Journal of Family Psychotherapy, 25:132–144, 2014

Copyright © Taylor & Francis Group, LLC

ISSN: 0897-5353 print/1540-4080 online
DOI: 10.1080/08975353.2014.910023

A Cognitive Behavioral Systems Approach

to Family Therapy

TERENCE PATTERSON
Department of Counseling Psychology, University of San Francisco, San Francisco,
California, USA

Family therapy, including conjoint approaches to couples, families,

and parent-child dyads, is infused with concepts adapted from gen-
eral systems theory. Many of the most popular models during the
period when family therapy flourished in the 1960s and 1970s
directly incorporated systems theory. As modifications and new
approaches came into vogue in the 1980s and 1990s, the contribu-
tions of systems concepts were eclipsed and theorists, researchers,
and practitioners often failed to acknowledge their contribution.
In an attempt to re-integrate these developments in state-of-the-art
family therapy, this article will explore systems theory, its com-
plementary characteristics with cognitive behavioral therapy, and
how these 2 approaches can be simultaneously applied to family
therapy in a comprehensive, integrative manner. The distinctions
between cognitive therapy, behavioral therapy, and (combined)
cognitive behavioral therapy will be delineated; after which cog-
nitive behavioral therapy interventions and their relationship to
systems concepts will be described. An illustrative model will be
presented with recommendations for future research.

KEYWORDS behavior therapy, cognitive therapy, family therapy,

systemic therapy, systems theory

Address correspondence to Terence Patterson, Department of Counseling Psychology,

School of Education, 2130 Fulton Street, San Francisco, CA 94117-1071, USA. E-mail:
pattersont@usfca.edu

132
 Cognitive Behavioral Systems Family Therapy 133

INTRODUCTION

An open system is a set of objects with attributes that interrelate in an

environment. The system possesses qualities of wholeness, interdepen-
dence, hierarchy, self-regulation, environmental interchange, equilibrium,
adaptability, and equifinality. (Littlejohn, 1983, p. 32)

EVOLUTION OF FAMILY SYSTEMS AND COGNTIVE

BEHAVIORAL CONCEPTS

General systems theory (GST) involves a set of analogous descriptors that

were originally applied to biology and later ascribed to physical and social
systems. GST was all the rage in the intellectual world in the 1920s, with
worldwide conferences held to laud its avant-garde approach to understand-
ing phenomena (von Bertalanffy, 1968). Systems theory1 as applied to family
therapy/psychology entails a number of principles including, for example
(Phipps, 2004; Phipps & Vorster, 2011; von Bertalanffy, 1968):

● Organization and wholeness: That a family behaves as a whole, that is, the
change in each member depends on all others.
● Non-summativity: That the whole is greater than the sum of its parts
suggests that: (1) the family behavior as a whole cannot be reduced to
their functioning alone or independently of one another (i.e., interac-
tion); (2) one member affects another member who affects that original
member (i.e., circular/non-linear causality); and (3) the meaning of the
(individual’s) part is determined by the (family as a) whole (i.e., context).
● Hierarchical order: That systems are subject to different orders or levels
indicates that a family, on the basis of its functions (i.e., rules), can be
divided into subsystems that are arranged on different levels.
● Open/closed nature: That open systems exchange input with the environ-
ment highlights that, because an open family system is one that constantly
interacts with the environment/other systems, it can tend toward increasing
order and organization (i.e., negentropy).
● Feedback: That systems can be self-regulating or purposeful by virtue of
the principle of feedback means that the family can achieve homeostasis
(i.e., restoring a system via negative feedback) or heterostasis (i.e.,
changing a system via positive feedback).

