Cognitive Behavioral Therapy & Relationship Counseling Research from the Harvard Medical School

  Harvard Medical School University of Pennsylvania School of Medicine By Frank M. Dattilio, Ph.D., ABPP Introduction Relationship counseling has become an increasingly popular avenue for attempting to remedy distressed relationships, in addition to the number of other alternatives available (e.g., marriage encounter weekends, self-help literature, etc). Of the many styles of relationship interventions, one […]

 

Harvard Medical School
University of Pennsylvania School of Medicine

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

Introduction

Relationship counseling has become an increasingly popular avenue for attempting to remedy distressed relationships, in addition to the number of other alternatives available (e.g., marriage encounter weekends, self-help literature, etc). Of the many styles of relationship interventions, one that has gained increasing recognition, among both the public sector and mental health practitioners is cognitive therapy (Nichols & Schwartz, 2006).

Cognitive therapy, originally developed by Aaron T. Beck, MD, is based on a theoretic rationale that posits that the manner in which one thinks and perceives determines greatly how one feels and behaves. Therefore, if a person interprets a situation as threatening, he or she may feel intimidated and experience the urge to withdraw or retaliate. However, the amount of information or evidence available may very well shift or expand perception. A classic example is the case of a man who notices his friend’s wife in a restaurant dining with a man other than her husband and having what appears to be an intimate conversation. Without sufficient information, this man might immediately conclude that his friend’s wife is being unfaithful and become upset by what he sees. However, if he were to learn that the man with whom she was dining was a family member, or close friend of the family, this might change his perception and have an impact on his emotional reaction. This example clearly depicts an arbitrary inference, based on erroneous or insufficient information – one of the classic tenets of cognitive therapy.

Cognitive therapy posits that thought, whether verbal or imaginal, evolves from beliefs, attitudes, and assumptions that are developed early in one’s lifetime. This is true of psychologic disturbances that very often stem from specific errors in thinking. These errors may be habitual and occur in relationships involving judgments and decisions based on interpretations or misinterpretations of one another’s actions, as in the case scenario above. Some of the more common system reasoning errors have been termed “cognitive distortions” and are listed in the table below:

Table 1
Cognitive Distortions

• Arbitrary inference refers to the process of drawing a specific conclusion in the absence of evidence to support the conclusion or even when the evidence is contrary to the conclusion (e.g., a woman whose husband arrives home one hour late from work concludes, “He must be seeing another woman”).

• Selective abstraction occurs when one detail is taken out of context ignoring other more salient features of the situation and a conclusion is drawn on the basis of this one detail (e.g., a woman whose husband fails to answer her greeting first thing in the morning concludes, “He’s ignoring me”).

• Overgeneralization refers to the pattern of drawing a general rule or conclusion on the basis of one or more isolated incidents and applying the concept to other unrelated situations (e.g., after being turned down for an initial date, a young man concludes, “All women are alike; I’ll always be rejected”).

• Magnification or minimization occurs when the significance of an event is evaluated as crucial or trivial when an objective assessment does not warrant this evaluation (e.g., an angry husband loses his temper upon discovering that they are out of milk and states to his wife, “You never keep up with the shopping”).

• Personalization refers to an individual’s proclivity to relate external events to himself or herself even when there is no logical basis for such a connection (e.g., a woman finds her husband slicing the vegetables she had already cut and assumes, “He hates the way I cook”).

• Dichotomous thinking is manifested by the tendency to place all experiences in one of two opposite categories, such as competent-incompetent, good-bad, or lovable-unlovable (e.g., upon soliciting his wife’s opinion on hanging a painting, she questions its location and the husband thinks to himself, “I can’t do anything right”).

The concept of cognitive distortions is displayed by couples whose expectations of each other frequently become violated once they have progressed well into their relationship. Couples commonly develop basic beliefs about relationships in general and the nature of couple interactions early in their lives. These beliefs may be derived from primary sources, such as parents, the media, or expectations drawn from early dating experiences, as well as idealization about what marriage and relationships should entail (Beck, 1988; Dattilio & Padesky, 1990).

