made her very upset.
Because the therapist had noticed that Wei was minimally active in
parenting during the family session, she had a goal of increasing his
involvement without challenging the roles in the family. She described
to the couple how children learn best when they have consistent feedback
regarding their behavior from the adults in their environment. The therapist
pointed out that she had noticed that when Xiu Ying gave Li instructions,
Li looked at Wei to see his reaction. The therapist said, “Wei, it is easy to
see that you are a very important person in Li’s life, and she looks for
your reactions. It seems to me that if you show her that you and Xiu
Ying are a close team, and that when Xiu Ying tells her something, she
302 Norman B. Epstein and Mariana K. Falconier

is speaking for both of you, Li will get a strong message about the expec-
tations that both of you have for her. One way that you can give Li that
message is to give her similar instructions and to tell her that she must
obey her mother. Wei and Xiu Ying, you are both smart and successful
people, and Li is lucky that she can learn a lot from both of you.” The
therapist then followed up this cognitive intervention with systematic
coaching of the parents in using effective parenting behavior in sessions
and planning “homework” for extending it to daily life.
The therapist addressed the boundary issue regarding the grandpar-
ents’ influence on Li’s behavior in a similar manner. She affirmed to Wei
and Xiu Ying that Wei’s parents were very helpful to the couple and
conveyed that she was familiar with the importance of grandparents in
Chinese families. At the same time, however, the therapist suggested
that Wei could encourage his parents to help Xiu Ying and him prepare
Li to be a better student by giving her practice in following directions
and cooperating with authority figures. This way of construing the guid-
ance to be given to his parents was probably more palatable for Wei
than any suggestion that he reduce their place in the family hierarchy
would have been.
The therapist then guided Wei and Xiu Ying in devising a simple
behavior chart with a list of two types of behavior that they wanted Li
to increase (make eye contact with parents when they address her, obey
requests such as “put the toy back on the shelf”) and three types of
behavior that they wanted her to decrease (whining, stomping her feet,
and screaming). With coaching, the couple drew the chart on a sheet
of paper, explained it to Li, and took it home to be posted on their
refrigerator. The therapist also guided the parents in thinking of specific
consequences, involving punishment for instances of negative behavior
and reinforcement of positive behavior, that they would use at home.
The therapist described the use of time-out procedures, and the parents
also agreed to try taking away for brief periods some of Li’s privileges
for instances of negative behavior. The therapist and the couple identi-
fied privileges (e.g., TV watching) that the couple felt comfortable
withdrawing temporarily, as well as small but meaningful rewards
(e.g., praise and hugs) that they could give Li when she exhibited desired
behavior. The parents also agreed to draw a star on Li’s behavior chart
each time she exhibited a desired behavior, and she earned rewards
(e.g., renting a movie, playing a game with a parent) for reaching
particular point totals.
The therapist stressed the importance of gradually shaping Li’s positive
behaviors rather than expecting her to make major changes suddenly.
 Cognitive-Behavioral Therapies 303

Xiu Ying and Wei agreed that initially they would immediately praise Li
if she complied at least partly with a request (e.g., putting some toys
away). The therapist emphasized the importance of being consistent in
providing negative consequences for any instances of noncompliance and
tantrum behavior. She encouraged the parents to communicate more at
home regarding their work with Li, using expressive and listening skills,
and they decided to schedule a 15-minute “check in” with each other
each evening after Li was asleep.

Recommended Readings
Baucom, D. H., Snyder, D. K., & Gordon, K. (2009). Helping couples get past the affair: A
clinician’s guide. New York, NY: Guilford Press.
Dattilio, F. M. (2010). Cognitive-behavioral therapy with couples and families: A comprehensive
guide for clinicians. New York, NY: Guilford Press.
Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples:
A contextual approach. Washington, DC: American Psychological Association.
Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. New York,
NY: W. W. Norton.
Miklowitz, D. J. (2002). The bipolar disorder survival guide: What you and your family need
to know. New York, NY: Guilford Press.
Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for PTSD.
New York, NY: Guilford Press.
Rathus, J. H., & Sanderson, W. C. (1999). Marital distress: Cognitive behavioral interventions
for couples. Northvale, NJ: Jason Aronson.

Glossary
acceptance: An individual’s attitude that a family member’s personal characteristic
or behavior falls within the range of his or her personal standards of how that
person should be; in contrast to an attitude that that person should change.

adjunctive intervention: A therapeutic technique that is added to enhance an

existing treatment by addressing an aspect of clients’ needs that is not adequately
addressed by the primary treatment.

agentic or individual-oriented needs: A person’s basic needs that involve

functioning and growth as an individual; for example, a need for autonomy.

assumption: An individual’s basic belief or schema about typical characteristics

of people and objects; for example, an assumption that men are generally unaware
of their feelings.
304 Norman B. Epstein and Mariana K. Falconier

attribution: An individual’s inference, that can vary in validity, about an unobserved

cause of an observed event, such as the cause of a spouse’s or a child’s sarcastic
remark.

automatic thoughts: Stream-of-consciousness thoughts that run through a

person’s mind and seem plausible to the person, whether or not they are accurate
or valid.

aversive control: An individual’s use of threats, criticism, and punishment to

control another person’s behavior.

behavior chart: A chart to log instances of specific behavior enacted by a family

member each day; most often used to log a child’s behaviors that parents want
to increase or decrease.

behavioral assessment: Monitoring frequencies of family members’ specific

acts and circumstances that precede and follow them, through family members’
observations and logs of their interactions at home, or therapist observation of
family interactions during sessions.

behavioral contract: A formal or informal written or oral agreement among

family members for each person to enact particular behaviors that are desired
by the others.

