>> Cognitive behavioral family therapy is an evident base model that is often preferred in community agencies, hospitals, and other places where managed care and insurance companies require accountability. This approach requires the counselor or therapist to identify and name a problem, develop an understanding of the cognitive emotional behavioral processes involved, and work to create a rational problem-solving within the family system. Based on the work of pioneers like Albert Ellis and B. F. Skinner, Aaron Beck and his associates delineated the cognitive foundations for addressing depression, anxiety, and more recently, the personality disorders. The following video is an adaptation of an actual case conducted by Dr. Frank Dattilio, a distinguished cognitive behavioral family therapist. We join the video as Dr. Bitter conceptualizes the family systematically. Throughout the demonstration, however, he will also focus on developing a clear understanding of the underlying cognitions and cognitive schemas that are at the foundation of the family's dysfunction. The fighting that occurs between the family members is a direct result of everyone believing that he or she should be in charge of the family all the time. The young woman is also fighting against herself, feeling that if she does not challenge her parents and fight every effort to interfere with her power, she will become weak and humiliated, similar to the way she used to be. Toward the end of the video, the therapist has identified the irrational ideas that are part of the young woman's process, and together the therapist and the client are ready to challenge the truth of them. >> Dr. Bitter: So let me just see if I have all of this so far. The two of you, Joel and Cassandra, were quite young when Trish was born, and you are now very busy with the work that you do, so due to that, Trish takes care of the kids sometimes and is a good daughter in a lot of ways. She has kind of become an extension of the parenting force, and that's good in a sense, but on the negative side -- and I'm just hypothesizing here -- my impression is that this gives Trish a right to feel entitled sometimes and let her believe that she can demand some things. And when you say no, for instance, that causes some conflict. >> Joel: Yes. >> Dr. Bitter: Yeah. So, would you say that's correct, too, Trish? >> Trish: I would. >> Dr. Bitter: Okay. So I want to get an idea about what your automatic thoughts are when these situations come up, what your beliefs might be and how you see these conflicts. Maybe we can get an idea of how you can look at them differently. My impression, Trish, is that you're probably a little bit confused by all of this. >> Trish: Well, yeah. I mean, yeah, I am because in a lot of ways they tell me, you know, "You're responsible for the children and take care of them and, you know, you can tell them to do this and this and this," and then at the same time I'm responsible for the horses and, in fact, I'm responsible for all the animals in the home. But they tell you "You're in charge, you're in charge, you're in charge. Oh wait, you're not in charge." >> Joel: I think if she had her way, she wouldn't watch the children at all. >> Trish: And he's right. >> Dr. Bitter: Okay. So Joel, what is your hope for her with the kids anyway? >> Joel: Well, I just wish that she would keep them from fighting with one another, make sure they're fed, not get into arguments. Just take care of them. That's all we want. >> Dr. Bitter: Okay. So, when you have this role, what are some of your thoughts and feelings about it? >> Trish: Well, it's really hard for me. I mean, I'm a real take-charge kind of person. I like to be in charge and tell everybody else what to do, and it's just confusing not knowing when I have that responsibility. >> Dr. Bitter: Mm-hmm. So when you're in charge, you're happy, but when you get around to wanting to tell Mom and Dad some of the things that, how you see them and what you think should be happening, that's when there's some conflict? >> Trish: Yeah, it's real difficult to know when I'm in charge and when I'm not. >> Dr. Bitter: Okay. So could we talk about some of these conflict areas specifically? >> Trish: Yeah. One area is how I treat my brothers and sister. >> Dr. Bitter: Okay, for example? >> Trish: Well, my sister and I don't get along at all. Like we fight and constantly throw insults at each other, and we can't get along pretty much under any circumstance. >> Dr. Bitter: And why would you say there's so much bitterness between the two of you? >> Trish: I would say I'm bitter because, just for the fact of her being born. She -- I really think that she took my parents away from me. >> Dr. Bitter: In what way? How's