Underlying Beliefs or Schema

As these beliefs or ideas develop, they become ingrained or constitute what cognitive therapists refer to as an underlying schema. It is the schema, or underlying belief, that generates certain automatic thoughts about the relationship, particularly when expectations are violated. These thoughts tend to be negative and are based on unfounded information. From these thoughts, expectations are formed and imposed on the spouse. Expectations based on erroneous or faulty information may become distorted and lead to further unrealistic expectations that then erode relationship satisfaction and contribute to dysfunctional interaction (Dattilio, 1998).

An example of this cycle is illustrated by John and Nicole, who displayed one of the most common misconceptions of couples: “True love lasts forever and couples in love don’t have to work at their relationship.” Consequently, after several years of marriage, when both John and Nicole began to notice that some of the spark had disappeared from their relationship, they panicked and developed automatic thoughts, such as, “Maybe we were never meant for each other” and “Our love should be ‘spontaneous’ and not something that requires a lot of work.”

These automatic thoughts and beliefs caused John and Nicole to pressure each other into demonstrating more spontaneous expressions of love. These unrealistic demands, unfortunately, placed undue stress on their relationship, inhibiting them more, and eventually escalating to the point that they had isolated each other completely and were on the brink of a separation.

Cognitive Therapy for Relationship Distress

Cognitive therapy with relationships focuses specifically on the general thinking styles behind couples’ perceptions, underlying beliefs about their relationship, and the nature of interactions between them.

Cognitions are viewed as being directly responsible for each spouse’s subjective dissatisfaction with the relationship and are addressed specifically during the course of treatment.

Some goals of cognitive therapy with relationships involve modifying unrealistic expectations about the relationship, correcting faulty attributions with the couple’s interactions, and ending self-destructive exchange. Along the way, other issues, such as the effect these aspects have on emotion and behavior, are also addressed. It is believed that through these avenues the therapist may successfully aid spouses or family members to alter the problematic course of their relationship.

Initially, the cognitive therapist conducts a case conceptualization by gathering background information about both partners and their relationship and focusing equally on the expectations that each maintain about the nature of the interaction in the relationship. This information may be collected either in an unstructured fashion (the therapist’s own style) or through the use of a structured intake form. The case conceptualization usually includes a complete history of the couple’s relationship, along with details regarding their single or married lives prior to the present relationship.

Additional information is also obtained, such as perceptions of their respective parents’ marital relationship, reasons for seeking treatment, length and duration of the problems, previous attempts at symptom/problem resolution (e.g., previous counseling, self-help programs), social lifestyle, and areas of compatibility/incompatibility. An additional area that is explored with each spouse is the schemas that have been transgenerationally passed on from their respective families-of-origins and how this affects their thinking (Dattilio, 2006). Relationship inventories and questionnaires are also sometimes used to gain further information regarding the manner in which spouses view each other and the problem in their relationship. To help spouses or family members better understand the cognitive model of relationship therapy, readings such as Love Is Never Enough (Beck, 1988) or Fighting for Your Marriage (Markman, Stanly, & Blumberg, 1994), may be assigned during the assessment phase.

Once the initial information has been ascertained, the spouses are then seen for individual sessions on separate days in order to delve more deeply into each partner’s perceptions of the relationship and into each partner’s thoughts and beliefs about change. The automatic thoughts and emotions of each spouse are explored in order to uncover underlying beliefs or schemas about themselves and their relationship.

For example, during the individual session with John, several of the items on one of the questionnaires were reviewed with him in order to clarify his perception of his relationship with Nicole. One of the items to which John had assigned a high value (strongly agree) was the statement, “I couldn’t do anything to improve our relationship if I tried.” Bordering on this statement, the therapist might begin to have John elaborate on his automatic thoughts through a technique known as “Downward Arrow.” This technique is used in order to pinpoint the individual’s sequence of thoughts and link emotions to the automatic thought.

Here the therapist elicits the automatic thought from the individual through the technique of Socratic questioning and continues by having him say, “If so, then what?” For example, the downward arrow technique would be applied to John’s statement in the following manner:

By using this technique, the therapist is able to show spouses how their automatic thoughts are linked to emotions and these emotions may be highly charged and affecting how they behave with each other.

More important, it also sets the groundwork to have them weigh out the evidence for their automatic thoughts and test their prediction as to whether their thoughts are based on accurate information. By doing this, individuals are better able to see the irrationality of their thoughts and entertain possible alternatives to their processing of cognitions and subsequent interactions. In one sense, they learn how to balance out their thinking with new evidence not observed before.