boundary: A degree of psychological or physical separation between people in

a relationship, such as the degree to which family members share personal
thoughts and feelings with each other.

cascade: A sequence in which one type of behavior by a member of a couple

or family leads to another type of behavior by another member, and over time
there is a positive or negative trend to the pattern; for example, when criticism
by one person leads to defensiveness by the recipient, which produces more
criticism, more defensiveness, and so on.

circular causality: The idea that people in a relationship have mutual effects on
each other, in a circular manner; for example, person A withdraws because person
B nags, and person B nags because person A withdraws.

classical conditioning: A learning process in which a stimulus that has been

relatively neutral for an individual (e.g., the sound of squealing car tires) elicits
an automatic reflexive response (e.g., anxiety symptoms) after the neutral stimulus
has been associated with another stimulus that produces the reflexive response
(e.g., a severe car accident).
 Cognitive-Behavioral Therapies 305

coercive family system: A pattern of family interaction in which parents and

children each use aversive behavior such as yelling and threats in attempts to
control each other’s actions.

cognitions: Forms and processes of thinking (e.g., attributions, expectancies,

assumptions, standards, selective perception) with which individuals process infor-
mation about themselves and the world.

cognitive distortions: Automatic, distorted processing of information (e.g.,

dichotomous thinking, emotional reasoning, maximization, minimization, mind
reading, overgeneralization, personalization).

cognitive restructuring: Therapeutic interventions intended to modify an indi-

vidual’s distorted or inappropriate thoughts, by challenging the logic of those
thoughts, presenting information concerning their validity, or examining their
impact on the individual’s life and relationships.

cognitive therapies: Forms of psychotherapy focusing on identifying an indi-

vidual’s distorted, invalid, or inappropriate forms of thinking that are contributing
to his or her psychological and/or interpersonal problems.

cognitive-behavioral approaches: Concepts and methods for understanding

and treating individual and relationship problems in terms of behavior patterns,
cognitions about oneself and others, and emotional responses associated with
those behaviors and cognitions.

communal needs: A person’s basic human needs that involve connections with
other people (e.g., a need for intimacy or deep sharing of personal experiences
with another person).

conduct disorder: A child’s or adolescent’s pattern of problematic behavior that

includes threats or harm to people or animals, damage to property, deceitfulness,
theft, or serious violations of rules set by parents, schools, and so forth.

consequences: The results that occur following an individual’s particular action,

either consistently or intermittently, and that reinforce or punish the person for
the action.

deconditioning: The weakening or eliminating of a previously classically or

operantly conditioned response by reversing the conditions that initially estab-
lished it; for example, reducing a child’s tantrum behavior by eliminating a
parent’s attention that reinforced it.
306 Norman B. Epstein and Mariana K. Falconier

deficits in communication skills: A person’s lack of ability to express himself or

herself verbally and nonverbally in a clear, direct, but nonaggressive manner, or a
lack of ability to pay close attention to another’s messages, understand his or her
perspective, and reflect back that understanding.

demand/withdraw: An interaction pattern between two people in which one

person tends to approach the other and press for attention and communication,
while the other person tends to withdraw, and each person’s type of behavior
elicits more of the other’s type of response.

depression: Psychological distress that may be chronic or occur in episodes and

that typically includes a variety of emotional symptoms (e.g., low mood), cogni-
tive symptoms (e.g., hopelessness, self-criticism), physiological symptoms (e.g.,
fatigue, poor appetite), and behavioral symptoms (e.g., withdrawal from other
people).

dichotomous thinking: A cognitive distortion in which an individual categorizes

people and events in all-or-nothing terms rather than considering degrees of
characteristics; for example, a parent who dichotomizes a child’s school grades
as “either A’s or failure.”

emotional reasoning: A cognitive distortion in which an individual interprets

his or her subjective emotions as objective facts; for example, when members of
a couple who have recently had little time together notice a lack of intimate
feelings and conclude that they no longer love each other.

emotional regulation: An individual’s ability to control the strength of the

emotions that he or she experiences and expresses.

expectancy: An individual’s inference involving a prediction about the probability

that an event will occur in the future under particular circumstances.

expressive skills: The abilities to be aware of one’s thoughts and feelings

and to express them to another person clearly, succinctly, and in a nonjudg-
mental way that encourages the listener to consider them without becoming
defensive.

extinction: The decreasing and possibly elimination, by removal of the reinforce-

ment, of an individual’s behavior that previously was given reinforcement.

functional analysis: Identification of the antecedent situational conditions that

tend to elicit an individual’s behavioral, cognitive, or emotional response, as well
as the consequences that follow the response and serve to reinforce, punish, or
extinguish it.
 Cognitive-Behavioral Therapies 307

functional family therapy: A behaviorally oriented therapy that focuses on ways

in which family members’ responses toward each other are due to the functions
that the responses serve in producing outcomes consciously or unconsciously
desired by the individuals.

gender role: The set of behavioral, cognitive, and emotional responses commonly
accepted in society as appropriate and desirable, as well as those considered inap-
propriate, for males or females.

good-faith agreement: A behavior contract in which each person agrees to

enact some of the behaviors desired by the other person without an agreement
about which behaviors he or she will choose. The individual’s compliance with
the other’s requests is not contingent on whether the other person carries out
his or her part of the agreement.

inappropriate thought processes: Cognitions that are irrelevant or extreme

such that they do not realistically fit circumstances in an individual’s personal
life; for example, holding a standard that one’s spouse or children should always
share one’s personal values and preferences.

intermittent reinforcement: When an individual receives reinforcing conse-

quences for his or her specific action occasionally or unpredictably rather than
after every instance of that action.

internal dialogue: An individual’s thoughts concerning a current experience;

for example, an internal debate about the pros and cons of behaving a particular
way toward family members.