The application, therefore, of GST to family therapy meant that for the
first time the family—and any other unit(s) of interaction for that matter,

1
This article refers specifically to systems concepts applied to family therapy, rather than the various
“systemic” models such as multisystemic (Huey, Henggeler, Brondino, & Pickrel, 2000), Milan systemic
family therapy (Boscolo, Cecchin, Hoffman, & Penn, 1987), and others.
134 T. Patterson

including a couple—could be understood as whole, that is, not just as indi-

viduals but also the relationship(s) between them. Accordingly, then, this
constituted an early, important development in thinking.
In many ways, GST actually paralleled a later evolution of psycholog-
ical theory, even art to a certain extent, in shifting away from linear (i.e.,
straight-line), formal structure and causality to more free form, expressionis-
tic models (Watzlawick, Weakland, Fisch, & Erickson, 1974). Picasso in the
art world and Maslow in psychology represented these trends. Developments
in GST and art also corresponded to the changes occurring in the field
of psychotherapy in general, as formal structures and procedures gradu-
ally gave way to greater flexibility and creativity. Psychoanalysis evolved
into psychodynamic therapy, and figures such as Carl Rogers (1961), Viktor
Frankl (1963), and B. F. Skinner (1938) introduced revolutionary theories and
methods antithetical to psychoanalysis. The field of family therapy emerged
in the 1950s, with pioneers such as Ackerman (1966) and Bowen (1978)
applying psychoanalytic principles to treat families. Other figures such as
Gregory Bateson at the Mental Research Institute (Bateson, 1980) embraced
a non-linear, more flexible systems therapy model that incorporated newer
humanistic and short-term approaches that included the concepts of GST.
As behavioral and cognitive theorists and practitioners entered the
family therapy field, new applications of learning or conditioning and cog-
nitive schemes emerged in psychotherapy. Robert Weiss (Vincent, Weiss,
& Birchler, 1975), Richard Stuart (1998), Howard Markman (Markman &
Floyd, 1980) and Neil Jacobson and Gayla Margolin (1979) pioneered behav-
ioral couple therapy (BCT), and John Gottman (1999) later became its
most prominent proponent. Andrew Christensen and Neil Jacobson devel-
oped an integrative model (Christensen, Jacobson, & Babcock, 1995). Gerald
Patterson (Patterson & Chamberlain, 1994), James Alexander (Alexander &
Robbins, 2010), and Robert Liberman (1970) introduced new models of
parent-child and family therapy, and Norman Epstein and Donald Baucom
(2002) and others developed cognitive procedures in couple therapy. Today,
these models and variations thereof—which tend to draw on elements of
behavior therapy (i.e., emphasizing observable behavior), cognitive ther-
apy (i.e., focusing on schemas or cognitions), or cognitive behavior therapy
(a combination of both)—are often more generally referred to as cognitive
behavioral therapy (CBT).
Having considered some of the earlier developments in CBT and sys-
tems theory, the aim of this article is to demonstrate that, as it pertains to
the practice of family therapy, CBT fits comfortably with systems theory and
incorporates many complementary concepts. To begin, the basic concepts
of behavior therapy, cognitive therapy, and CBT within family therapy will
be described. After this, an examination of the complementarity between
CBT and systems theory will be undertaken, followed by an illustration of
how a combination of these models may constitute an effective method of
intervention with families.
 Cognitive Behavioral Systems Family Therapy 135

BEHAVIOR THERAPY, COGNITIVE THERAPY, AND CBT

IN FAMILY THERAPY

It is important to clarify that the term CBT has come to be considered as

an approach that attends to both cognitions and behaviors. Common areas
can be identified between them and clinical practice usually employs both
aspects, although purists exist in both areas, and radical behaviorists and
cognitive psychologists often find the orientations to be independent of each
other. Today “CBT” is a common response to surveys on theoretical orienta-
tion (Solem, Vogel, & Hofmann, 2010), despite the fact that many clinicians
are not well trained in either method and often use an eclectic, ad hoc
approach.
Cognitive therapy per se, identifies internal processes and does not
directly address the (stimulus-response) sequences of behavior as conven-
tionally understood. “Cognitive” indicates that specific attention is being
given to thought processes, and in pure cognitive therapy thoughts are
viewed as the key to dysfunctional emotions and behaviors (Beck, 1967).
Cognitive restructuring then becomes the primary intervention.
Behavior therapy, on the other hand, focuses on observable, quan-
tifiable behaviors within the environment in context, and addresses their
antecedents and consequences. Its theory and practice can be summarized
as follows (Corey, Corey, & Callanan, 2012):