Automatic thoughts play an integral part in the emotional turmoil of couples in distress. Through the use of such techniques as Downward Arrow and others, one may elicit an individual’s automatic thoughts and link them with the emotional responses. The next step is to help the individuals weigh the evidence in support of their automatic thought and then test the thought against that evidence. Through this technique, the therapist is able to help spouses identify distorted thoughts and label them according to the list of distortions presented earlier. For example, referring to the sequence of John’s automatic thoughts and emotions, the therapist may have John ask himself: “What is the evidence that exists in favor of my statement, ‘I couldn’t do anything to improve the relationship?’ What evidence exists that is contrary to such a statement? Could there be an alternative explanation?” It is also important for the therapist to help John mediate some of his emotional responses by examining what he tells himself about his relationship.

Let us suppose that the evidence in support of John’s statements is that he has tried to do as much as he could to enhance his relationship with Nicole. The therapist would have him ask the question: “Are there some things that perhaps I missed?” Then he was asked to review some of his ideas for improving the relationship, but from a different angle. As a rational response to his statement, subsequent to weighing the evidence, John may restructure his statement in the following manner:

Table 2
John’s Automatic Thoughts and Rational Self-Statements

Automatic Thought Label/Emotion

Rational Self-Statement
surface after a consultation with an objective third party. Our relationship deserves as much as we can give. There must be other alternatives.”

Emotion Increased Optimism

By weighing the evidence and having John develop rational self-statements or alternative responses; he is able to see that his original automatic thought is distorted and that the error can be labeled as “Selective Abstraction.” He can also see the connection between restructuring his thoughts and changing how he feels. In this case, John’s emotion changes from frustration to being more hopeful, but with some caution. This technique is used with both spouses and can be performed directly in the conjoint session. It can also be assigned as a homework exercise on a regular basis. Homework is also another very important aspect of cognitive therapy in that it serves to galvanize what is learned during the course of the therapy sessions.

“I couldn’t do anything to improve our relationship if I tried.” Selective Abstraction; Frustration

“I am not perfect and neither is Nicole. Perhaps I did miss something that may

Unfortunately, some cases do not adhere so easily to this type of restructured thinking, and additional techniques must be employed. When a therapist asks about specific incidents, arguments, or previous automatic thoughts, some people may not be able to recall all of the details. When this happens, imagery and replay techniques may be helpful. In imagery, spouses are asked to think back to where they were and what they were doing when the incident or argument occurred. This exercise can foster greater access to the emotions they were experiencing at the time.

Once they are able to capture the image, they are asked to replay the actual situation just as it occurred. Replaying entails having the couple visualize the automatic thoughts that flashed into their mind at the time. They are asked to write down specific thoughts and then possible alternative responses. This exercise enables the therapist to see where they are making their mistakes, but, more important, it also encourages the couple to monitor their automatic thoughts and consider alternative responses to apply in future situations.

Reframing Distorted Perceptions

It is interesting that when spouses who are in therapy are asked about the qualities that initially attracted them to their mates, the adjectives used are often the inverse of ones presently used to describe them. For example, Nicole said she was first attracted to John based on the following qualities: “Thrifty, thoughtful, caring, with a great sense of humor.” Later, when asked to list the areas of discontent, she described him as: “Cheap, ignorant, manipulative, silly, and ridiculous.” When these characteristics were seen in parallel, Nicole realized that her current view of John’s qualities was actually the flip side of her original view of him. That is, her perception of what were once desirable qualities had shifted completely. So, did John change? Or did Nicole’s perception of him change? Or was there a change on both of their parts?

These tools can help couples interrupt the vicious cycle of conflict, enabling them to see how and when distortions in their thinking may have contributed to viewing each other negatively and then reacting accordingly. It is important for the therapist to help partners understand that the feelings that were once present likely still exist, but in a different frame, and that by restructuring this frame and casting the characteristics in a positive light, the relationship itself can be seen from a different perspective.

An integral part of cognitive couples’ therapy also involves communications training and problem solving. Given that difficulties between couples often derive from very basic communication breakdowns such as interrupting or listening too passively, retraining certain communication skills may have a powerful effect. Speaking and listening behaviors are the two prime problem areas. The following is a list of basic guidelines for the listener:

• Maintain good eye contact while listening attentively and acknowledging your spouse.

