Handbook of Behavioural Family Therapy

Ian R.H. Falloon, Ian R.H. Falloon, Ian Falloon

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781317411727
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1988, behavioural family therapists worked in an area that had greatly changed since its inception over 20 years before. Growing out of the pioneering work of Gerald Patterson, Robert Paul Liberman, and Richard Stuart, whose backgrounds vary from psychology to psychiatry to social work, behavioural family therapy (BFT) had evolved to encompass systems theory, considerations of the therapeutic alliance, as well as approaches to accounting for and restructuring family members' subjective experiences through cognitive strategies.

As BFT had not been the 'brain child' of any one charismatic innovator, but rather of a wide array of clinicians and researchers developing and rigorously testing hypotheses, it is fitting that this much-needed summation of the field was a collaborative product of an array of well-established practitioners of the time. They discuss in Part 1 of the book the theoretical parameters of BFT, focusing on modular behavioural strategies, the indications for therapy, assessment of family problems, pertinent issues arising in clinical practice, and approaches to the problem of resistance to change. Contributors to Part 2 then apply theory to such clinical situations as 'parent training' and helping families cope with patients suffering from developmental disabilities, alcoholism, schizophrenia, senile dementia, as well as anxiety, obsessive-compulsive, and depressive disorders. Specific attention is also given to acute inpatient and primary health-care settings.

While BFT had already proved quite effective in treating a great number of family problems, it was only in its infancy at the time of writing. As Falloon says in his overview 'all exponents of the method are constantly involved with the process of refinement, each clinician is a researcher, each family member is a research subject, and each researcher is contributing to clinical advancement.'

This openness, in combination with a willingness to modify 'sacred' tenets of behaviourism while adapting proven techniques from other family therapies, made this title a landmark in its field. As such, it was not only of interest to all clinicians and researchers with a behavioural slant, but also to all family therapists who wished to challenge themselves to develop an integrative approach.

HANDBOOK OF BEHAVIOURAL FAMILY THERAPY

PART ONE

GENERAL ISSUES

1

Behavioral Family Therapy: An Overview

IAN R. H. FALLOON

Buckingham Mental Health Service, England

FRANCIS J. LILLIE

Central Clinic, Colchester, England

BACKGROUND

Historical Perspectives

Behavioral family therapy has developed from the application of learning theory principles in several different clinical settings and client groups. No one charismatic innovator can be attributed with its discovery. However, it is evident that the earliest reports of family-oriented interventions tended to be associated with the involvement of parents in the modification of the disturbed behavior of their children. These initial programs were extremely simple single case studies.

Williams (1959) reported a successful intervention to reduce the bedtime tantrums of a young child. The parents were instructed to put the child to bed in an affectionate manner, to close his bedroom door, and ignore his subsequent protestations. The use of this extinction paradigm typified efforts to transfer the principles of social learning theory, which were based on studies in the psychology laboratory, including animal research, to clinical intervention in the natural environment.

An approach that has continued application today is the use of classical conditioning in the control of enuresis. Lovibond (1963) developed a bed and pad apparatus that parents employed to assist them with their bedwetting children. Boardman (1962) trained parents in the effective use of a punishment paradigm to deal with the aggressive, antisocial behavior of a 5 year old. Wolpe (1958) described involving spouses as cotherapists in anxiety management interventions. Risley and Wolf (1967) trained parents in the operant reinforcement of speech in their autistic children. In all of these approaches, the family was involved in the application of the specific modification of a target behavior in a family member.

One of the earliest reports that reflected a shift from a patient-focused analysis of behavioral deviance was that of Wahler, Winkel, Peterson, and Morrison (1965). Their views were postulated in the following paragraph:

Most psychotherapists assume that a child’s parents compose the most influential part of his natural environment. It is likely, from a learning theory viewpoint, that their behaviors serve a large variety of stimulus functions, controlling both the respondent and operant behaviors of their children. It then follows that if some of the child’s behavior is considered to be deviant at a particular time in his early years, his parents are probably the source of eliciting stimuli and reinforcers which have produced, and are curently maintaining this behavior. A logical procedure for the modification of the child’s deviant behavior would involve changing the parents’ behavior. These changes would be aimed at training them both to eliminate the contingencies which currently support their child’s deviant behavior, and to provide new contingencies to produce and maintain more normal behavior which would compete with the deviant behavior, (p. 114)

Despite extensive observations of the reciprocal nature of child and parent interactions associated with deviant behaviors, however, the interventions employed tended to resemble the methods employed with laboratory subjects. Parents were instructed to respond to their child’s behavior in a highly specific way by the therapist, and success was determined by a reduction in deviant behavior during the treatment sessions.

