Week 9

What are your thoughts concerning the theories presented this week? What aspects of the theories resonate or make more sense to your personal style of counseling? What aspects or concepts within these theories do you think would be a challenge for you, and why?

This assignment only needs to be about 3 paragraphs nothing huge. just answering the questions above.

Cognitive-behavioral couple and Family therapy (CBC/FT)

Life Cycle Analysis

Narrative Therapy

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CHAPTER

11Behavioral and Cognitive- Behavioral Theories: Approaches and Applications Marvarene Oliver and Yvonne Castillo Texas A&M University–Corpus Christi

Behavioral and cognitive-behavioral couple and family therapy are currently generally conceptualized under the broad domain of the cognitive-behavioral approach. Arising initially from behaviorism and later adding information from cognitive psychology and systems thinking, specific frameworks within the broad domain of cognitive-behavioral couple and family therapy (CBC/FT) vary, some- times significantly. Cognitive-behavioral theorists, scholars, and clinicians give greater or lesser emphasis to variables addressed in theory and practice, depending in part on where they fall on a continuum between a more behavioral or a more cognitive orientation. In addition, specific models vary about how much and in what way systems thinking is considered. While most behavioral and cognitive- behavioral approaches are not strictly considered systemic approaches to working with families, they do share with systems theory an emphasis on rules and communication processes, as well as attention to the reciprocal impact of each family member’s behaviors and attitudes on others. Some leading figures in CBC/ FT argue that the attention to mutual impact of family members’ thoughts, behaviors, and emotions, as well as attention to the context in which families operate, provide a systemic overlay for this approach (Baucom, Epstein, Kirby, & LaTaillade, 2010; Dattilio, 2010). Some approaches (e.g., functional family ther- apy, integrative behavioral therapy, and some forms of cognitive-behavioral therapy) strongly stress a systemic perspective that cannot easily be dismissed by critics.

However, all cognitive-behavioral approaches share an emphasis on research and clearly outlined goals, ongoing assessment, and treatment interventions. Because of this commitment to a scientific approach, as well as the relative ease

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of standardizing treatment and measuring outcomes, cognitive-behavioral approaches are the most researched treatments in the arena of couple and family counseling. There have been more studies demonstrating the efficacy of CBC/FT approaches than any other model (Datillio, 2010; Datillio & Epstein, 2005). While other therapies have demonstrated efficacy at least as strong as CBC/FT, the quantity and role of research in CBC/FT is currently unmatched in other approaches (Atkins, Dimidjian, & Christensen, 2003). Not only is CBC/FT well-researched with a sound empirical base, it is among the most-used approaches to couple and family therapy. For instance, Northey (2002), in a national survey of members of the American Association for Marriage and Family Therapy, noted that over 27% of 292 randomly selected therapists identified cognitive-behavioral family therapy (CBFT) as their primary treatment modality, and CBFT was the most frequently cited of all models mentioned.

Distinguishing among variations in CBC/FT theory and practice can be challenging for a number of reasons. Not only are there variations based on closer alignment with behavioral or cognitive elements and the relative importance of a systemic perspective, but there have also been several phases of development of CBC/FT. Each of these has spawned related threads of theory, research, and practice. Each thread provides concepts and principles that are important for the well-trained counselor to understand. In addition, both research and theory may address either couple or family approaches, or both. While couple and family treatments share similarities, they do not always translate precisely from working with couples to working with families. Research is generally clearly demarcated as being with and for couples, or with and for families. Nonetheless, general principles of behavioral and cognitive-behavioral approaches share many similarities, whether working with couples or with families.

BACKGROUND

Counselors who are interested in working from a cognitive-behavioral perspective should be knowledgeable about both behavioral and cognitive therapy and the foundational concepts on which each is based. Behavioral and cognitive-behavioral approaches have their origins in science; the scientific method was critical in the development of the behavioral approach to working with problems, and it remains critical today. The scientific method that characterized early behaviorism remains a critical component of CBC/FT.

First-Wave Approaches

Gurman (2013) conceptualized the development of cognitive and behavioral approaches to couple and family therapy as a series of waves (see Table 11.1). He includes both behavioral and cognitive-behavioral work within the behavioral couple/family therapy (BC/FT) paradigm, and called the earliest period the first wave in the evolution of behavioral therapy’s core principles and clinical thought. During the early days of BC/FT, which was closely linked to traditional

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stimulus-response learning theory, there was no consideration of internal events such as thoughts or emotion because those could not be readily observed, nor was there much attention given to interpersonal processes. A major premise underlying this approach is that all behavior is learned and that people, including families, act according to how they have been reinforced or conditioned. Behavior in the family or couple is maintained by consequences, also called contingencies. Unless new behaviors result in consequences that are more desired, they will not be maintained. In addition, the focus is on maladaptive current behaviors as the target of change. From a traditional behavioral perspective, it is not necessary to look for underlying causes; behavior that is not desirable can be extinguished and replaced by more desirable behavior. Finally, many behavioral family therapists believe not everyone in the family has to be treated for change to occur. When one person comes for treatment, he or she is taught new, appropriate, and functional skills. Those who are more systemic in their thinking focus on dyadic relationships, such as parent– child or couple. Today, BC/FT relies on the same theoretical foundation as individual behavior therapy in that it utilizes principles of classical and operant conditioning. However, modeling, attention to cognitive processes and self-regu- lation, and focus on interactions between family members have been incorporated into behavioral practice. Gerald Patterson, Richard Stuart, and Robert Liberman are generally associated with this first wave of behavioral treatment of couple and family problems.