investment: The degree to which an individual puts time and energy into a
relationship.

irrational belief: An individual’s unrealistic belief about characteristics that an

individual or relationship should or must have, which leads the individual to
respond with emotional upset and negative behavior when actual events fail to
meet the standard.

learning principles: Concepts about processes by which individuals acquire new

knowledge and behavioral and emotional responses, as well as processes by which
responses are weakened.

linear causal thinking: An individual’s concept that the causal relationship

between two people’s responses exists in only one direction (i.e., person A’s
behavior produces person B’s behavior); in contrast to circular causal thinking,
which focuses on mutual influences.
308 Norman B. Epstein and Mariana K. Falconier

listening skills: Communication skills for accurately receiving information from

another person who is expressing thoughts and emotions; for example, abilities
to take another’s perspective, avoid thinking about one’s own thoughts and feel-
ings instead of focusing on those expressed by the other person, and reflect back
what was heard.

magnification: A cognitive distortion in which an individual exaggerates the

effects of an event beyond what the evidence suggests is accurate; for example,
catastrophic thinking such as “My daughter was disciplined at school for talking
in class. Her reputation is ruined.”

mind reading: A cognitive distortion in which an individual observes an aspect

of another person’s behavior and makes an arbitrary inference or attribution that
he or she knows the other’s unstated thoughts and emotions; for example, “She
stayed at work later than she told me she would, so she obviously decided the
work was more important than spending time with me.”

minimization: A cognitive distortion in which an individual underestimates

qualities or effects of a person or event beyond what the evidence suggests is
accurate; for example, an individual whose spouse turned down a job opportunity
so the couple would not have to face moving might conclude, “It was no big
sacrifice for her.”

mutual influences: A process in couple or family interactions in which each

person’s behavior simultaneously affects and is affected by others’ behavior; as
when a child’s tantrums elicit stress, frustration, and harsh punishment from
parents, and in turn the parents’ yelling and harsh punishment elicit frustration,
anger, and tantrum behavior from the child.

negative reciprocity: The tendency for members of a relationship, especially a

distressed one, to reciprocate negative actions toward each other, either imme-
diately or at a later time.

negative tracking: A form of selective perception, particularly common in

distressed couples and families, in which an individual notices a family member’s
negative behavior but overlooks the person’s neutral or positive acts.

negative trait label: Using a broad personal trait label to describe and explain
a person’s behavior; for example, describing a child as being a “selfish” person
rather than exhibiting particular selfish acts.

neutral stimulus: A condition or event that has no natural automatic effect

on increasing or decreasing an individual’s behavioral, cognitive, or emotional
responses.
 Cognitive-Behavioral Therapies 309

observational learning: A process through which an individual learns how to

perform particular responses merely by observing another person’s performance
of them; as when a child imitates a parent’s way of expressing anger.

operant conditioning: A process through which an individual learns to enact

particular behaviors more or less frequently, based on the reinforcing or punish-
ing consequences that occur when he or she exhibits those behaviors.

overgeneralization: A cognitive distortion in which a person concludes that

an event that actually occurs only occasionally either never or always occurs; for
example, a man whose wife sometimes complains about his failing to clean up
after himself may overgeneralize, “You always criticize me.”

parenting training: Developing parents’ knowledge of normal child development

and teaching them effective, nonaggressive methods for increasing their children’s
positive behavior and decreasing their children’s negative behavior.

personalization: A cognitive distortion in which an individual interprets an

event as related to his or her own actions, when in fact the event may have been
caused by other factors; for example, a man notices his wife seems upset and
automatically concludes, “She’s angry at me.”

positive reinforcement: Consequences provided for an individual’s behavior

that result in the person exhibiting that behavior more frequently in the future,
presumably because the individual experiences the consequences as pleasant.

power/control: The degree to which a member of a family has input and

impact on decisions that the family makes about its priorities and activities.

punishment: Consequences provided for an individual’s behavior that result in

the person exhibiting that behavior less frequently in the future, presumably
because the individual experiences the consequences as aversive.

quid pro quo agreement: A behavior contract in which each person agrees to
enact particular behaviors desired by the other person, and each person’s adher-
ence to the agreement is contingent on the other’s adherence to it.

rational-emotive therapy: A psychotherapy approach, developed by psychologist

Albert Ellis, focusing on modifying irrational beliefs that elicit an individual’s
dysfunctional emotional and behavioral reactions to events in his or her life.

reflexive response: A behavioral or emotional response that occurs naturally and

automatically, such as fear a person instantaneously feels at the moment when a
truck is about to hit his or her car.
310 Norman B. Epstein and Mariana K. Falconier

relaxation techniques: Procedures, such as tensing and relaxing muscles in each

part of one’s body, or practicing slow deep breathing, that an individual can use
to increase overall physical relaxation and to reduce tension.

schema: An individual’s generally long-standing basic concept or belief about

characteristics of people, a particular object, a type of interpersonal relationship,
or a type of event.

selective abstraction / selective perception: A cognitive distortion in which

an individual notices certain aspects of information available in a situation and
overlooks other information.

self-statement: A form of cognition in which an individual gives himself or

herself an instruction to guide his or her thoughts (e.g., “Listen to my parents’
instructions”), behavior (e.g., “Tell her how I am feeling, but don’t blame her”),
or emotions (e.g., “Stay cool, just relax”).

sentiment override: When an individual’s emotional and behavioral responses

to another person are determined more by preexisting feelings toward the person
than by the person’s present behavior.

shape: To gradually develop an individual’s new response by rewarding him or

her for small approximations of the end goal; for example, reinforcing a child
for cleaning part of his or her room.