● Classical conditioning highlights certain respondent behaviors, as in

changing a neutral stimulus into a conditioned stimulus or one that elicits
a predictable response.
● Operant conditioning focuses on actions that operate on the environ-
ment to produce consequences and involves response prevention, and
reinforcement methods.
● Social learning gives prominence to the reciprocal interactions between
an individual’s behavior and the environment.

In addition to the above, behavior analysis (O’Donohue & Ferguson,

2006) also contributed much to the development of behavior therapy.
Behavior analysis involves both classical conditioning and operant principles
and relies on systematic assessment procedures rather than on unverifiable
theories. Such behavioral models have either evolved into approaches inte-
grating elements from other therapies or their methods have expanded as
their evidence base has increased. Consider, for example, the use of expo-
sure therapy. This therapy, which entails the gradual exposure of the client
to a variety of fear stimuli while simultaneously providing an opposite expe-
rience, such a relaxation, has now become an empirically validated and
accepted treatment for post-traumatic stress disorder (PTSD; Foa, 2011).
136 T. Patterson

Because family therapy generally focuses on behavioral outcomes, the

focus of this article is primarily on the behavioral components of CBT with
couples and families, while acknowledging that CBT is the most commonly
used term for an integrative process. In fact, in considering the role of cogni-
tive in comparison to behavioral components in couple therapy, at least one
study (Halford, Sanders, & Behrens, 1993) found that while clinically useful,
there is no empirical evidence that adding the cognitive approach to basic
behavior therapy improves outcomes.

COGNITIVE BEHAVIORAL FAMILY THERAPY

In reality, as most cognitive behavioral family therapy was developed and

is primarily practiced with couples, this article will frequently refer to cou-
ple therapy as an aspect of family therapy (Patterson, 2005). Two aspects
will be considered in this regard, namely BCT and cognitive couple therapy
(CCT). The key focus in BCT is on the operant aspects, or the responses that
occur following a behavior. For example, desirable behaviors are appro-
priately reinforced, and undesirable ones are extinguished or punished.
An action elicits a chain of responses initially from a respondent, back to
the initiator, back to the respondent and multi-directionally to others in the
environment/system. This operant factor illustrates that responses do not
operate in isolation, that is, behaviors are not viewed as linear or one-way
occurrences. Actions that precede and follow the event, the total environ-
ment (work, home, community, family, etc.), and characteristics of each
person are key factors in assessment, treatment, and prevention.
Applied to BCT, Jacobson & Margolin (1979) describe three basic
elements:

● Communication—listening, receiving, and responding.

● Problem solving—respectful, collaborative, and systematic generating of
solutions to priority issues.
● Behavior exchange—equity in task allocation.

If the change brought about by the behavior in BCT is reinforcing, the

chances are strengthened that the desired behavior will occur again. If the
behavior is not reinforced, the likelihood of its recurrence is diminished.
BCT has been not only the most researched model of couple ther-
apy, but also the most effective with specific populations, including PTSD
(Monson, Fredman, & Adair, 2008); substance abuse (Fals-Stewart, O’Farrell,
Birchler, Córdova, & Kelley, 2005); and juvenile offenders (Sexton & Turner,
2010). Effectiveness studies have also demonstrated that BCT can pro-
duce equal or better results than individual therapy with such disorders
 Cognitive Behavioral Systems Family Therapy 137

as depression (Beach, Whisman, & O’Leary, 1994), child conduct disorder,

(Dadds, Schwartz, & Sanders, 1987), and eating disorders (Bulik, Baucom,
Kirby, & Pisetsky, 2011), among others.
A CCT model that has been prominent in recent decades places empha-
sis on the reciprocal cognitions and interactions of partners in a relationship
(Epstein & Baucom, 2002). Expectations, attributions, and fixed perceptions
are key to behavior, and intervention is geared toward changing a range of
faulty cognitions. While some CCT therapists work directly with behaviors,
the premise is that accurate cognitions will result in desirable behaviors.