that? >> Trish: I think they -- I just don't have their attention anymore, their focus, and that bothers me. >> Dr. Bitter: Okay, so the only attention that you get is when you're being the responsible oldest child? >> Trish: I don't know about that. >> Dr. Bitter: Do you think that it might be why you assume the role sometimes? Because that's your way of getting some attention? >> Trish: Possibly. >> Dr. Bitter: Okay. If you didn't have the role or responsibility, do you think you'd get any attention from your parents? >> Trish: I don't know. >> Dr. Bitter: Well, it's something to think about, isn't it? >> Trish: Yeah. >> Dr. Bitter: So, do you get along with your sister on anything? >> Trish: Well, once in a blue moon. I mean, there are times when it's really seldom that we'll actually talk about something and not argue or not fight, but mostly we do fight. I get along with my brothers better. >> Dr. Bitter: Why is that? >> Trish: Because they listen to me more. I get along really well with Alan. >> Joel: That's because he does whatever she says. >> Trish: Well, he thinks I'm a god and, you know, he does everything that I say. You know, Andy is a little bit more stubborn, more strong-willed like myself, so there are definite times when he and I will fight, but overall he'll listen to me. You know, sometimes I'll tell him to do something and he won't do it, and that's when we will actually fight it out. >> Dr. Bitter: Okay. And who usually wins? >> Trish: Well, I do because I'm bigger. >> Dr. Bitter: And then what happens? >> Joel: Then he goes off to his room or somewhere by himself. He plays Power Rangers or something. And sometimes I say something to her. Sometimes she takes the correction, but sometimes she doesn't. >> Dr. Bitter: Okay, so the conflict comes in relation to who's asserting power and who's got responsibility? >> Trish: Well, partly, but it's also about the horses, too, because there's times when, you know, I'm in charge of the horses and there's times when I will actually make a, you know, correction about the horses, and that causes conflict, too. >> Dr. Bitter: Okay, so how do you work out disagreements in your family? What are the rules? >> Trish: Whoever yells the loudest wins. >> Joel: There are no rules. >> Dr. Bitter: So the person with the loudest voice? >> Joel: No. >> Trish: Every once in a while. >> Dr. Bitter: Okay. Well, at least that's your perception, huh? >> Trish: Usually, I mean, we have to compromise and if we do compromise, and if we don't, then basically you've got someone saying, "Fine, do it your way." >> Dr. Bitter: Okay, so everybody keeps at it until somebody gives in, and then if no one gives in, then that's when compromise happens? >> Trish: Usually. >> Dr. Bitter: Okay. Mom, what are your perceptions about the family in terms of how you deal with this kind of stuff? What's your schema for the family process? >> Cassandra: Well, as far as how we resolve conflict, it's not the way I would like it to be. I mean, I hate to argue and yell and all that stuff. I just, you know, basically I wish that he would be a little bit more calm when he addresses the children and would just talk to them about stuff. Basically I just wish everything was easier than it is right now. >> Dr. Bitter: Okay, but how do you deal with it? >> Cassandra: Mostly we just talk about it. I mean, as far as the horse things concerned with Trish, we just talk about it. I don't get angry very often, but if we are far off from a compromise, then I'll, you know, jump in and take over. >> Dr. Bitter: Okay, and how do you do that? >> Cassandra: Well, I'll just, I'll get the horse and I'll tell her to go inside. >> Dr. Bitter: And she listens? >> Cassandra: Mm-hmm. >> Dr. Bitter: Okay. So Trish, what goes on through your mind when your mom says that? >> Trish: When she says to "Give me the horse"? >> Dr. Bitter: Yes. >> Trish: Well, we, it's not good to fight in front of the horses. It upsets them, and we always compromise in front of the horses. It's just not good to fight in front of them. >> Dr. Bitter: Okay, so you give in then? >> Trish: Well, it's just not good to fight in front of the horses, so if that's what I have to do, then I will. >> Dr. Bitter: Okay, so if you're not in front of the horses, what happens then? >> Trish: Well, if we're going to compromise, that's the best way to do it because it's just never good to be in the barn fighting or be out in the yard fighting and for the horses to see it. So lots of times we'll just say "Let's try this, and if this doesn't work, let's try something else." >> Dr. Bitter: Okay. What's your perception, Joel, about how the family works things out? >> Joel: Well, I... think there's this whole attitude thing, and