This role of the behavior therapist as the expert adviser to the family was clearly established at the time Gerald Patterson and his colleagues from Eugene, Oregon, wrote their landmark paper entitled ‘‘Reprogramming the Social Environment” (Patterson, McNeal, Hawkins, & Phelps, 1967). Patterson et al. realized that observation of family interaction in a laboratory or clinical environment was far removed from the behavior displayed in the natural environment of the home. As a result, they developed methods of sampling periods of family interaction in the home. Observers were trained to spend time collecting data in the home at times when all the family members were together. This often required constraints on family behavior to achieve the goal of having all family members together in one or two rooms. Observers were instructed to avoid interacting with family members and to adopt a “fly-on-the-wall” role. It can be argued that such “unnatural” conditions must inevitably have changed family interaction patterns and may have produced no more naturalistic behavior than that obtained in clinical settings.

The empirical basis for behavioral family interventions was clearly demonstrated by these extensive efforts to obtain observations of family behavior. Family interactions were coded in a standardized manner. The antecedents and the responses associated with a targeted behavioral episode (e.g., tantrum or violent outburst) were analyzed. Repetitive patterns of behavior that were contingent on each specified episode were hypothesized as contributing to the origin and/or maintenance of the undesirable behavior. The undesirable behavior was defined by the family, not the therapist, and its frequency was assessed during the series of observations prior to planning any intervention strategies. This provided a baseline measure with which therapeutic progress could be compared.

The interventions attempted to train parents in the principles of social learning theory, with the assistance of programmed workbooks (e.g., Patterson, 1971), and in the application of specific strategies designed to eliminate the contingencies that appeared “programmed” to induce the undesired behavior. In the case example in the 1967 article cited earlier, Patterson and his colleagues acknowledged that to produce change in the case of a 5-year-old boy with isolated, withdrawn, and bizarre behavior, merely training the parents to respond to his deviant behavior was insufficient.

To produce a change it seemed necessary to change several aspects of this social system, simultaneously. Therefore, the initial programmes were designed to fulfil four functions: (1) train the mother to use positive reinforcers, (2) train her to initiate more social contacts, and (3) at the same time train Earl to function as a more effective social reinforcer for the behavior of the parent, and (4) initiate more social contacts to his parents, (p. 187)

Such an approach, which attempted to alter behavior in a reciprocal manner, even when disturbed young children were involved, distinguished behavioral family therapy from the parent-training approaches that were employed widely during the 1970s.

Patterson’s pioneering work extended into the realms of parental behavior patterns, where his brilliant exposition of the manner in which reciprocity in coercive exchanges between couples tends to lead to increasingly ineffective problem solving contributed to the development of behavioral marital therapy. This is demonstrated in the following excerpt from a case study (Patterson & Hops, 1972):

“Wife: You still haven’t fixed that screen door.

“Husband: (Makes no observable response, but sits surrounded by his newspaper.)

“Wife: (There is a decided rise in the decibel level of her voice.) A lot of thanks I get for all I do. You said three weeks ago….

“Husband: Damn it, stop nagging at me. As soon as I walk in here and try to read the paper I get yelling and bitching.

“Wife: (Shouting now) You’re so damn lazy that’s all I can do to get things done!

“Husband: All right, damn it, I’ll fix it later! Now leave me alone!”

In this situation, the husband has trained the wife to increase the volume in order to get him to comply. She is more likely to resort to shouting next time she needs some change in his behavior. He, on the other hand, has learned that a vague promise will “turn off the pain.”

The second major figure in the development of behavioral family therapy was Robert Liberman. In his 1970 paper, “Behavioral Approaches to Family and Couple Therapy,” he outlined the application of an operant learning framework to the family problems of four adult index patients with depression, intractable headaches, social inadequacy, and marital discord. In addition to employing contingency management of mutual reinforcers of deviant behavior, Liberman introduced the use of the imitative learning concepts of Bandura and Walters (1963) to family therapy. He also emphasized the importance of basic therapeutic skills, such as the development of a therapeutic alliance with the family. In contrast to Patterson’s focus on observable interaction patterns between parents and children, Liberman conducted a behavioral analysis largely through interviews with each family member. Family members were invited to suggest changes they desired in the behavior of themselves and others in the family, both in relation to identified problem behaviors as well as constructive life goals. The ultimate choice of specific behavioral goals remained the prerogative of the therapist as did the formulation of the therapeutic strategy. However, it was made clear that behavioral analysis would continue throughout therapy and that the therapy would be modified according to changes in the problem behaviors. Throughout, the therapist adopted the role of an expert educator. An example of this appoach was described in Liberman’s Case 2 (1970):

My behavioral analysis pointed to a lack of reinforcement from Mrs. S’s husband for her adapative strivings. Consequently her depressions, with their large hypochondriacal components, represented her desperate attempt to elicit her husband’s attention and concern. Although her somatic complaints and self-depreciating accusations were aversive for her husband, the only way he knew how to “turn them off” was to offer sympathy, reassure her of his devotion to her, and occasionally stay home from work. Naturally, his nurturing her in this manner had the effect of reinforcing the very behavior he was trying to terminate.

