Cognitive–Affective Behavior Therapy
For individuals in the U.S. & U.S. territories
In Cognitive–Affective Behavior Therapy, Dr. Marvin R. Goldfried shows how this approach works. Although primarily a cognitive–behavioral approach, this therapy also incorporates elements of experiential therapy so as to increase the possibility of the client having connective experiences between sessions. In this session, Dr. Goldfried works with a 31-year-old woman who is struggling with expressing her feelings and being vulnerable in the most serious relationship she has had since her divorce 8 years ago.
This DVD features a client portrayed by an actor on the basis of actual case material.
The client, Janet, has thought on and off about seeing a psychologist for 4 or 5 months. She has been feeling depressed about her relationships with others; she is tired of feeling frustrated and unhappy, and she wants to change. A colleague at work suggested that she see Dr. Goldfried.
Janet has been in a relationship with Larry for about 6 months. She has had many relationships since her divorce 8 years ago, but none of them lasted for more than 7 or 8 months. Often these relationships were with married men or men who were in some way "not real possibilities." Janet believes that her relationship with Larry has the potential to be "the real thing." In Larry, she has finally met someone with whom she feels she might be able to really open up; someone whom she can trust; to whom she might be able to show "her real self," but she doesn't know how.
Janet doesn't want to "blow it" with Larry. She wants to be able to express herself, to get angry, to tell him what she wants in the relationship. But she can't, and Larry is getting frustrated with Janet's inability to express her feelings. When he tries to get her to talk about herself, Janet shifts the conversation back to him. Sometimes she gets very distant, inexpressive, and removed. Sometimes she has fits of temper and just blows up over small things. When she gets angry, she is afraid of her anger and often feels that it is inappropriate. She would like to share her feelings but she is afraid of expressing what she wants, but then she is afraid of losing Larry if she doesn't open up. They seem to fight about insignificant things, like Larry being late or forgetting to call her. Janet says that she "feels trapped" by her inability to express her feelings, but she is afraid "to open the door."
Session 1: Dr. Goldfried began the session by asking, "Tell me, what prompted you to get in contact with me at this particular time?"
Janet described her concerns about her relationship with her boyfriend.
Dr. Goldfried asked Janet about her recent past with other men and about her marriage. Janet told him about her other relationships in the 8 years since her marriage. She rarely stayed in a relationship for more than 7 or 8 months, by which time it would become too strained and stressful for her. During each of Janet's relationships, she was monogamous.
Toward the end of the session, Dr. Goldfried described what would happen in therapy. He told Janet that he would spend the first two sessions and part of the third session getting to know her as a person. He informed her that by the third session he would share with her what he thought.
He described the therapeutic alliance that they would seek to achieve, which was composed of three parts:
- a bond between the patient and the therapist, in which the patient must feel comfortable and assured that the therapist is in tune with the patient and that the therapist has the patient's interests at heart;
- establishment of goals for the therapy; and
- agreement about the means of therapy.
Dr. Goldfried asked Janet to fill out a biographical questionnaire and mail it back to him before their second session, and he requested that she complete the Beck Depression Inventory, which he also wanted her to mail back to him before their second session.
Dr. Goldfried saved the last 5 to 10 minutes to ask Janet whether she has any questions for him. She had a few questions about his background and training, which he answered. Finally, he asked Janet if she was interested in working with him. She answered yes.
Session 2: Dr. Goldfried used the information from the biographical questionnaire Janet mailed to him as a launching point for their second session. He asked her specific questions about things that stood out in her "history," such as her relationship with her father and mother, the death of her father, her previous marriage, and why she only went to college for 3 semesters. Janet told him about the financial situation after her father's death and being unable to afford to finish college. She told him about secretarial school and her work history as a highly successful legal secretary.
Session 3: In the third session, Janet and Dr. Goldfried explored in greater detail her relationships with men, focusing on Larry as the initial example and her marriage and two other 8-month relationships as further examples. Dr. Goldfried looked for themes and patterns of overlap in her experiences with men. A pattern of cycling monogamous relationships emerged.