that's what bothers me. The kids have it, in particular, and it's like when we were home schooling, Trish was always rolling her eyes and saying people were stupid, and she did that so much, and I really hated that. And the kids do that all the time. I've never liked it. I sure didn't do that when I was growing up. If I'd done that, I would have been hit. Well, I would have been. Okay, maybe I wouldn't. I don't know. >> Dr. Bitter: Okay, so sometimes you pull rank when something like that goes on? So how does that work for you? >> Joel: Not well. Cassandra handles things much better, things like that much better. She's had more experience. She's raised children already. She grew up in a large family. She interacts really well with others, and she was on the debate team and all that good stuff. >> Dr. Bitter: Oh, oh, the debate team. >> Joel: Tell me about it. >> Trish: I was actually kicked out of class with debating with teachers and winning. >> Dr. Bitter: That's something you're good at. You probably got that from your mother. Joel, so it sounds like when you say that you don't have certain skills, it's more like you don't have anything to draw on from your own family of origin. >> Joel: Yeah, because in my family when I grew up, things just went smooth. >> Dr. Bitter: Yeah, that's one of the problems with that. So is it fair to say that one of the ideas that you had about your own family's life is that it would go smoother? >> Joel: Yeah. >> Dr. Bitter: Okay. And what happens in your family when the family violates that expectation? >> Joel: I get nervous. >> Dr. Bitter: And, I don't know, do you withdraw when you get nervous? >> Joel: Sometimes. I should. >> Dr. Bitter: What would be the difference between the times when you do and the times when you don't? >> Joel: Well, sometimes, sometimes we get into it, I get really into it, and I'm hammering a point home, and I just can't let go on that. And I get the feeling that they just don't get what I'm saying and I don't like that. >> Dr. Bitter: So it's important to you that people listen to you and do what you expect them to do? >> Joel: Yeah. >> Dr. Bitter: Okay. And then your wife, what role does she play when this happens? >> Joel: She handles things with a lot more common sense. She'll say, "Why didn't you just say this?" "Well, I didn't. I reacted." >> Dr. Bitter: Okay. Does she ever cut you off or undermine you in some way? >> Joel: She tries to. She tries to, but I don't handle that well. >> Dr. Bitter: Okay. So, are there times when you want things to go smoother that you actually heed your wife and let her handle things so they will go a little smoother? >> Joel: Yeah, I'm starting to do that more, but she's working now and she's more stressed. She's actually not handling things as well as she used to now either. >> Dr. Bitter: Okay. So my understanding is that there's a lot going on here, and that the way this family works is that it's really a tradeoff of which individual is going to take control. Everybody is kind of trading places about when they will be in power and when they'll be in control. Let me ask you a question as a whole family. Is this working for you? >> Trish: Sure. >> Dr. Bitter: So it works for you, Trish? How does it work? >> Trish: Well, I mean, I don't like the fighting part about it, but I like being able to be in charge and take charge, because that's who I am. And that's the only part that I wish we could get figured out would be, you know, who's in charge when? Because that's what I don't know and that's what's confusing for me. Because it's an automatic response for me to be in charge and tell everybody else what to do. And it's hard for me to know when I'm not supposed to be doing that. >> Dr. Bitter: And who else wants that to happen? >> Joel: Well, I just want for there to be some rules. >> Dr. Bitter: But you don't have any? >> Joel: No. >> Dr. Bitter: Okay. So, Mom, where are you with this? >> Cassandra: Well, I always think I'm in charge. >> Dr. Bitter: Okay, so at some point or another, you all think you're in charge. >> Cassandra: Mm-hmm. >> Dr. Bitter: What if I were to say that my impression is that nobody is in charge here? >> Cassandra: But how can it be just one person? I mean, some people have to follow sometimes and not others. >> Joel: Well, it's like sometimes it's a democracy, and other times, it's not like that at all. >> Dr. Bitter: And when it's not a democracy, what is it then? >> Joel: It's a fight. Usually it's a big fight. >> Dr. Bitter: What's been the biggest fight? >> Cassandra: When she left for two days. We didn't have a clue where she was. >> Trish: I was in my room. >> Joel: You sure weren't very loud in your room. >> Dr. Bitter: So you just left? >> Trish: I didn't just leave. Mom told me to leave, and I thought, "Well, I'll leave." So I went and stayed a couple of days with some friends. >> Dr. Bitter: Okay. Trish, what would it mean for you just not to fight? What would it be like if you just acquiesced and just gave in to what they were wanting? >> Trish: I don't know. I don't think I could do that. That's just too much for me. I have to be in control. >> Dr. Bitter: Mm-hmm. So what's your belief system about that? What are your thoughts about needing to be in control? >> Trish: I don't know. I just, I don't do well with taking orders from others, and I don't like authority, so I would just have a hard time doing that. >> Dr. Bitter: Mm-hmm. So when you take charge of everything, regardless of what it is, is it practical? Is it working out for you? >> Trish: No, but I've learned to adapt that way and it works for me. Nobody pushes me around, and I'm okay with that. >> Dr. Bitter: Okay. How does it go for you in other places, like school or any of that? >> Trish: I don't have a problem anymore. I mean, when I was being home-schooled, I learned how to, you know, to adapt and I learned who I was, and that's helped me to be able to take charge and be in charge of me and everybody else. >> Dr. Bitter: So when you left, Trish, did you know what impact it would have on your mother and father? Was it a strategy you were using? It kind of sounds like a strategy to me. >> Trish: I don't know about that. >> Dr. Bitter: Well, it did have an effect, didn't it? >> Trish: Yes. >> Dr. Bitter: And you knew what the effect would be? >> Trish: Well, sometimes you have to do what you have to do. >> Dr. Bitter: I'm wondering -- that's an interesting cognition. I'm wondering -- or what actually I would call a schema, I'm wondering if that's something the whole family shares. "You have to do what you have to do." When the going gets tough everyone believes that they must do what they have to do to maintain power and control? >> Cassandra: Yes, I think that's true for me, and I think it's true for him, too. >> Dr. Bitter: So suppose for just a moment, Trish, that there was an alternative that you could use. Is that possible? Can you consider, even, an alternative? >> Trish: Well, I guess so. I mean, definitely there was definite alternatives before things got so heated. I could have just said yes and been submissive and just let things go. >> Dr. Bitter: What would that have meant if you had done that? >> Trish: I just can't do that. I just can't, you know, walk away or take authority like that. It just doesn't work for me. >> Dr. Bitter: Okay. So the thought is that "I have to leave," and the alternative is "Well, maybe I don't have to leave." See if I'm getting that right. And if you hadn't left then, I guess, what would have happened? >> Trish: We would have definitely continued fighting. >> Cassandra: Not if you'd just gone to your room. That's all we were asking you to do. >> Dr. Bitter: So, not leaving would mean that you would have to submit? And what would, why would that, do you think, be so awful? >> Trish: I just can't go back to that. I just, I want to be in charge and I want to be the one in control, and I just couldn't go back to that. >> Dr. Bitter: Then what? What would happen then? >> Trish: We would just get tired of fighting and someone would give up and then someone would win. >> Dr. Bitter: So not leaving would mean that you would have to submit. And what I want to know is why that would be so awful for you. >> Trish: I don't know. I just can't do that. >> Dr. Bitter: Yeah, I know. You don't want to do it or you won't do it because you believe it will be awful and horrible, but what I'm trying to find out is what goes into the belief that it would be so awful and horrible so that we can see if it's true or not. >> Trish: I guess I'm just too strong for that. >> Dr. Bitter: Okay. Is that it? That you kind of associate not fighting with being weak? Not strong, maybe what you were like before that year of home-schooling? >> Trish: I will never go back to that again. I will never go back to that quiet, mousy girl that let everybody push her around. >> Dr. Bitter: Okay, so the automatic response is that you never miss a chance to get into a fight and to feel the strength of winning because if you give in, you think you're going to go back to being weak, to being pushed around and fighting, even if you're just doing it for practice with your parents. It's a way for you to feel like you're still strong. It's almost like the words are, "I must fight at every opportunity, or I'll be blown away." >> Trish: Something like that. >> Dr. Bitter: Well, I think it would be really important for us to find out whether that's really true or not.