COMPLEMENTARITY BETWEEN CBT AND SYSTEMS THEORY

The integration of systems theory with CBT forms a cognitive behavioral

systems approach to family therapy that is simple and elegant for the prob-
lems discussed in the previous section and other issues that clients present.
The cognitive and behavioral nature of direct, problem-focused treatment
involving significant others allows for observation, feedback, and interven-
tion with the structures and dynamics of systems as they present themselves,
and for response patterns to be modified directly. While most forms of family
therapy allow for the concepts from systems theory to come into play, CBT
provides a flexible framework for assessment and a pathway for treatment in
a focused and time efficient fashion. The interlocking concepts that provide
integration between systems and CBT can be summarized as follows:

● Structure and organization refers to patterns in which individuals are

arranged (and rearranged) in a system. Highly organized systems can
either be functional or dysfunctional, open or closed, and some structure
is necessary if the system is not to disintegrate. CBT is a highly structured
model, which involves identifying dysfunctional thinking, connecting them
to behaviors, and modifying thinking that is more consistent with desired
behaviors.2
● Contextuality a central tenet in both systems and behavioral theory,
involves the concept that individuals and groups do not live in isolation,
and that they affect the environment and are in turn influenced by it.
In the operant sense, behavior elicits a response and is in turn affected by
that response. Contextuality allows behavior to be fully understood and
addressed.

2
It should be noted here that the cognitive component of CBT relates to intrapsychic phenomena,
and when cognitive therapy is practiced independently, the internal world of the individual is focused
upon. The more common application of CBT incorporates the intrapsychic to some degree, but the
interactive and contextual aspects (observable behaviors) of the relationship are also emphasized.
138 T. Patterson

● Communication and other overt behaviors involving circularity are present

in open and closed systems; one action elicits a reaction in which feedback
loops occur back and forth. These can expand to the surrounding envi-
ronment and create multiple cross exchanges. Behavior therapists look
for contingencies of response through communication patterns, and how
those responses create new exchanges. Jacobson and Margolin (1979), as
noted earlier, posited communication as one of the three key elements
of BCT.
● Homeostasis is related to the above elements in that individuals and
systems strive to maintain a balance that is constantly challenged by inter-
action with the environment and the inevitable response-initiation cycle
that ensues. Interaction requires a response, which can make the status
quo impossible and a new adaptation unavoidable. The focus on direct,
in-session and daily activities in CBT inevitably disrupts old patterns and
aims directly at achieving a more functional balance within the system.

APPLICATION OF COGNITIVE BEHAVIOR SYSTEMS THERAPY

Comprehensive CBT involves systematic assessment that includes the follow-

ing: Structured interviews, paper and pencil or computerized inventories,
structured and coded observation, behavioral logs or records, and physio-
logical measures. Data on logical categories and quantities of behavior are
recorded and prioritized as a key to intervention and modification of proce-
dures throughout treatment. A baseline of behaviors is established and targets
for change are established. Collaboration with clients is key to understanding
behaviors and developing and modifying treatment plans. Intervention takes
place with an understanding of the contingencies of behavior (antecedents
and consequences), and can include: Stimulus control, response prevention,
positive and negative reinforcement, shaping and extinguishing behaviors,
exposure and systematic desensitization, emotion modulation, and cognitive
restructuring.
Ongoing assessment may indicate that behaviors have increased,
declined, or remained at baseline, and interventions may be modified at any
point. Feedback is also obtained periodically so that the client’s perception
of the treatment is fully understood and used to assess the need for a change
in intervention. Assessment upon termination of treatment and at periodic
intervals thereafter is common in research studies and useful in clinical treat-
ment. CBT therapists evaluate not only improvement in target behaviors, but
also the secondary impact of various interventions.
Many of these standard interventions are common to all varieties of
CBT couple and family models, with the emphasis depending upon the
orientation of the clinician. One who is more cognitively oriented in couple
 Cognitive Behavioral Systems Family Therapy 139