situational conditions: Characteristics of the physical or interpersonal setting

in which a behavioral, cognitive, or emotional response occurs; for example, the
amount of structure in home and classroom settings associated with a child’s
controlled versus hyperactive behavior.

social exchange theory: A theory that members of any relationship exchange

actions that each person experiences as costs and benefits, and each person feels
satisfied in the relationship to the degree to which he or she perceives receiving
a favorable ratio of benefits to costs.

standard: A belief or schema an individual holds about characteristics that

individuals and relationships “should” have. Standards can vary in flexibility,
extremeness, and the degree to which they are realistic.

stress inoculation: Methods to prepare an individual to cope with stressful situ-

ations; for example, training to use self-statements about relaxing and speaking
calmly to family members who are upset.
 Cognitive-Behavioral Therapies 311

subjectivity: The degree to which a person’s experiences of events involve

idiosyncratic interpretations rather than objective perception of external reality.

systematic desensitization: Gradually decreasing an individual’s negative cogni-

tive, emotional, and behavioral responses to a situation that the person finds
stressful, by exposing the person to increasingly stressful aspects of the situation
while having him or her practice relaxation techniques during the exposure.

time-out: A discipline technique that removes a child from sources of reinforce-

ment by placing him or her in a place of isolation (for example, a chair in a
corner, with no access to entertainment or attention from others) for a fixed
amount of time.

unrealistic belief: See IRRATIONAL BELIEF.

References
Aguilera, A., Garza, M. J., & Muñoz, R. F. (2010). Group cognitive-behavioral therapy
for depression in Spanish: Culture-sensitive manualized treatment in practice. Journal
of Clinical Psychology: In Session, 66, 857–867.
Alexander, J. F., Waldron, H. B., Robbins, M. S., & Neeb, A. A. (2013). Functional family
therapy for adolescent behavior problems. Washington, DC: American Psychological
Association.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A., & Walters, R. H. (1963). Social learning and personality development. New
York, NY: Holt, Rinehart and Winston.
Barkley, R. A. (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and
treatment (2nd ed.). New York, NY: Guilford Press.
Barkley, R. A., & Benton, C. M. (1998). Your defiant child: 8 steps to better behavior. New
York, NY: Guilford Press.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic.
New York, NY: Guilford Press.
Barton, C., & Alexander, J. F. (1981). Functional family therapy. In A. S. Gurman &
D. P. Kniskern (Eds.), Handbook of family therapy (Vol. I, pp. 403–443). New York, NY:
Brunner/Mazel.
Baucom, D. H., & Epstein, N. (1990). Cognitive-behavioral marital therapy. New York, NY:
Brunner/Mazel.
Baucom, D. H., & Epstein, N. (1999). It takes two to tango: There are some individuals in
there interacting with each other. Paper presented at the annual meeting of the Association
for Advancement of Behavior Therapy, Toronto, November 13.
Baucom, D. H., Epstein, N. B., LaTaillade, J. J., & Kirby, J. S. (2008). Cognitive-behavioral
couple therapy. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed.,
pp. 31–72). New York, NY: Guilford.
Baucom, D. H., Epstein, N., Rankin, L. A., & Burnett, C. K. (1996). Assessing relation-
ship standards: The inventory of specific relationship standards. Journal of Family
Psychology, 10, 72–88.
312 Norman B. Epstein and Mariana K. Falconier

Baucom, D. H., Epstein, N., Sayers, S., & Sher, T. G. (1989). The role of cognitions in
marital relationships: Definitional, methodological, and conceptual issues. Journal of
Consulting and Clinical Psychology, 57, 31–38.
Baucom, D. H., & Lester, G. W. (1986). The usefulness of cognitive restructuring as an
adjunct to behavioral marital therapy. Behavior Therapy, 17, 385–403.
Baucom, D. H., Porter, L. S., Kirby, J. S., Gremore, T. M., Wiesenthal, N., Aldridge,
W., . . . Keefe, F. J. (2009). A couple-based intervention for female breast cancer.
Psycho-Oncology, 8, 276–283.
Baucom, D. H., Sayers, S. L., & Sher, T. G. (1990). Supplementing behavioral marital
therapy with cognitive restructuring and emotional expressiveness training: An outcome
investigation. Journal of Consulting and Clinical Psychology, 58, 636–645.
Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., & Stickle, T. R. (1998). Empiri-
cally supported couple and family interventions for marital distress and adult mental
health problems. Journal of Consulting and Clinical Psychology, 66, 53–88.
Baucom, D. H., Snyder, D. K., & Gordon, K. (2009). Helping couples get past the affair: A
clinician’s guide. New York, NY: Guilford Press.
Beach, S.R.H., Dreifuss, J. A., Franklin, K. J., Kamen, C., & Gabriel, B. (2008). Couple
therapy and the treatment of depression. In A. S. Gurman (Ed.), Clinical handbook of
couple therapy (4th ed., pp. 545–566). New York, NY: Guilford Press.
Beach, S.R.H., & O’Leary, K. D. (1992). Treating depression in the context of marital
discord: Outcome and predictors of response for marital therapy vs. cognitive therapy.
Behavior Therapy, 23, 507–528.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY: Interna-
tional Universities Press.
Beck, A. T. (1988). Love is never enough: How couples can overcome misunderstandings, resolve conflicts,
and solve relationship problems through cognitive therapy. New York, NY: Harper & Row.
Beck, A. T., & Emery, G. (with Greenberg, R. L.). (1985). Anxiety disorders and phobias:
A cognitive perspective. New York, NY: Basic Books.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York, NY: Guilford Press.
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY:
Guilford Press.
Birchler, G. R., Fals-Stewart, W., & O’Farrell, T. J. (2008). Couple therapy for alcoholism
and drug abuse. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed.,
pp. 523–544). New York, NY: Guilford Press.
Blechman, E. A. (1985). Solving child behavior problems at home and at school. Champaign,
IL: Research Press.
Bodenmann, G. (2005). Dyadic coping and its significance for marital functioning. In
T. Revenson, K. Kayser, & G. Bodenmann (Eds.), Couples coping with stress: Emerging
perspectives on dyadic coping (pp. 33–50). Washington, DC: American Psychological
Association.
Bradbury, T. N., & Fincham, F. D. (1990). Attributions in marriage: Review and critique.
Psychological Bulletin, 107, 3–33.
Bradbury, T. N., & Fincham, F. D. (1992). Attributions and behavior in marital interac-
tion. Journal of Personality and Social Psychology, 63, 613–628.
Bulik, C. M., Baucom, D. H., Kirby, J. S., & Pisetsky, E. (2011). Uniting couples (in the
treatment of ) anorexia nervosa (UCAN). International Journal of Eating Disorders, 44, 19–28.
Carter, B., & McGoldrick, M. (Eds.) (1999). The expanded family life cycle: Individual, family,
and social perspectives (3rd ed.). Boston: Allyn and Bacon.
 Cognitive-Behavioral Therapies 313