Table 11.1 Development of Cognitive and Behavioral Approaches

Theory Examples of Major Principles

First wave Behavioral family therapy (BFT) Traditional behavioral couple therapy (TBCT)

Stimulus-response learning theory Behavior is learned No consideration of internal events, underlying causes, or emotions

Skill deficits important Second wave Cognitive-behavioral couple therapy

(CBCT) Enhanced cognitive-behavioral couple therapy (ECBCT)

Cognitive variables as mediators Stimulus-organism-response theory Internal processes, context, and core themes important

Third wave Integrative behavioral couple therapy (IBCT)

Acceptance and commitment therapy (ACT)

Behavioral activation therapy Functional family therapy (FFT) Functional analytic therapy

Importance of self-regulation Recognition of limits of change-oriented interventions

Importance of context No class of behavior privileged

Developing third wave

Mindfulness training enhancement to CBCT

Integration of dialectical behavior therapy and CBCT

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Richard Stuart and Robert Weiss conducted research on couples in the 1960s. The first publication on behavioral couple therapy (BCT) was written by Stuart (1969), who has been called the founding father of behavioral marital therapy. His later text, Helping Couples Change: A Social Learning Approach to Marital Therapy (Stuart, 1980), became a classic that remains widely known and referenced. Stuart (1980) used social exchange theory and operant conditioning principles to increase the ratio of positive behaviors to negative behaviors in couples. He noted that in nondistressed relationships, partners reciprocally exchanged a higher ratio of positive behaviors than negative ones, and initially he coached partners to reward each other using tokens for enacting behaviors that were viewed as positive by each other. Behavioral couple therapists gradually replaced token economies with written contracts and good faith contracts for behavioral exchanges, and added communication and problem-solving skills training. For example, a therapist working with a couple who experiences conflict about the relative importance of work and fun might help the couple devise a contract in which one partner agrees to cleaning the bathrooms once a week. In exchange, the other partner agrees to spend two Saturday afternoons a month doing a fun activity together.

Another key figure in the first wave of BC/FT is Robert Liberman (1970), who utilized social learning principles to work with couples and families. He is often credited with adding strategies of therapist modeling and client behavioral rehearsal of new behaviors to treatment. He also used behavioral analysis of couple and family interaction patterns around presenting problems, and included in his work with couples a focus on unintentional reinforcement of undesirable behavior. In conjunction with colleagues, he reported results of a 10-session behavioral marital group therapy that involved training in communication skills; contingency contracting; increasing recognition, initiation, and acknowledgment of pleasing interactions; and redistributing time spent in recreational and social activities (Liberman, Wheeler, & Sanders, 1976).

Gerald Patterson is often credited with originating behavioral family therapy (BFT) at the Oregon Social Learning Center (OSLC). Patterson (1974) and fellow researchers at the University of Oregon noted the importance of operant con- ditioning principles in working with children, and studied parental use of reinforcers and punishers to increase a child’s desired behaviors and reduce negative ones. Patterson believed that parents and other significant adults could be change agents in the lives of children with behavioral problems, and he identified a number of specific behavioral problems and interventions for correcting them. He was instrumental in writing programmed workbooks for parents’ use in helping their children and families modify behavior. The Parent Management Training- Oregon Model, developed by colleagues at the OSLC, is now a widely accepted evidence-based model for promoting prosocial skills and preventing and reducing mild to severe conduct problems in children. In addition, Weiss, Hops, and Patterson (1973) discovered that some parents needed relationship skills in addition to parenting skills, and they applied learning-based principles and methods such as the use of behavioral exchange, contracting for positive experiences, and skills development to the treatment of distressed couples (Atkins et al., 2003; Baucom et al., 2010).

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SIDEBAR 11.1 CASE STUDY: HOW CAN JOSHUA GET BACK ON TRACK?

Makayla and Jeremy came for family counseling with their 13-year-old son, Joshua. When Joshua entered middle school 2 years ago, his grades began dropping. Previously a good student, Joshua was now barely passing. Joshua has skipped school a number of times and was sent to a disciplinary campus for 6 weeks. He is frequently several hours late coming home from school. When his father is not home, he is verbally aggressive toward his mother whenever she directs him to do homework or chores. Jeremy has come in from work on several occasions to find his wife in tears and Joshua in his room with his door locked, playing computer games. When Jeremy is at home, Joshua sullenly responds to direction. In session, Jeremy mostly stares at the floor and says he just doesn’t want to be treated like a child. As a behavioral family counselor, where will you start?

Although they are not now associated with the first wave of behavioral therapy, at least two others should be included in any discussion of CBC/FT, although each for a different reason. John Gottman, who began his career with an interest in mathematics and earned three of his four degrees with a mathematics emphasis, became interested in psychophysiology and earned a PhD in clinical psychology in 1971. He began his work at the University of Washington in 1986 and established his Family Research Lab, familiarly known as the Love Lab. Thousands of hours of data were collected in the Family Research Lab, including audio and video recordings, use of heart monitors, and information from a chair that monitored fidgeting during different kinds of conversations. He has conducted extensive study on marital stability and divorce prediction, and is known for precision in his research. Even though he is not a cognitive-behavioral theorist, his findings have been important in research of behavioral and cognitive-behavioral approaches to couple and family therapy (e.g., Baucom, Epstein, LaTaillade, & Kirby, 2008; Datillio & Epstein, 2005; Dimidjian, Martell, & Christensen, 2008; Gurman, 2013). Gottman (1999) has identified multiple factors that contribute to relational dissatisfaction, as well as factors that seem to be critical in long-term relational success. For example, couples who are stable and happy regularly make repair attempts when things go awry in their interactions. Repair attempts are used to soften or mend what might otherwise lead to defensiveness or hurt, and are especially important during conflict. On the other hand, couples who are unstable and unhappy have low levels of positivity to negativity in their relationships and higher occurrence of criticism, defensiveness, contempt, and stonewalling.

Neil Jacobson, who started out to be a psychoanalytic and humanistic-oriented clinician, became a behavior therapist after reading the work of Albert Bandura, an influential psychologist and researcher. Jacobson was drawn to the accountability, empiricism, and methodologies associated with the theory. During his academic

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career, he developed a clinical practice based on research, which helped refine his theoretical contributions to behavioral marital therapy and domestic violence. Work with graduate students also kept him focused on theory. Jacobson indicated that behaviorism is at the base of his theory, but that clinical application is more eclectic. He was intent on bridging the gap between academic research and in-the- trenches, clinical outcome research. Until his death, Jacobson was on the leading edge of the family therapy field and was involved in longitudinal research on couples, including an 8-year study with Gottman concerning male batterers (Jacobson & Gottman, 1998). One major outcome of his meticulous attention to research and refining his way of working with couples was his introduction of integrative behavioral couple therapy (IBCT, discussed later) with Andrew Chris- tensen, his long-time colleague. This orientation represented a major change from traditional behavioral couple therapy (TBCT). It includes the idea that acceptance is as important as behavior change in couple therapy and, in fact, may be more likely to facilitate change with some kinds of relationship problems than a direct focus on change. Jacobson and Christensen wrote a number of articles together and with other colleagues, and Christensen has continued research and writing about work with couples since Jacobson’s death in 1999.