During five half-hour sessions I focused primarily on Mr. S, who was the mediating agent of reinforcement for his wife and hence the person who could potentially modify her behavior. I actively redirected his attention from his wife ‘‘the unhappy, depressed woman” to his wife “the coping woman.” I forthrightly recommended to him that he drop his extra job, at least for the time being, in order to be at home in the evening to converse with his wife about the day’s events, especially her approximations at successful home-making. I showed by my own example (modeling) how to support his wife in her effort to assert herself reasonably with her intrusive mother-in-law and an obnoxious neighbor, (p. 113)

Liberman’s approach, based on self-report data alone, is in stark contrast to the detailed observations employed by Patterson; this may reflect the differing backgrounds of the psychodynamic training of the psychiatrist and the psychology laboratory training of the psychologist, as was prevalent in the United States at that time. However, the crux of both approaches was the restructuring of the reciprocal exchange of rewards in family relationships, so that mutually desirable transactions replaced interactive patterns hypothesized as contributing to the development and maintenance of problem behaviors.

The behavioral approach was contrasted with other developing family therapy methods in two major ways. First, the behavior therapist specified family problems in concrete, observable terms. Second, therapeutic strategies were planned in a highly specific manner based on an empirical theory of behavior change. Strategies were subjected to empirical analyses of their effects in achieving specific behavioral goals. Although brief case reports did not convey the significance attached to the therapeutic alliance, this was regarded as important as in any other approach. Liberman (1970) emphasized that

[T]he behavioral approach does not simplistically reduce the family system and family interaction to individualistic or dyadic mechanisms of reinforcement. The richness and complexity of family interaction is appreciated by the family therapist working within a behavioral framework, (p. 116)

Liberman went on to describe the family dynamics of one of his case reports in family systems terms. The behavioral family therapist and the clients do not need to understand these dynamics in order to change the system, if a careful behavioral analysis is conducted. Treatment failures are viewed as failures of the behavioral hypotheses and in need of further assessment and different strategies. Liberman (1970) offered one final comment:

Hopefully, further clinical and research progress made by behavioral oriented therapists will challenge all family therapists, regardless of theoretical learnings, to specify more clearly their interventions, their goals, and their empirical results. If these challenges are accepted seriously, the field of family therapy will likely improve and gain status as a scientifically grounded modality, (p. 117)

It is a sad comment that this challenge has not been adequately answered by family therapists of all persuasions, including behavior therapists! There remains a dearth of well-designed empirical studies to match the enthusiastic clinical applications of these methods.

The third major influence on the early development of behavioral family therapy was the contingency contracting approach of Richard Stuart (1969). Stuart, a social worker, focused on the interpersonal environment in which family members responded to one another. Rather than considering how undesired responses of a “deviant” family member could be modified, the therapist focused on how the exchange of positive behavior could be maximized. The principle of reciprocity was introduced. Stuart cited Thibaut and Kelley (1959) when postulating that

[T]he exact pattern of interaction which takes place between spouses is never accidental; it represents the most rewarding of all the available alternatives. This implies that the interaction between spouses is never accidental; it represents the best balance which each can achieve between individual and mutual rewards and costs.

These concepts of balance and behavior exchange had been developed earlier in the work of Don Jackson (1965), using the medical and social analogies of “homeostasis” and “quid pro quo.” Stuart suggested that in order to influence the behavior of another person, a family member must build up his or her status as a mediator of reinforcement and that this was best achieved by providing noncontingent rewarding behavior to the target person. In other words, a family member is more likely to change his or her behavior in order to please somebody who pleases him or her and will be less motivated to change behavior to please a person who is not seen as unconditionally rewarding. The frequently repeated phrases “I’d do anything to please him” and “Why should I please him?” reflect these basic tenets on the social context of behavior change.

Stuart’s formulation suggested a strategy for enhancing the mutual attractiveness of family members, even in situations where long-standing acrimonious, coercive interaction existed. This approach involved taking the initial focus of intervention away from the presenting problems of the family to constructing a setting in which the frequency and intensity of mutual positive reinforcement are maximized. Family members are required to search for the positive qualities of one another rather than to dwell on their weaknesses. This is carried out in four steps:

1. There must be a rationale for mutual change.

2. Each partner of a dyad must initiate changes in his or her behavior first.

3. The frequency of targeted behavior must be recorded on a chart.

4. There must be a contract for a series of exchanges of desired behaviors.

In his initial efforts, Stuart (1969) employed the operant method of exchanging tokens as rewards for targeted desired behaviors. In this way, one person could build up a “credit” balance by performing a high frequency of behaviors desired by other family members, which could later be exchanged when he or she was the recipient of rewarding behavior from others. Refinements of this approach dispensed with tokens. Mutual exchanges were based on written contracts. Although much of Stuart’s work has been devoted to marital discord, his contingency contracting and principles of enhancing the mutual positive reinforcement potential of family members has been used widely by behavioral family therapists (e.g., Patterson, 1971).

It may be concluded that behavioral family therapy developed from the careful application of learning theory principles to the problems of family discord and distress. This approach owed less to the charismatic leadership of its early protagonists and more to evidence of its effectiveness in clinical practice. Although I have focused on three pioneers who played major roles in the initial developments of th...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Contributors
• Foreword
• Contents
• Part I: General Issues
• Part II: Specific Applications
• Index