Chambless, D. L. (2012). Adjunctive couple and family intervention for patients with
anxiety disorders. Journal of Clinical Psychology: In Session, 68, 548–560.
Christensen, A. (1988). Dysfunctional interaction patterns in couples. In P. Noller &
M. A. Fitzpatrick (Eds.), Perspectives on marital interaction (pp. 31–52). Philadelphia, PA:
Multilingual Matters, Ltd.
Christensen, A., Sullaway, M., & King, C. (1983). Systemic error in behavioral reports of dyadic
interaction: Egocentric bias and content effects. Behavioral Assessment, 5, 131–142.
Chronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T., & Pelham, W. E., Jr. (2004).
Enhancements to the behavioral parent training paradigm for families of children
with ADHD: Review and future directions. Clinical Child and Family Psychology Review,
7, 1–27.
Dattilio, F. M. (Ed.). (1998a). Case studies in couple and family therapy: Systemic and cognitive
perspectives. New York, NY: Guilford Press.
Dattilio, F. M. (1998b). Cognitive-behavioral family therapy. In F. M. Dattilio (Ed.), Case
studies in couple and family therapy: Systemic and cognitive perspectives (pp. 62–84). New
York, NY: Guilford Press.
Dattilio, F. M. (2010). Cognitive-behavioral therapy with couples and families: A comprehensive
guide for clinicians. New York, NY: Guilford Press.
Dattilio, F. M., & Bahadur, M. (2005). Cognitive-behavioral therapy with an East Indian
family. Contemporary Family Therapy, 27, 367–382.
Dattilio, F. M., & Padesky, C. A. (1990). Cognitive therapy with couples. Sarasota, FL: Profes-
sional Resource Exchange.
Deffenbacher, J. L. (1996). Cognitive-behavioral approaches to anger reduction. In K. S.
Dobson & K. D. Craig (Eds.), Advances in cognitive-behavioral therapy (pp. 31–62).
Thousand Oaks, CA: SAGE.
Dishion, T. J., & Patterson, S. G. (2005). Parenting young children with love, encouragement,
and limits. Champaign, IL: Research Press.
Duarte-Vélez, Y., Bernal, G., & Bonilla, K. (2010). Culturally adapted cognitive-behavioral
therapy: Integrating sexual, spiritual, and family identities in an evidence-based treat-
ment of a depressed Latino adolescent. Journal of Clinical Psychology: In Session, 66,
895–906.
Dunn, R. L., & Schwebel, A. I. (1995). Meta-analytic review of marital therapy outcome
research. Journal of Family Psychology, 9, 58–68.
Durtschi, J. A., Fincham, F. D., Cui, M., Lorenz, F. O., & Conger, R. D. (2011). Dyadic
processes in early marriage: Attributions, behavior, and marital quality. Family Relations,
60(4), 421–434.
Eidelson, R. J., & Epstein, N. (1982). Cognition and relationship maladjustment: Devel-
opment of a measure of dysfunctional relationship beliefs. Journal of Consulting and
Clinical Psychology, 50, 715–720.
Ellis, A. (1962). Reason and emotion in psychotherapy. New York, NY: Lyle Stuart.
Ellis, A., Sichel, J. L., Yeager, R. J., DiMattia, D. J., & DiGiuseppe, R. (1989). Rational-
emotive couples therapy. New York, NY: Pergamon.
Epstein, N. (1982). Cognitive therapy with couples. American Journal of Family Therapy,
10(1), 5–16.
Epstein, N. (2001). Cognitive-behavioral therapy with couples: Empirical status. Journal
of Cognitive Psychotherapy, 15, 299–310.
Epstein, N., & Baucom, D. H. (1993). Cognitive factors in marital disturbance. In K. S.
Dobson & P. C. Kendall (Eds.), Psychopathology and cognition (pp. 351–385). San Diego,
CA: Academic Press.
314 Norman B. Epstein and Mariana K. Falconier

Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples:
A contextual approach. Washington, DC: American Psychological Association.
Epstein, N. B., Berger, A. T., Fang, J. J., Messina, L., Smith, J. R., Lloyd, T. D., . . . Liu,
Q. X. (2012). Applying Western-developed family therapy models in China. Journal
of Family Psychotherapy, 23, 217–237.
Epstein, N. B., Chen, F., & Beyder-Kamjou, I. (2005). Relationship standards and marital
satisfaction in Chinese and American couples. Journal of Marital and Family Therapy,
31, 59–74.
Epstein, N., & Eidelson, R. J. (1981). Unrealistic beliefs of clinical couples: Their rela-
tionship to expectations, goals and satisfaction. American Journal of Family Therapy, 9(4),
13–22.
Epstein, N., Schlesinger, S. E., & Dryden, W. (Eds.). (1988). Cognitive-behavioral therapy
with families. New York, NY: Brunner/Mazel.
Epstein, N., & Williams, A. M. (1981). Behavioral approaches to the treatment of marital
discord. In G. P. Sholevar (Ed.), The handbook of marriage and marital therapy (pp. 219–286).
New York, NY: Spectrum.
Estrada, A. U., & Pinsof, W. N. (1995). The effectiveness of family therapies for selected
behavioral disorders of childhood. Journal of Marital and Family Therapy, 21, 403–440.
Falconier, M. K. (2013). Traditional gender role orientation and dyadic coping in immi-
grant Latino couples: Effects on couple functioning. Family Relations, 62, 269–283.
Fincham, F. D., & Bradbury, T. N. (1987). The impact of attributions in marriage: A
longitudinal analysis. Journal of Personality and Social Psychology, 53, 510–517.
Fincham, F. D., & Bradbury, T. N. (1992). Assessing attributions in marriage: The rela-
tionship attribution measure. Journal of Personality and Social Psychology, 62, 457–468.
Fincham, F. D., Bradbury, T. N., & Scott, C. K. (1990). Cognition in marriage. In F. D.
Fincham & T. N. Bradbury (Eds.), The psychology of marriage: Basic issues and applications
(pp. 118–149). New York, NY: Guilford Press.
Fincham, F. D., Harold, G. T., & Gano-Phillips, S. (2000). The longitudinal association
between attributions and marital satisfaction: Direction of effects and role of efficacy
expectations. Journal of Family Psychology, 14, 267–285.
Fiske, S. T., & Taylor, S. E. (1991). Social cognition (2nd ed.). New York, NY: McGraw-Hill.
Forgatch, M. S., & Patterson, G. R. (2010). Parent management training—Oregon model:
An intervention for antisocial behavior in children and adolescents. In J. R. Weisz &
A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed.,
pp. 159–178). New York, NY: Guilford Press.
Fruzzetti, A. E., & Iverson, K. M. (2006). Intervening with couples and families to treat
emotion dysregulation and psychopathology. In D. K. Snyder, J. A. Simpson, & J. N.
Hughes (Eds.), Emotion regulation in couples and families: Pathways to dysfunction and health
(pp. 249–267). Washington, DC: American Psychological Association.
Gelman, C. R., López, M., & Foster, R. P. (2005). Evaluating the impact of a cognitive-
behavioral intervention with depressed Latinas: A preliminary report. Social Work in
Mental Health, 4 (2), 1–16. doi: 10.1300/J200v04n02_01.
Goldstein, M. K. (1971). Behavior rate change in marriages: Training wives to modify
husbands’ behavior. Dissertation Abstracts International, 32(18), 559.
Gore, K. L., & Carter, M. M. (2003). Incorporating the family in the cognitive-behavioral
treatment of an African-American female suffering from panic disorder with agora-
phobia. Journal of Family Psychotherapy, 14, 73–92.
Gottman, J. M. (1994). What predicts divorce? The relationship between marital processes and
marital outcomes. Hillsdale, NJ: Lawrence Erlbaum.
 Cognitive-Behavioral Therapies 315

Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. New York,
NY: W. W. Norton.
Greenberg, L. S., & Goldman, R. N. (2008). Emotion-focused couples therapy: The dynamics
of emotion, love, and power. Washington, DC: American Psychological Association.
Guerney, B. G., Jr. (1977). Relationship enhancement. San Francisco, CA: Jossey-Bass.
Gupta, R., & Bhoomika, K. (2010). Specific cognitive deficits in ADHD: A diagnostic
concern in differential diagnosis. Journal of Child and Family Studies, 19, 778–786.
Gurman, A. S. (2013). Behavioral couple therapy: Building a secure base for therapeutic
integration. Family Process, 52, 115–138.
Hahlweg, K., & Markman, H. J. (1988). Effectiveness of behavioral marital therapy:
Empirical status of behavioral techniques in preventing and alleviating marital distress.
Journal of Consulting and Clinical Psychology, 56, 440–447.
Halford, W. K., & Bouma, R. (1997). Individual psychopathology and marital distress. In
W. K. Halford & H. J. Markman (Eds.), Clinical handbook of marriage and couples
intervention (pp. 291–321). Chichester, England: Wiley.
Halford, W. K., Sanders, M. R., & Behrens, B. C. (1993). A comparison of the general-
ization of behavioral marital therapy and enhanced behavioral marital therapy. Journal
of Consulting and Clinical Psychology, 61, 51–60.
Henggeler, S. W., & Sheidow, A. J. (2012). Empirically supported family based treatments
for conduct disorder and delinquency in adolescents. Journal of Marital and Family
Therapy, 38, 30–58.
Heyman, R. E., & Neidig, P. H. (1997). Physical aggression couples treatment. In W. K.
Halford & H. J. Markman (Eds.), Clinical handbook of marriage and couples intervention
(pp. 589–617). Chichester, England: Wiley.
Hrapczynski, K. M., Epstein, N. B., Werlinich, C. A., & LaTaillade, J. J. (2011). Changes
in negative attributions during couple therapy for abusive behavior: Relations to
changes in satisfaction and behavior. Journal of Marital and Family Therapy, 38,
117–132.
Huber, C. H., & Milstein, B. (1985). Cognitive restructuring and a collaborative set in
couples’ work. American Journal of Family Therapy, 13(2), 17–27.
Jacobson, N. S., & Christensen, A. (1996). Integrative couple therapy: Promoting acceptance
and change. New York, NY: W. W. Norton.
Jacobson, N. S., Fruzzetti, A. E., Dobson, K., Whisman, M., & Hops, H. (1993). Couple
therapy as a treatment for depression. II: The effects of relationship quality and therapy
on depressive relapse. Journal of Consulting and Clinical Psychology, 61, 516–519.
Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning
and behavior exchange principles. New York, NY: Brunner/Mazel.
Jacobson, N. S., & Moore, D. (1981). Spouses as observers of the events in their relation-
ship. Journal of Consulting and Clinical Psychology, 49, 269–277.
Johnson, S. M. (1996). The practice of emotionally focused marital therapy. New York, NY:
Brunner/Mazel.
Kaczynski, K. J., Lindahl, K. M., Malik, N. M., & Laurenceau, J. P. (2006). Marital
conflict, maternal and paternal parenting, and child adjustment: A test of mediation
and moderation. Journal of Family Psychology, 20, 199–208.
Kaslow, N. J., Broth, M. R., Smith, C. O., & Collins, M. (2012). Family-based interven-
tions for child and adolescent disorders. Journal of Marital and Family Therapy, 38,
82–100.
Kazdin, A. E. (2005). Parent management training: Treatment for oppositional, aggressive, and
antisocial behavior in children and adolescents. New York, NY: Oxford University Press.
316 Norman B. Epstein and Mariana K. Falconier