Traditional Behavioral Couple Therapy

Traditional behavioral couple therapy (TBCT) was built on two major precepts: (1) that marital dissatisfaction arises when the ratio of rewards to costs is too low, which means there are inadequate behavior-maintaining contingencies, and (2) that part- ners have deficits in interpersonal skills. In clinical practice, this resulted in an emphasis on increasing positive behavior, decreasing negative behavior, and using reciprocity rather than coercion for behavior change, as well as on providing communication and problem-solving skills training. Therapy from this perspective follows a predictable format, with problem behaviors operationally defined and targeted. Behavioral interventions, such as contingency management and behavioral exchange, are used to decrease negative behaviors and increase positive ones, and skill training in communication and problem solving is provided. Overall, the tone is didactic because the therapeutic process involves much teaching and training.

Critiques of TBCT challenge traditional notions of behavioral theory. As early as the late 1970s, critics noted that BCT of that era did not take into account context (Gurman & Kniskern, 1978; Jacobson & Weiss, 1978). Gurman (2008) stated that poor communication and problem-solving skills serve a defensive function, and noted that couples who do not use such skills with each other nevertheless evidence those same skills in other relationships. Thus, the skill deficits addressed by communications and problem-solving training are not significant enough to warrant explicit instruction for many couples. Rather, the problem to be addressed in therapy is more about how to access skills partners already possess in the context of the relationship. Such arguments aside, change in how TBCT is conceptualized and practiced came largely from research within the field. This is not surprising, because behavior therapy in general strongly values empirical evidence. Research indicated, for example, that gains achieved during treatment were not sustained by a

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large portion of couples. This informationled to various hypotheses about why gains from TBCT are not sustained long term. In clinical practice, it was also evident that some couples donotbenefit from change-oriented work,especially those whoarenot compromising, collaborative, or trusting. Gurman (2013) and others (Christensen et al., 2004; Jacobson & Christensen, 1998) noted that TBCT did not include a mechanism for dealing with what Gottman (1999) called perpetual problems, which may account for nearly 70% of what couples regularly argue about. Perpetual problems often include things that involve differences in personality or relationship needsthatareexperiencedaspartofone’sessential self.Forexample,onepartnermay be an introvert and the other an extrovert, which may lead to differences in how each wants to spend leisure time or how much time each wants to spend alone.

Second-Wave Approaches

The emphasis on mediational cognitive variables constitutes the second wave in behavioral therapy (Gurman, 2013), particularly with the development of cognitive theory. As early as the 1950s, some behaviorists began to argue that the stimulus- response cycle as conceived in traditional behavioral psychology was not automatic, but rather was mediated by cognitions. The importance of the one who experienced a stimulus was recognized as a critical part of the cycle (stimulus-organism- response). At about the same time, cognitive theorists and clinicians were proposing their own ideas about how people change. Personal constructs and schemas were recognized as important in understanding how couples and family members gather information, interpret it, and predict events. Thus, therapists who believed the role of cognition was important began working with couples and families about, for example, beliefs they held about what couple or family life should ideally be. Cognitive psychology literature continues to contribute to awareness of potential sources of distortion in client cognitions about events in the family.

Changing the way family members act, as well as their dysfunctional attitudes or beliefs, is central to second-wave approaches. Although goals will vary according to presenting problems and the counselor’s particular frame of reference, there are a number of facets that characterize the approaches in this section. Among those are: (a) facilitating the family’s ability to see patterns of behavior and understand the interaction among cognitions, emotions, and behavior (Kalodner, 1995); (b) diminishing problem behaviors or interactions and increasing positive ones (Nichols & Schwartz, 2004); and (c) improving each couple or family member’s functioning in a way that improves the overall relationship (Weiss & Perry, 2002).

SIDEBAR 11.2 ASSESSMENT: A FOUNDATIONAL COMPONENT OF CBC/FT

Assessment plays a pivotal role in CBC/FT and is an integral part of the therapeutic process. In fact, it isn’t really possible to do CBC/FT without it. Assessment begins at or even before the first session and continues until the conclusion of therapy. Assessment is used to monitor progress,

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refine goals, and determine appropriate interventions. Therapists who practice from a CBC/FT model will vary to some degree in what they assess depending on their particular approach. However, some of the more common purposes of assessment from a CBC/FT perspective are to:

• Establish initial goals and refine them throughout therapy • Identify behaviors and cognitions that are problematic for the couple

or family • Understand what clients want • Understand how and why particular problems are impacting the

clients’ lives • Monitor progress • Determine interventions that address problems presented for a

particular couple or family • Set the stage for change

Cognitive-Behavioral Couple Therapy

Cognitive-behavioral couple therapy (CBCT) has its roots in BCT, cognitive therapy, and basic research in cognitive psychology (Baucom et al., 2008). Cogni- tive-behavioral couple therapy (CBCT) arose from concerns that TBCT was clinically limited because of its lack of attention to internal processes. Cognitive theory was developing as early as the 1960s, and its usefulness in clinical settings was becoming evident in the 1980s. During the 1980s, couple therapists began to attend to cognitive processes such as “attributions, expectancies, assumptions, standards, and schemas with most attention paid to the ways in which such information processing was focally important to intimate relationships” (Gurman, 2013, p. 121). Cognitive-behavioral couple therapy builds on skills-based interventions of BCT that target couple communication and behavior exchanges by directing partners’ attention to explanations they construct for each other’s behavior and to expectations and standards they hold for their own relationship and for relation- ships in general (Epstein & Baucom, 2002). Despite several decades of research, CBCT, whether considered a modality of its own or a set of adjunctive procedures to be integrated with other approaches, has only recently become a major force in the field of couple and family therapy (Datillio, 1998, 2001; Datillio & Epstein, 2003).

