Family Therapy

The final option is to engage family members in conjoint therapy. The therapist may choose this option if assessment has led to a complex case conceptualization that involves serious problems with family interactions. Of course, family members must also be amenable to this type of treatment. A decision to engage in family therapy may not occur until after one or two family meetings with the cognitive therapist.

If a therapist and family agree that family therapy may be helpful, they need to decide whether family therapy should occur in addition to or in lieu of individual therapy for the identified patient. Evidence (reviewed below) suggests that couple therapy—on its own—can be an effective intervention for treating depression. If the case conceptualization suggests that much of the patient's depression is associated with family problems, and the patient has few problematic cognitions or behaviors that are unrelated to family interactions, the family and therapist may choose to do family therapy only. After family therapy is completed, the therapist and patient may evaluate whether further individual therapy is indicated.

If family problems seem to be only a part of the identified patient's problem list, and she has other types of problems as well (e.g., illness, general social skills deficits, etc.), or if the patient seems to demonstrate a pervasive pattern of dysfunctional beliefs about herself, then the combination of CT and family therapy may be indicated. At this point, the therapist and family members need to decide who will conduct the family therapy. There are two options: The individual cognitive therapist may also conduct family therapy, or the cognitive therapist may refer the family to another therapist. The advantage of having one therapist conduct both individual and family therapy is that the therapist and family can further develop an integrative case conceptualization and treatment rationale that is not confusing or contradictory. This conceptualization can then be used to guide both the individual and the conjoint treatment.

However, a therapist may have ethical and other concerns about conducting both individual and family therapy. He/she may be concerned about forming a productive alliance with all family members. If the therapist is seeing one person individually, the rest of the family may believe that the therapist is most closely allied with that particular person. We do not believe that this issue is insurmountable; however, it is important that it be addressed directly with the family, and that all family members be encouraged to voice any concerns that they may have. The therapist needs to ensure that he/she does not inadvertently favor one individual over another. Of course, this concern is not unique to this situation; a family therapist must always be conscious of whether he/she is siding with one particular member of a family.

A second issue is that of confidentiality. We recommend discussing confidentiality at the outset and setting parameters around safety for the patient and other family members. We encourage family members to reveal information that affects the patient's treatment and improves family functioning. Individual sessions may be confidential to allow each participant to disclose information to the therapist that might be important. The therapist can help to identify information that would benefit other family members and encourage the patient to share this information with them. If the patient is not ready to reveal information to others, the therapist can help that person look at the advantages and disadvantages of disclosing the information in family sessions or work on the issues until he/she can disclose them to the family or partner.

For each case, the therapist and family should weigh the pros and cons ofwhether to have the individual cognitive therapist conduct family therapy. Families' preferences are obviously important. If an outside referral is chosen, close collaboration between the two therapists (with the family's permission) is essential.

Whether a clinician sees family or refers them, family sessions for family therapy should be compatible with the general philosophy and format of CT; that is, family sessions should be problem-focused and present-oriented in family therapy. The therapist strives to have a collaborative relationship with all family members. Conceptualization of family problems focuses on understanding the interactions between cognitions, emotions, and behaviors for each individual, and the impact of each family member on the others. There should be a focus on setting measurable goals and regularly assessing how closely family members are to meet their goals. Family therapy should be time-limited and include other features of CT, such as setting an agenda for each meeting and assigning homework.

We believe that several types of treatments for family problems may be successfully integrated with CT, including cognitive-behavioral couple therapy (Epstein & Baucom, 2002), integrative couples therapy (Jacobson & Christensen, 1996a), and problem-centered systems therapy of the family (Ryan et al., 2005).

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