Kirby, J. S., & Baucom, D. H. (2007). Integrating dialectical behavior therapy and cognitive-
behavioral couple therapy: A couples skills group for emotion dysregulation. Cognitive
and Behavioral Practice, 14, 394–405.
LaTaillade, J. J. (2006). Considerations for treatment of African American couple rela-
tionships. Journal of Cognitive Psychotherapy: An International Quarterly, 4, 341–358.
LaTaillade, J. J., Epstein, N. B., & Werlinich, C. A. (2006). Conjoint treatment of intimate
partner violence: A cognitive behavioral approach. Journal of Cognitive Psychotherapy, 20,
393–410.
Leahy, R. L. (1996). Cognitive therapy: Basic principles and applications. Northvale, NJ: Jason
Aronson.
Lebow, J. L., Chambers, A. L., Christensen, A., & Johnson, S. M. (2012). Research on
the treatment of couple distress. Journal of Marital and Family Therapy, 38, 145–168.
Liberman, R. P. (1970). Behavioral approaches to family and couple therapy. American
Journal of Orthopsychiatry, 40, 106–118.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New
York, NY: Guilford Press.
Lucksted, A., McFarlane, W., Downing, D., Dixon, L., & Adams, C. (2012). Recent
developments in family psychoeducation as an evidence-based practice. Journal of
Marital and Family Therapy, 38, 101–121.
Margolin, G., & Weiss, R. L. (1978). Comparative evaluation of therapeutic components
associated with behavioral marital treatments. Journal of Consulting and Clinical Psychol-
ogy, 46, 1476–1486.
Markman, H. J., Stanley, S. M., & Blumberg, S. L. (2010). Fighting for your marriage: Posi-
tive steps for preventing divorce and preserving a lasting love (3rd ed.). San Francisco, CA:
Jossey-Bass.
Martell, C. R., Safren, S. A., & Prince, S. E. (2004). Cognitive-behavioral therapies with lesbian,
gay, and bisexual clients. New York, NY: Guilford Press.
Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach. New York,
NY: Plenum Press.
Miklowitz, D. J. (1995). The evolution of family-based psychopathology. In R. H. Mikesell,
D. D. Lusterman, & S. H. McDaniel (Eds.), Integrating family therapy: Handbook of family
psychology and systems theory (pp. 183–197). Washington, DC: American Psychological
Association.
Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar disorder: A family-focused treatment
approach. New York: Guilford Press.
Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for PTSD:
Harnessing the healing power of relationships. New York, NY: Guilford Press.
Morton, T. L., Twentyman, C. T., & Azar, S. T. (1988). Cognitive-behavioral assessment
and treatment of child abuse. In N. Epstein, S. E. Schlesinger, & W. Dryden (Eds.),
Cognitive-behavioral therapy with families (pp. 87–117). New York, NY: Brunner/Mazel.
Mueser, K. T., & Gingrich, S. (2006). The complete family guide to schizophrenia: Helping
your loved one get the most out of life. New York, NY: Guilford Press.
Nicholson, B., Anderson, M., Fox, R., & Brenner, V. (2002). One family at a time: A preven-
tion program for at-risk parents. Journal of Counseling and Development, 80, 362–371.
Nicoll, M., Beail, N., & Saxon, D. (2013). Cognitive behavioural treatment for anger in
adults with intellectual disabilities: A systematic review and meta-analysis. Journal of
Applied Research in Intellectual Disabilities, 26(1), 47–62.
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.
 Cognitive-Behavioral Therapies 317