Cognitive Restructuring Although CBCT is considered a single entity, Gurman (2013) identified three particular emphases in theory and practice. The first, cognitive restructuring, involves core cognitive therapy methods such as identifi- cation and modification of partners’ automatic thoughts and the use of Socratic questioning to determine evidence for partner attributions about each other and about relationships. For example, some people have an unrealistic or untrue belief that if their partner loves them, then the partner will never let them down or

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disappoint them. A therapist working with a focus on cognitive restructuring might help an individual identify and change this belief to something that is more helpful and accurate. This approach is the most frequently researched version of behavioral couple therapy.

Couple and Family Schemas A second emphasis in CBCT considers partner schemas (Gurman, 2013). Therapists working with couples and families who focus on schemas pay attention to fundamental central belief structures (schemas), particularly as they relate to beliefs about areas such as intimate relationships, parenting, children, and self-worth. While many CBCT therapists believe schemas are a critical part of couple relationships and work with them in therapy, one particular form of CBCT, couple schema therapy, is significantly different from TBCT and more generic CBCT. The couple schema model includes concepts from object relations and other psychodynamic approaches and encourages imme- diate experiencing of strong emotions in order to make dominant schemas more accessible.

SIDEBAR 11.3 CASE STUDY: MARIANNA AND ADOLPHO

Marianna and Adolpho have been married for 13 years. When they first married, both worked and shared household responsibilities. They now have two children, ages 7 and 9. When their children were born, they mutually decided that Marianna would stay home “until they were a little older.” They have come into counseling because of increasing distance, anger, and conflict between them. Marianna wants to go back to work, and Adolpho wants her to stay at home. He likes their lifestyle and says he doesn’t understand why she wants to change it; however, Marianna thinks he just wants her to continue managing most of the household responsibilities, a job that gradually shifted to being primarily hers. Consider some of the schemas that could be relevant to the couple’s current distress. Are there beliefs you would be listening for? What are they? What do you need to know about your own schemas?

Enhanced Cognitive-Behavioral Couple Therapy Enhanced cognitive-behav- ioral couple therapy (ECBCT) is the third and most fully developed emphasis in CBCT. Epstein and Baucom (1990, 2002) expanded their initial cognitive-behav- ioral approach to include attention to broader patterns and core themes as well as attention to discrete behaviors. They note the importance of individual character- istics and the ways in which individual characteristics impact couple relationships. These authors also recognize the role environmental stressors play in couple relationships. Finally, they give more emphasis to the role of emotion in couple relationships, including the reciprocal impact of emotion on wants, needs, and motives. Epstein and Baucom draw significantly from a variety of theoretical

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orientations, including emotionally focused therapy and insight-oriented marital therapy, to integrate CBT conceptualizations with an understanding of motives and needs. This approach includes substantial emphasis on increasing positive experiences and emotions rather than focusing primarily on decreasing nega- tives, as well as consideration of positive experiences beyond the couple rela- tionship itself. Enhanced cognitive-behavioral couple therapy incorporates systems theory, acknowledging the reciprocal relationship between the couple and the environment.

Enhanced cognitive-behavioral couple therapy includes the use of traditional CBCT techniques; however, interventions concerning communication and prob- lem solving are provided as rehabilitative rather than skills training. The distinction is important because, as Epstein and Baucom (2002) pointed out, satisfied couples do not use step-by-step processes for having difficult conversations or solving problems. From a rehabilitative perspective, these interventions are better used as steps to help couples break negative patterns. Once that occurs, the clinician will offer interventions that encourage other ways to more naturally respond to each other. These might include interventions designed to help each partner selectively attend to the other’s positive behaviors, interrupt negative inferences each partner may make about the other’s intentions, delineate and change problematic expec- tancy, modify implicit and explicit assumptions about intimate relationships, and challenge maladaptive/inflexible standards for partner behavior. By attending to the couple’s interaction with extended family and the community and assessing current relational stressors that originate outside the couple itself, ECBCT also takes a much more comprehensive approach to clinical assessment than had been shown in TBCT’s typical emphasis on the immediate interaction of the couple dyad. A particularly striking enhancement of ECBCT is its inclusion of principles of intervention from emotionally focused therapy, especially those that are aimed at deepening affective experience.

According to Gurman (2013), the most clinically significant contribution of ECBCT was the development of principles for the treatment of individual psychological difficulties within couple therapy. When one partner has an individ- ual problem, such as panic disorder, the other partner may be enlisted to help in the therapeutic process. Enhanced cognitive-behavioral couple therapy also examines how an individual’s clinical problem affects the couple relationship and how couple interaction may impact an individual’s psychiatric disorder. Problematic couple dynamics can complicate the therapeutic process for the individual client, and dysfunctional patterns must be addressed. Finally, ECBCT has been used as a general couple therapy to improve overall couple functioning in areas where dysfunction contributes to the development or maintenance of a disorder.

SIDEBAR 11.4 RESOURCES FOR ASSESSMENTS

There are a number of excellent sources for couple and family assess- ment. As with assessments used with individual clients, counselors should have a clear rationale for their use with couples and families. In addition,

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counselors should be aware of the possibility of cultural bias, either in construction or in interpretation of results. Some recent sources of information about couple and family assessment include:

• Assessment of Couples and Families: Contemporary and Cutting- Edge Strategies (Sperry, 2004)

• Handbook of Family Measurement Techniques (Vols. 1–3) (Touliatos, Perlmutter, & Straus, 2001)

• Measures for Clinical Practice: A Sourcebook. Vol. 1: Couples, Families, and Children (4th ed.) (Fischer & Corcoran, 2007)

• Sourcebook of Marriage and Family Evaluation (L’Abate & Bagarozzi, 1993).

In addition, Cognitive-Behavioral Therapy with Couples and Families: A Comprehensive Guide for Clinicians (Dattilio, 2010) includes an appen- dix containing a thorough compilation of assessments, as well as an entire chapter about assessment procedures for couples and families.