therapy would begin with the thoughts of each spouse about his or her
partner, and focus intervention on developing more functional cognitions
and behaviors. A more behavioral CBT therapist would begin with the
antecedents and consequences of the target behaviors, note the thoughts of
each about these behaviors, and apply positive reinforcement and response
prevention as primary methods.
Applied in conjunction with systems concepts, then, CBT relies heavily
on organization and wholeness, placing emphasis on the structural elements
of client behaviors (antecedents and consequences), and views clients in
the entire context of their environment. Therapeutically, CBT adheres to
a fluid structure involving assessment, treatment formulation, and ongoing
evaluation. Non-summativity applies to CBT in viewing the functioning of
whole system rather than the individual member alone as the essential focus
of intervention.
Hierarchical order is evident in CBT in recognizing that boundaries are
necessary in subsystems in terms of age, roles, and relative influence, and
without them structure and order are not possible. Feedback applies to CBT
in the emphasis on multi-directional, clear communication in relationships;
the openness of a system both within itself and to the environment affects
the degree and type of communication that occurs.
As can be seen from the above, intervention in (integrated) cognitive
behavior systems therapy requires a constant focus on systems components
while using a flexible structured approach. One of the most salient advan-
tages of this model is maintaining the focus on the interactive aspects of
the couple or family, rather than on the internal processes of individuals.
In circular and non-summative fashion, the therapist uses a wide angle lens
in viewing the family, seeing the unit as a whole rather than as individual
members.
A brief practical illustration of the use of CBT and its complementarity
with systems concepts will highlight the simplicity and ease of use in family
therapy.

Illustration of Cognitive Behavioral Systems Approach to Family

Therapy
Let us now look at two examples of processes in family systems.

Example A: Family A is faced with the death of a close grandparent, the

job loss of the mother, and an accident by the teenage son. They typ-
ically do not discuss difficult matters nor express their emotions to each
other easily. There is no clear delineation of responsibility for chores, such
as bill paying or for social activities, and the children do not know who
140 T. Patterson

to go to for advice or permission. They tend to be reactive to events

in the sense that they rarely plan ahead, and have generally maintained
the same routines and relationships among themselves for 20 years. They
also are not “joiners,” in that they are not members of churches, com-
munity organizations, or social groups. They maintain their equilibrium
by neither openly discussing these issues nor planning to address them.
Consequently, the anxiety is mounting within and among them, a younger
son is becoming depressed, and a financial crisis is approaching.
Example B: Family B is facing the same stressors as Family A, but as their
routine is to have dinner together each evening when they discuss major
issues, they are aware of the details of these events and of each others’
reactions to them. The parents are clearly in charge of major decisions and
responsibilities are well defined. They are organizers and planners and the
children have developed this approach as well. The family has clear ideas
of how to decrease spending and increase income, deal with the accident,
and they are planning a memorial for the beloved grandparent together.
They participate regularly in school, church, and community activities,
and as an open system, others are stepping forth to assist and offer con-
dolences. They maintain an equilibrium as well, and the emotional climate
is positive and no family members are symptomatic.

Systems concepts can be clearly seen in both families. Family A lacks

organization, structure, boundaries, communication (feedback loops) and
exemplifies a closed system. Their homeostasis maintains them as a unit,
but also allows the tension to mount as a potential crisis and disintegration
looms. Their connection to a larger ecosystem is lacking, furthering their
tendency toward disorder and pathology. Conversely, Family B is organized
with an appropriate parental hierarchy, clear rules and boundaries, and flex-
ibility in adapting to critical life changes. Their stress is by moderated by
these factors and their ties to outside groups. Their balance and wholeness
can facilitate their growth as a unit and protect those individuals who might
otherwise become symptomatic.
Now add to this CBT principles and the therapist may then proceed as
follows with Family A:

● A thorough assessment would be conducted to obtain a view of the entire

context of the family and each individual’s views and behaviors;
● A plan would be developed with the family to identify changes that would
be reinforcing to each family member and the entire system, and an
appropriate hierarchy would be developed between parents and children;
● Goals such as open communication and connection with the larger com-
munity would be identified and prioritized, with responsibility assigned to
specific individuals;
 Cognitive Behavioral Systems Family Therapy 141

● Potential obstacles to success and ways to circumvent them would be

discussed; progress would be monitored daily by family members and
evaluated regularly in therapy sessions;
● Ongoing feedback would be elicited from each family member and
modifications would be employed as needed.

QUESTIONS FOR FUTURE RESEARCH

This article has described CBT as one of the most widely researched forms
of family therapy and illustrated how it can be integrated with systems con-
cepts. Yet, as in any model, there are no simple prescriptions on how to
proceed, and the methods are not cut and dried. Questions remain on how
the integration of cognitive, behavioral, and systems principles can extend
its benefits more deeply and broadly in family intervention science. Having
identified that these approaches would appear to be highly complementary,
future research could shed light on important questions such as:

● Which proximal and distal antecedents to couple, family, and parent-child

behaviors should be prioritized across cultures, problems, settings, and
specific family forms?
● How far should circular effects of problems and resulting interactions be
explored and which can be viewed more linearly (i.e., in terms of cause
and effect)?
● How can homeostasis be maintained in terms of maintaining old patterns
of behavior and dealing with potential disintegration of a family or abuse
of a member?
● How can the perceptual styles and cultural backgrounds of individual fam-
ily members be assessed more precisely in order to achieve an optimal
balance of cognitive and behavioral techniques?
● What are the keys to determining which and when direct behavioral or
cognitive interventions will be effective for couples and families most likely
to drop out of therapy after a few sessions?

SUMMARY AND LIMITATIONS

This article has demonstrated that systems and cognitive behavioral

approaches interlock organically and, in combination, form a pragmatic
approach to therapy with couples and families. In fact, systems concepts
can expand the scope of any type of therapy, including treatment of indi-
viduals and groups, as long as clients are viewed in their larger contexts
and multiple factors are considered in assessing and treating presenting
142 T. Patterson

problems. Behavior and cognitive therapies in isolation have been fre-

quently viewed as overly intellectual and mechanistic and, indeed, without
a systems lens they can be limited. CBT approaches add structure and tech-
niques to the systems approach, while systems concepts broaden basic CBT
methods.
However, limitations exist in the application of CBT and systems mod-
els to family therapy. CBT in isolation can result in rigid, formulaic methods,
while systems models can ignore situations where clear cause and effect
sequences exist, temporary equilibrium may rapidly lead to family break-
down, and urgent situations may not be addressed in a timely manner.
An example of when the concept of reciprocity or circularity is taken to the
extreme is in a family where repeated, one-way abuse of a family member
occurs. Such abuse should not be viewed solely in terms of cause and effect
or circularity; there is clearly a perpetrator and a victim, as well as precipitat-
ing events, and swift action must be taken to provide safety. An appropriate
view would be to assess the antecedents and consequences of the abuse,
and immediately take action to protect the victim in an ethical and legal
manner. An integrated CBT and systems approach would take the assess-
ment of reciprocity into account while using effective CBT methods. This
approach would increase the opportunity for safety and autonomy of the
victim of abuse.
Understood holistically, a cognitive behavioral systems approach can be
applied effectively to many different types of problems, settings, and pop-
ulations. But just as with any specialized approach, a significant amount of
intensive training is required in order for results to be robust and reliable.
Rigid adherence to a single school of therapy can be ineffective in multi-
cultural, naturalistic, dynamic settings such as schools, community agencies,
correctional facilities, and crisis situations. The flexibility of a (integrated)
cognitive behavioral systems approach to family therapy makes it applicable
to multiple, diverse environments and populations.

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