• Do not interrupt, and clarify what you hear during conversations so that you are tracking the real intent of the message.

• Reflect back what you hear in order to acknowledge that you understand the message.

• Monitor your body language so that it conforms to a style that shows you are interested in what is being said.

The following is a list of basic guidelines for the speaker:

• Try to be attentive as you speak, making sure that your body language and eye contact are in keeping with your verbal message.

• Try to ask questions that elicit more than a yes or no answer from your spouse.

• Be careful not to ramble or be too verbose. Give your spouse a chance to clarify what he or she is hearing.

• Welcome silence. This shows you that the listener is thinking about what is being said.
• Avoid cross-examination. Try to use tact and diplomacy in the delivery of your message.

Both spouses should periodically summarize the content of their conversation so that they can set a direction for constructive follow-up. It is also recommended that they put aside time everyday to practice these communication skills.

Course of Treatment

Typically, cognitive therapy with couples is relatively short-term, but some situations may require more extensive sessions. This determination is based largely on the degree of disturbance in the relationship. The course and frequency of the sessions are also contingent upon the nature and severity of the relationship conflicts, as well as how amenable the couple is to working them through. Therapy sessions are typically scheduled at least once per week to start. Later, sessions are spaced further apart in order to provide more time for completion of assignments, including homework and various exercises. Individual homework might entail monitoring automatic thoughts and weighing evidence. Joint homework assignments might include structured communication exercises or making decisions together.

As the couple begins to make headway, sessions are usually scheduled every two weeks or even less frequently, depending on the therapist’s assessment of the relationship. Sessions should eventually be tapered off to monthly visits for about 3 months, with follow-up booster sessions scheduled as needed. Booster sessions usually consist of reviewing the basic principles of cognitive couple therapy with the spouses and reinforcing the techniques that have been learned during the course of treatment. Booster sessions might also focus on specific crises, as the therapist helps the couple to process the situation through the model and its relevant applications.

Because it is important for spouses to witness in each other the individual changes that each must make in order to have a successful relationship, the majority of therapy sessions are conjoint. However, individual sessions are helpful for gathering certain types of information and for observing behavioral changes when partners are not together. Throughout the course of treatment, separate sessions may be periodically scheduled in order to focus more specifically on individual issues and to strengthen the person’s use of the techniques.

Conclusion

This has been a very brief introduction to the use of cognitive therapy for relationship distress. It is also noteworthy that cognitive therapy has become attractive to practitioners of other modalities. Cognitive

therapy techniques can be integrated very easily with many other modalities. In an edited text by Dattilio (1998), a large majority of theorists from other modalities attest to cognitive therapy’s ability to be incorporated into their approaches. In addition to the research evidence supporting its efficacy, this model appeals to those interested in a proactive approach to solving problems and building skills that couples can use in order to cope with the many predictable and unpredictable circumstances in life.

Frank M. Dattilio, Ph.D., ABPP, is on the Faculty of Psychiatry at both Harvard Medical School and the University of Pennsylvania School of Medicine. He also works as a clinical psychologist in private practice. He is one of the pioneers of cognitive therapy with couples and families and has lectured in more than 40 countries. He has published 14 books and more than 200 scholarly articles and book chapters. His works have been translated into 24 languages and are widely used in training programs throughout the world.

REFERENCES
Beck, A. T. (1988). Love is never enough. New York: Harper Collins.

Dattilio, F. M. (1998). Case studies in couple and family therapy: Systemic and cognitive perspectives. New York: Guilford.

Dattilio, F. M. (2006). Restructuring schemata from family-of-origin in couple therapy. Journal of Cognitive psychotherapy, 20(4), 359-373.

Dattilio F. M. & Padesky, C. A. (1990). Cognitive therapy with couples. Sarasota, FL: Professional Resource Exchange.

Markman, H. J., Stanley, S. & Blumberg, S. L. (1994). Fighting for your marriage. San Francisco: Jossey- Bass.

Nichols, M. P. & Schwartz, R. C. (2006). Family therapy: Concepts and methods. New York: Pearson Education, Inc.

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