Third-Wave Approaches

In recent years, there has been an increasing focus on the use of acceptance and mindfulness-based approaches within CBCT (Levin & Hayes, 2009). Gurman (2013) categorized these as the third wave of behavioral therapy. A number of factors resulted in this self-regulation phase (Gurman, 2008), including increasing research demonstrating ceiling effects of standard CBT approaches; the use of CBT approaches in application to problems in living as well as treatment of specific symptoms, such as depression and anxiety; and the influence of Eastern thought on Western mental health perspectives. Among those included by Gurman are acceptance and commitment therapy, behavioral activation therapy, dialectical behavior therapy, functional analytic therapy, and integrative behavioral couple therapy. We believe that functional family therapy also rightfully fits here. Each of these approaches addresses criticisms that previous behavioral approaches are reductionistic and mechanistic because each approach insists that psychological experiences, processes, and events can only be understood in context. Gurman noted that no class of behavior, whether feelings, thoughts, or something else, is privileged in third-wave approaches.

Integrative Behavioral Couple Therapy

Integrative behavioral couple therapy (IBCT) is both contextually based and behavioral (Christensen, Jacobson, & Babcock, 1995; Jacobson & Christensen, 1996, 1998). Arguably the most visible BCT approach, IBCT differs significantly from CBCT’s continued emphasis on changing maladaptive behaviors, particularly thoughts, and focuses more attention on functional analysis of behavior. Functional

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analysis of behavior is concerned with the purposes that behaviors serve. From an IBCT perspective, functional analysis moves beyond identification of events that led to a problem behavior and looks instead for broad classes of behaviors or themes of variables. The IBCT therapist looks for the common theme in groups of behaviors that lead to dissatisfaction in couple relationship. In addition, the IBCT therapist looks for common themes in the dissatisfied partner’s reactions, emphasizing that the importance of reaction to ineffective behavior is as critical as the behavior itself to couple satisfaction (Dimidjian et al., 2008).

First published in 1995, IBCT grew out of TBCT (Christensen et al., 1995). While TBCT is one of the most researched treatments for couples and meets the criteria for empirically supported treatments, Jacobson and his colleagues were skeptical of the clinical significance of the approach and published a reanalysis of outcome data on TBCT ( Jacobson et al., 1984). Further research revealed that TBCT was more likely to be effective for particular couples (e.g., more com- mitted, younger, less distressed couples who were not emotionally disengaged). Jacobson and Christensen (1996) also noted that for some couples and some problems, TBCT’s emphasis on producing change was not effective and could actually add to couples’ distress. Jacobson and Christensen concluded that acceptance was the thing that was missing and that acceptance may in itself promote change.

In adding acceptance as an essential part of their approach, Christensen and Jacobson focused significant attention on how a partner views and responds to a behavior that is not desirable in that partner’s view, rather than attending solely to behavior change on the part of the individual enacting a behavior that is undesirable to the partner. This view is one that takes into account the reciprocal nature of couple interactions. Working with couples in this way gives recognition to the fact that there are some perpetual or unsolvable problems in couple relationships. In addition, attending to both partners’ actions and responses to such problems and including acceptance can mediate increased change in behavior. In addition to a different focus on change, IBCT also differs from TBCT through its emphasis on contingency-shaped, rather than rule-shaped, behavior. Rule- governed interactions mean that a partner is given a rule and punished or reinforced in relation to whether the behavior is performed. Contingency-shaped behavior, on the other hand, is determined by the natural consequences of performing a behavior. Jacobson and Christensen’s approach is predicated on the idea that enduring changes are more likely to happen because of shifts in natural consequences, or contingencies. Thus, there is significant time spent in the therapeutic process on creating these shifts (Christensen et al., 2004; Jacobson & Christensen, 1996, 1998).

Working within an IBCT model requires particular skills and attributes, including flexibility and comfort with change. The clinician may function as a coach or teacher, for example, and may use structured and specific communication techniques. However, the highest priority is “maintaining a focus on the case formulation of the couple” (Dimidjian et al., 2008, p. 79). Being a compassionate listener, being attentive to both verbal and nonverbal communication, and being able to remain focused on the couple’s central theme despite specific complaints

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that arise are critical, as is the ability to communicate genuine empathy for each person. Ultimately, the stance of the IBCT therapist is “non-confrontational, validating, and compassionate” (Dimidjian et al., 2008, p. 79).

There are techniques used in IBCT that are used in other approaches as well; however, the rationale for their use may be different (Dimidjian, Martell, & Christensen, 2002, 2008). Empathic joining is used to foster acceptance. The clinician is, in some senses, teaching by doing. Unified detachment is used to help partners get emotional distance from their conflicts by encouraging intellectual analysis of problems, and it is also a way to promote acceptance. Both empathic joining and unified detachment are intended to help partners talk without accusa- tion and to foster greater intimacy and closeness. Interventions aimed at increasing tolerance, and therefore letting go of trying to change each other, are used with problems that are unlikely to be solved and that are not likely to produce more intimacy and closeness, but may also be used with acceptance interventions. Examples of interventions designed to promote tolerance include pointing out positive aspects of negative behavior, practicing negative behavior in session, faking negative behaviors at home between sessions, and promoting self-care. It is important to note that Jacobson and Christensen (1996, 1998) specifically state that there are behaviors that should not be tolerated and that, for couples with particular problems, IBCT is not appropriate. For instance, domestic violence should not be a target of acceptance or tolerance. Behaviors that jeopardize the well-being of either member of the couple should not be a focus of either acceptance or tolerance interventions; thus, another treatment approach should be used.

Change is not ignored in IBCT. Strategies aimed at producing change include behavior exchange, communication training, and problem-solving training. These are typical interventions that are also used in TBCT; however, IBCT clinicians are less likely to insist on particular forms of communication (e.g., “I feel . . . when you . . .”) or problem solving and will individualize training to the needs of particular couples, including or excluding elements of typical skills training as appropriate for a particular couple.