Dr. Goldfried returned Janet to a discussion about her relationship with Larry. With a goal of slowing down the deterioration of her relationship with Larry, Dr. Goldfried suggested that he might want to have a session with Larry. Because Larry is supportive of Janet's being in therapy, Janet agreed that a meeting between Dr. Goldfried and Larry might be useful.
Dr. Goldfried then turned to a further discussion of the therapeutic alliance. He restated the need for the bond between Janet and him, a sense within her that he understands what they are discussing.
He explained that they would work to establish a priority of goals for the therapy. Janet clearly identified three goals (in order): her relationship with Larry, eventual resolution of her interpersonal problems at work, and a better long-term relationship with her mother, if possible.
Dr. Goldfried described the process of the therapy. He explained that Janet needed to learn how to tune into what she needs and to find a means of expressing those needs. She and Dr. Goldfried would attempt to achieve this through role-playing as an imaginary rehearsal of behavior in the hope of removing Janet's barriers. Dr. Goldfried described the various "risk-taking" scenarios that Janet would act out between sessions. Each role-play or risk-taking homework assignment would focus on one small step in Janet's hierarchy of fears, based on her readiness to do so.
Session 4: to be viewed.
The approach is predominantly cognitive–behavioral in orientation, but with the incorporation of contributions from experiential and interpersonally oriented psychodynamic therapy. It is possible to incorporate elements from these different orientations by thinking of the change process as involving certain common principles. Included among these general principles of change is the facilitation of expectations that the psychotherapy will be helpful; the presence of an optimal therapeutic relationship; the offering of feedback for purposes of increasing the patient's awareness; the encouragement of corrective experiences; and the emphasis on continued reality testing, a form of "working through."
The different therapeutic orientations reflected in this demonstration may be viewed as implementing the more general principles of change. The three major orientations to psychotherapy have something unique to offer, each complementing the other. Thus, behavior therapy has developed innovative methods for increasing the likelihood of the patient having corrective experiences between sessions. Interpersonally oriented psychotherapy helps us to use the interaction therapeutically as a sample of issues relevant to the patient's life problems. Experiential therapies allow the facilitation of affective arousal, providing patients with a better awareness of what they want or need.
In the DVD, the therapist attempts to increase the patient's expressiveness by helping her tune into her feelings and intentions, encouraging her to respond in accordance with these rather than with the concerns she may have about the potential reactions of others. By starting with an experiential focus on what the patient feels and wants, the behaviorally oriented rehearsal methods may be constructed as an "inside-out" approach to assertion and expressiveness training. The vignette in which the patient becomes angry at the therapist illustrates how this response may be used as a sample of the patient's interactional difficulties.
Marvin R. Goldfried, PhD, is professor of psychology and psychiatry at State University of New York, Stony Brook. In addition to teaching, clinical supervision, and research, he maintains a limited practice of psychotherapy in New York, New York.
A diplomate of the American Board of Professional Psychology, a fellow in the American Psychological Association, and an editorial board member of several journals, he has written numerous articles and books. His most recent book is From Cognitive–Behavior Therapy to Psychotherapy Integration. Dr. Goldfried is cofounder of the Society for the Exploration of Psychotherapy Integration.
- Goldfried, M. R. (1985). From cognitive behavior therapy to psychotherapy integration. New York: Springer Publishing Company.
- Goldfried, M. R., & Davison, G. C. (1994). Clinical behavior therapy (expanded ed.). New York: Wiley.
- Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change. New York: Guilford Press.
- Linehan, M., Goldfried, M. R., & Goldfried, A. P. (1979). Assertation training: Skill acquisition or cognitive restructuring. Behavior Therapy, 10, 372–388.
- Norcross, J. C., & Goldfried, M. R. (Eds.) . (1992). Handbook of psychotherapy integration. New York: Basic Books.
- Stricker, G., & Gold, J. R. (Eds.) . (1993). Comprehensive handbook of psychotherapy integration. New York: Plenum Press.
- Teasdale, J. D. (1993). Emotion and two kinds of meaning: Cognitive therapy and applied cognitive science. Behaviour Research and Therapy, 31, 339–354.
- Wachtel, P. L. (1977). Psychoanalysis and behavior therapy: Toward an integration. New York: Basic Books.
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