O’Farrell, T. J., Murphy, M., Alter, J., & Fals-Stewart, W. (2010). Behavioral family coun-
seling for substance abuse: A treatment development pilot study. Addictive Behaviors,
35, 1–6.
O’Leary, K. D., & Turkewitz, H. (1978). Marital therapy from a behavioral perspective.
In T. J. Paolino & B. S. McCrady (Eds.), Marriage and marital therapy: Psychoanalytic,
behavioral and systems theory perspectives (pp. 240–297). New York, NY: Brunner/Mazel.
Patterson, G. R. (1971). Families. Champaign, IL: Research Press.
Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia.
Pavlov, I. P. (1932). Neuroses in man and animals. Journal of the American Medical Associa-
tion, 99, 1012–1013.
Prager, K. J. (1995). The psychology of intimacy. New York, NY: Guilford Press.
Pretzer, J., Epstein, N., & Fleming, B. (1991). The Marital Attitude Survey: A measure
of dysfunctional attributions and expectancies. The Journal of Cognitive Psychotherapy:
An International Quarterly, 5, 131–148.
Rathus, J. H., & Sanderson, W. C. (1999). Marital distress: Cognitive behavioral interventions
for couples. Northvale, NJ: Jason Aronson.
Robin, A. L., & Foster, S. L. (1989). Negotiating parent-adolescent conflict: A behavioral-family
systems approach. New York, NY: Guilford Press.
Roehling, P. V., & Robin, A. L. (1986). Development and validation of the Family Beliefs
Inventory: A measure of unrealistic beliefs among parents and adolescents. Journal of
Consulting and Clinical Psychology, 54, 693–697.
Rotter, J. B. (1954). Social learning and clinical psychology. Englewood Cliffs, NJ:
Prentice-Hall.
Safren, S. A., & Rogers, T. (2001). Cognitive-behavioral therapy with gay, lesbian, &
bisexual clients. In Session: Psychotherapy in Practice, 5, 629–643.
Sanders, M. R., Cann, W., & Markie-Dadds, C. (2003). The Triple P-Positive Parenting
Programme: A universal population-level approach to the prevention of child abuse.
Child Abuse Review, 12(3), 155–171.
Schwebel, A. I., & Fine, M. A. (1994). Understanding and helping families: A cognitive-behavioral
approach. Hillsdale, NJ: Lawrence Erlbaum.
Sexton, T. L., & Alexander, J. F. (2003). Functional family therapy: A mature clinical
model for working with at-risk adolescents and their families. In T. L. Sexton, G. R.
Weeks, & M. S. Robbins (Eds.), Handbook of family therapy: The science and practice of
working with families and couples (pp. 323–348). New York, NY: Brunner-Routledge.
Shadish, W. R., & Baldwin, S. A. (2003). Meta-analysis of MFT interventions. Journal of
Marital and Family Therapy, 29, 547–570.
Shadish, W. R., & Baldwin, S. A. (2005). Effects of behavioral marital therapy: A meta-analysis
of randomized controlled trials. Journal of Consulting and Clinical Psychology, 73, 6–14.
Shadish, W. R., Montgomery, L. M., Wilson, P., Wilson, M. R., Bright, I., & Okwumabua,
T. (1993). Effects of family and marital psychotherapies: A meta-analysis. Journal of
Consulting and Clinical Psychology, 61, 992–1002.
Skinner, B. F. (1953). Science and human behavior. New York, NY: Macmillan.
Skinner, B. F. (1971). Beyond freedom and dignity. New York, NY: Knopf.
Stuart, R. B. (1969). An operant-interpersonal treatment for marital discord. Journal of
Consulting and Clinical Psychology, 33, 675–682.
Stuart, R. B. (1980). Helping couples change: A social learning approach to marital therapy.
New York, NY: Guilford Press.
Sue, S. (2006). Cultural competency: From philosophy to research and practice. Journal
of Community Psychology, 34, 237–245. doi: 10.1002/jcop.20095
318 Norman B. Epstein and Mariana K. Falconier

Thibaut, J. W., & Kelley, H. H. (1959). The social psychology of groups. New York, NY:
Wiley.
Vanzetti, N. A., Notarius, C. I., & NeeSmith, D. (1992). Specific and generalized expec-
tancies in marital interaction. Journal of Family Psychology, 6(2), 171–183.
Voss Horrell, S. C. (2008). Effectiveness of cognitive-behavioral therapy with adult ethnic
minority clients: A review. Professional Psychology: Research and Practice, 39, 160–168.
Watson, J. B., & Raynor, R. (1920). Conditioned emotional reactions. Journal of Experi-
mental Psychology, 3, 1–14.
Webster-Stratton, C., & Herbert, M. (1994). Troubled families—Problem children: Working
with parents: A collaborative process. Chichester, England: Wiley.
Weiss, R. L. (1980). Strategic behavioral marital therapy: Toward a model for assessment
and intervention. In J. P. Vincent (Ed.), Advances in family intervention, assessment, and
theory (Vol. 1, pp. 229–271). Greenwich, CT: JAI Press.
Weiss, R. L., & Heyman, R. E. (1990). Observation of marital interaction. In F. D.
Fincham & T. N. Bradbury (Eds.), The psychology of marriage: Basic issues and applica-
tions (pp. 87–117). New York, NY: Guilford Press.
Weiss, R. L., Hops, H., & Patterson, G. R. (1973). A framework for conceptualizing
marital conflict, a technology for altering it, some data for evaluating it. In L. A.
Hamerlynck, L. C. Handy, & E. J. Mash (Eds.), Behavior change: Methodology, concepts
and practice (pp. 309–342). Champaign, IL: Research Press.
Wetchler, J. L., & Piercy, F. P. (1996). Behavioral family therapies. In F. P. Piercy, D. H.
Sprenkle, J. L. Wetchler, & Associates, Family therapy sourcebook (2nd ed.) (pp. 106–128).
New York, NY: Guilford Press.
Whisman, M. A., & Beach, S. R. H. (2012). Couple therapy for depression. Journal of
Clinical Psychology: In Session, 68, 526–535.
Whisman, M. A., & Snyder, D. K. (1997). Evaluating and improving the efficacy of con-
joint couple therapy. In W. K. Halford & H. J. Markman (Eds.), Clinical handbook of
marriage and couples interventions (pp. 679–693). Chichester, UK: Wiley.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University
Press.
Zimet, D. M., & Jacob, T. (2001). Influences of marital conflict on child adjustment: Review
of theory and research. Clinical Child and Family Psychology Review, 4, 319–335.