Although there are no specific contraindications indicated for IBCT other than domestic violence, Dimidjian et al. (2008) note that it is important that IBCT be conducted in a culturally sensitive and specific manner; thus, clinicians are cautioned to be careful about working with couples with a cultural background outside the clinician’s experience or knowledge. Dimidjian et al. indicated that IBCT may require some modification when used with gay, lesbian, and bisexual clients to ensure attention to potential social, cultural, or individual issues around self-acceptance.

Research examining the effectiveness of IBCT has demonstrated that it is an effective approach. A large clinical trial of 134 seriously and chronically distressed couples, for instance, examined results of IBCT and TBCT treatment. Couples in both treatment conditions showed substantial gains that were maintained over a 2-year follow-up; however, results favored IBCT over TBCT, with IBCT couples who stayed together reporting being significantly happier than TBCT couples (Christensen, Atkins, Yi, Baucom, & George, 2006).

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Acceptance and Commitment Therapy

As discussed previously, some couples have been found not to benefit from change- oriented approaches. When such approaches are not likely to work, or when partners do not acknowledge there is a problem, acceptance may be a core process that is critical for improving relational distress. In fact, Jacobson and Christensen (1996) indicated that acceptance is critical in any successful marriage. One relatively new approach, acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), has been suggested for couples to address the reality that there are those for whom change-oriented approaches do not work, in part because partners are not motivated or willing to enter into the therapeutic process (Dattilio & van Hout, 2006). Acceptance and commitment therapy targets avoidance and efforts to control aversive experiences (Hayes et al., 1999), excessive response to cognitive content, and the inability to make and keep commitments to change (Hayes, 2004). Individuals learn how to be mindful of their cognitive and emotional responses to their partner, as well as to their own behavior in the relationship. In addition, couples are helped to clarify values they hold about the relationship and commit to acting in ways consistent with their values, despite unwanted thoughts and feelings that may not be consistent with those values (Peterson, Eifert, Feingold, & Davidson, 2009). Counselors working from an ACT model help couples approach, rather than avoid, thoughts, feelings, and bodily states that are aversive and that are linked with particular relationship patterns and dynamics. A goal is for partners to become more able and willing to approach situations that have been avoided in the past and act in ways that improve relationship satisfaction and intimacy (Peterson et al., 2009).

Functional Family Therapy

Functional family therapy (FFT) was originally developed by James Alexander, Cole Barton, and Bruce Barton. It was first presented as a textbook in 1982 (Alexander & Parsons, 1982), and was more recently described by Sexton (2011). In addition, there have been numerous book chapters and articles describing and reporting on the effectiveness of FFT (e.g., Henggeler & Sheidow, 2002; Sexton, 2011; Sexton & Turner, 2010). Functional family therapy was developed specifi- cally for the purpose of working with families dealing with severe adolescent behavioral problems, with the intent of providing a clinically useful model grounded in research. The approach synthesizes behavioral, cognitive, and sys- temic thought, but is viewed by its developers as distinct from all of them (Barton & Alexander, 1981). It is an evidenced-based approach that has demonstrated effectiveness in community-based applications with a variety of problems and a wide range of clients. Those who practice FFT in adherence to the model demonstrate profound respect for individual families and each family member, and take pains to learn about the particular contexts in which the family and its individual members live. In addition, those who work from an FFT model are both flexible and creative within specific phases of the therapeutic process, tailoring

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strategies and techniques to match the individual families with whom they work. It is an approach that requires adherence to the model to be effective, but in a nonmanualized way that recognizes the uniqueness of each family (Barton & Alexander, 1981; Sexton, 2011).

From the FFT perspective, all behavior of individual family members is adaptive and serves a function. No individual in the family is blamed, and the counselor works to understand the functions that behaviors are trying to fulfill for each family member and the family as a whole. In identifying and accepting these functions as important, the counselor seeks to understand meanings of behaviors and interactions in the family. The counselor can then use reframing to help individual family members develop alliances with each other. Alliance within the family is viewed as a requirement for motivation to change current behaviors, as is counselor–client alliance. Further, motivation is not viewed as something with which clients must enter therapy; rather, it is viewed as a result of alliance building that provides family members with the knowledge that they are understood by other family members, can trust each other, and share an idea about how to achieve change. Alliance among family members is often lacking in families in which there is a history of serious behavioral disruptions; thus, FFT emphasizes not only behavior change but also change in family members’ subjective attitudes about behaviors. Beginning to establish change in subjective perceptions about other family members, as well as building alliance, are essential tasks of the first phase of treatment (engagement/motivation phase) and continue until completion of ther- apy (Sexton, 2011).

The second stage of treatment is the behavior change phase. The primary goal of this phase is changing specific behavioral skills of family members, though from a therapeutic rather than a teaching perspective and within a relational context. Immediate concerns are addressed initially, followed by bigger issues involving risk and protective factors. Dealing with risk factors includes both changing those that can be changed as well as building in family protective factors. Skills that may be addressed include parent–child communication, parental supervision, consistency in parenting, problem solving and negotiation, and conflict reduction. Determining which skills are needed and how those should be developed for a specific family with its unique contexts, culture, and history requires an individualized treatment plan to address immediate concerns, set appropriate goals, and fit the relational functions of each family member. Assessment during this phase includes identifying both targets and barriers to change as well as determination of how to match the relational functions of problematic behaviors (Sexton, 2011).

The third and final phase of treatment is designed to generalize, maintain, and support family change. It includes strategies for generalizing skills, maintaining change, and incorporating community and family resources into treatment. Fami- lies learn to adapt when new problems arise, be consistent even when using skills that are not completely effective, be realistic in their expectations, and use natural elements of their communities that are helpful as supports when facing normal challenges of family life. Assessment is used to determine interventions that will help family members achieve these goals (Sexton, 2011).

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Additional Third-Wave Developments

According to Datillio (2010), mindfulness training is a useful enhancement to cognitive-behavioral therapy as opposed to stand-alone treatment for marital distress. He reviewed research concerning mindfulness practice with couples and linked outcomes of those studies with cognitive-behavioral views of couple distress and relationship satisfaction. Mindfulness is appropriate for enhancing empathy in couples and may be important in lowering levels of relational negativity and avoidance as well as promoting acceptance.

Another emergent approach to working with couples merges dialectical behavior therapy and CBCT (Kirby & Baucom, 2007). The joining of these two approaches is intended to address emotion dysregulation in the context of the couple relationship. Kirby and Baucom (2007) provided a couples group targeting emotion regulation, relationship skills, and the interplay of strong emotions and relationship dynamics. Results indicated that treatment had an impact in several domains, including reduction in depressive symptoms and emotion dysregulation and an increase in relationship satisfaction and confidence in one’s partner’s ability to regulate emotion.

MAJOR CONSTRUCTS

Many of the major ideas that are foundational in CBC/FT have been addressed in sections describing specific theoretical approaches. However, there are some common elements that are widely understood as basic constructs that counselors working from a CBC/FT model should know.

Contingency Contracting

Contingency contracts are behavioral contracts designed to help people negotiate desirable behavior change. Contracts are specific about who will do what under what conditions and for what reward. Good faith contracts are oral agreements and may be less specific than written contracts.

Cognitive Distortions

Distortions generally come from underlying core beliefs, and are often activated by emotional distress. Examples include mind reading, all-or-nothing thinking, jumping to conclusions, assuming that feelings are facts, disqualifying the positive, and making negative interpretations with no evidence. They may also take the form of irrational beliefs, such as “I must have all of your attention” or “We must always agree.”

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Reinforcement and Punishment

Operant conditioning involves reinforcement, which is used to increase behavior, and punishment, which is used to decrease behavior. Positive reinforcement introduces a consequence to behavior that is more likely to cause the behavior to occur again. Negative reinforcement occurs when something that is not wanted is taken away following a desired behavior, thus increasing the likelihood of the behavior occurring again. In like manner, positive punishment introduces an aversive consequence to behavior that is intended to reduce the occurrence of the behavior, and negative punishment removes something that is desired or valued in order to reduce the occurrence of the behavior.

Experiential Avoidance

Experiential avoidance is the attempt to avoid experiences, thoughts, feelings, and other internal experiences even when such avoidance causes harm. Avoidance may take the form of attempts at suppression or psychological withdrawal. Third-wave CBC/FT approaches attempt to reduce experiential avoidance in order to provide a way for behavior change to occur.

Automatic Thoughts

Automatic thoughts can be thoughts, images, or memories that are spontaneous responses to events or situations. They tend to be persistent and may seem to come out of nowhere. Automatic thoughts are generally believed to be readily available to the conscious awareness, but may not be noticed by the one experiencing them. They are often described as “just knowing” and may feel true. Automatic thoughts are related to schemas.

Underlying Assumptions

Underlying assumptions are conditional beliefs that can often be phrased as “If . . . then . . .” statements. Underlying beliefs are related to schemas, and are often described as a middle level of belief. Underlying assumptions may be thought of as conditional rules by which an individual operates in the presence of particular events or experiences.

Schemas

Schemas are enduring sets of core beliefs and attitudes about a variety of things, including oneself, other people, relationships, and the world, around which later perceptions are organized. Schemas (or schemata) are activated when a new situation arises that, to the individual, resembles the situations or experiences in which the schema was learned. When a schema is activated, the individual will interpret events through core beliefs that may be inaccurate, resulting in cognitive distortions and misperceptions of reality.

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SIDEBAR 11.5 SELF-AWARENESS: WHEN COUPLES AND FAMILIES ARE DIFFERENT FROM YOU

Part of being multiculturally competent in working with couples and families involves being aware of our own biases about the ways couples and families should ideally operate. We can check ourselves by thinking about and discussing questions such as those listed below. What other questions are raised when you think about your responses and listen to responses of others?

• How open am I to going outside my way of thinking about relation- ships and families?

• In what ways might clinical practices marginalize those who are ethnically or culturally different from the majority culture? From those living in or near poverty?

• What do I need to learn about families that are not like mine in some important way?

• What can I learn from couples and families whose lives are very different from my experience?

• What do I not understand about the multiple contexts in which couples and families live?

TECHNIQUES

There are many specific techniques used in BC/FT and CBC/FT. Some of the most common are briefly described here. Interventions should be chosen inten- tionally and with purpose. Comprehensive coverage of cognitive-behavioral inter- ventions for use with couples and families are included in texts by Rathus and Sanderson (1999) and Datillio (2010).

Education About the Model

In behavioral and cognitive-behavioral treatment, educating the couple or family is a critical part of intervention. The counselor will present didactic information about the model itself and also about specific concepts. In addition, the use of homework and its importance in the therapeutic process will be addressed. An early homework assignment designed to provide education about the model of therapy might include specific reading assignments that orient clients to concepts that will be emphasized during the course of treatment (Datillo & Epstein, 2005).

Socratic Questioning

During assessment interviews, the counselor may gather information about cogni- tions and processes that are particular to the family but that cannot be assessed by

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questionnaires. Socratic questioning is a method of questioning intended to guide discovery on the part of clients. It helps both clients and the counselor to identify clients’ core beliefs, including their distorted ideas and attitudes. Socratic ques- tioning can circumvent psychological defenses that may be activated during assessment and treatment. Assisting couple and family members in identifying their own core beliefs or unhelpful attitudes may be more helpful than having those pointed out by the counselor (Beck, 1995; Dattilio, 2000).

Communications Training

Communications training is viewed as an essential component of most approaches to CBC/FT and has long been used in most theoretical approaches to couple and family treatment. In addition to providing guidelines for expressing thoughts, feelings, opinions, preferences, and the like, clients are also given instructions about how to listen effectively and how to let others know they have been heard. Counselors generally model communication skills and provide opportunities to practice in session with the counselor acting as a coach. Improved communication can reduce distorted cognitions and help clients regulate emotion, both in how emotion is experienced and how it is expressed. Communications training is also routinely used in relationship enhancement training.

Problem-Solving Training

Problem-solving training is used to help couples and families learn to approach and deal with problems in an effective manner. Instruction, both verbal and written; behavioral rehearsal; and coaching from the therapist are important parts of the training. At-home practice is assigned, with follow-up in sessions to deal with issues that may arise. Problem-solving training generally involves teaching clients several specific steps that are common to most problem-solving models. These steps might include, for example: (a) clearly identify the problem, (b) generate possible solutions without evaluating them, (c) evaluate and choose an option, (d) put the option into place, and (e) reevaluate.

Behavioral Exchange Agreements

Behavioral exchange is still an important construct in CBC/FT; however, clinicians generally try to avoid having one member’s behavior change be dependent on that of another. Unilateral behavior change is encouraged, and didactic information about personal commitment, negative reciprocity, and the ability to control only one’s own actions is typically provided to help reduce reluctance to take the first step. For instance, each individual might be asked to identify a behavior that their partner or family members would like to see changed or that would improve the atmosphere in the family, and then to make that change regardless of the actions of others.

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Behavioral Rehearsal

Couples and family members are often asked to rehearse specific skills they have learned, and when rehearsal occurs in session, the counselor can model and coach during practice. According to Dattilio (2010), behavioral rehearsal is an essential part of treatment because the counselor gains insight about what couples and family members have understood.

Role Reversal

Spouses or a parent and child may be asked to discuss a problem with each person taking the other’s role. Role reversal can help in developing empathic under- standing of the other’s position and help each person become aware of their own misconceptions about the other. It can also be used as a way for each person to demonstrate a preferred way for the other to behave.

Modification of Cognitions

Changing extreme or distorted cognitions is an important element in CB/FT. A number of methods are used to teach family members to identify automatic thoughts and associated emotions/behaviors. For example, clients may be taught to identify and label cognitive distortions and then be assigned behavioral experi- ments to test their own predictions in order to help them challenge their distor- tions. Counselors may ask clients to recollect past interactions and to use role play and imagery to practice acting or thinking in a different way. Thought records forms that have been modified for use with couples and families may be assigned as homework, with clients instructed to record their thoughts about the relationship, including precursors and consequences of their thinking. They may also be challenged to identify more helpful ways of thinking (Dattilio, 2010). Thought stopping is another common technique from CBT that can be used in CB/FT. Clients are instructed to pay attention to how they think, and when they become aware of distorted or unwanted thoughts, to actively tell themselves to stop in order to interrupt dysfunctional thinking patterns.

Identification of Core Beliefs and Schemas

Downward arrow is a particular type of intervention designed to help people discover underlying assumptions and core beliefs behind their automatic thoughts. It is also used to help people who have difficulty in expressing emotion. When an automatic thought is identified, the counselor might ask, “If that were true, what would that mean to you?” Depending on the response, the counselor might ask the same question again. Once identified, schemas and core beliefs about relationships can be changed or modified, or other core beliefs can be encouraged. When working with those who have difficulty with emotional response, the counselor will also coach clients to notice internal cues to their emotions.

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LIMITATIONS

One limitation is that most cognitive-behavioral approaches to couple and family therapy can be conducted from a reductionistic or mechanistic stance, particularly by those who are inexperienced in working with couples and families. Lack of attention to family systems, including the multiple contexts in which couples and families live, may result in initial gains followed by a return to pretherapy functioning. Feelings and attitudes do not always change as a result of behavior alteration, and treatment goals may be reached without resolving underlying negative emotions (Nichols & Schwartz, 2004).

With notable exceptions, such as in the case of FFT, there is limited research about outcomes of BC/FT and CBC/FT approaches with couples and families that specifically addresses cultural, ethnic, or other diversity concerns. However, the importance of context together with concentration on client goals can provide some measure of attention to multicultural issues. In addition, several authors have pointed to various aspects of diversity in their research. Baucom et al. (2010) noted that gender, ethnicity, and cultural background can have an effect on a variety of factors in couple relationships. A number of authors have also noted gender differences in how partners respond to relational stress and how partners process information about their relationship (Gottman, 1999; Rankin, Baucom, Clayton, & Daiuto, 1995; Sullivan & Baucom, 2005). In addition, the strong contextual focus of IBCT, ECBCT, and FFT requires significant attention to multiple and over- lapping contexts in which people live. Stressors from the environment, such as poverty, violence, and experiences of discrimination, as well as themes and patterns particular to individual families are assessed, with the intention of enabling couples and families to negotiate recurrent problems and build on their strengths (Kelly, 2006; Kelly & Iwamasa, 2005; LaTaillade, 2006).

The emphasis on skills training by some CBC/FT practitioners, whether or not there is evidence that the skill exists and is just not being used, can cause counselors to ignore more salient issues that underlie whatever communication problems may exist. In addition, explicitly focusing on skill deficits, expectations, or attributions may cause some couples to become more aware of characteristics that were previously unknown or overlooked. In addition, some couples are not collaborative or trusting, and change-oriented work does not seem to be effective for those people. Counselors focused on behavior change may not only fail to be helpful but may also be harmful.

Finally, and perhaps most importantly, because the interventions appear to be relatively simple, counselors may use strategies they do not fully understand, unaware that unskilled use can result in significant unintended consequences for the couple or family.

SUMMARY

Rather than a single therapeutic approach, the umbrella of CBC/FT covers a number of specific approaches. This chapter has provided an overview of several of

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them. Cognitive-behavioral approaches to working with couples and families have repeatedly demonstrated efficacy in treating couple and family issues. In skillful hands, CBC/FT offers a relatively brief approach to treatment that has been demonstrated to improve a variety of presenting problems. It is pragmatic and offers a wide variety of interventions.

USEFUL WEBSITES

The following websites provide additional information relating to the chapter topics.

Association for Behavioral and Cognitive Therapies http://www.abct.org National Association of Cognitive-Behavioral Therapists http://www.nacbt.org Integrative Behavioral Couple Therapy http://ibct.psych.ucla.edu American Association for Marriage and Family Therapy http://www.aamft.org International Association of Marriage and Family Counselors http://www.iamfc.org

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Foundations of Couples, Marriage, and Family Counseling, edited by David Capuzzi, and Mark D. Stauffer, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=1913918. Created from waldenu on 2021-04-28 16:21:55.

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