Cognitive Behavior Family Therapy of Psychosomatic Disorders with an Emphasis on Positive Psychotherapy

doi:10.4236/psych.2012.312A163

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Psychology

2012. Vol.3, No.12A, 1104-1109

Published Online December 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.312A163

1104

Cognitive Behavior Family Therapy of Psychosomatic Disorders

with an Emphasis on Positive Psychotherapy

Mohammad Khodayarifard, Saeed Akba ri Zardkhaneh

Psychotherapy & Child Clinical Psychologist, Faculty of Psychology and Education,

University of Tehran, Tehran, Iran

Email: [email protected], [email protected]

Received August 15th, 2012; r evised September 17th, 2012; accepted October 14th, 2012

Objective: The purpose of the present study is to examine the effectiveness of cognitive behavioral fam-

ily therapy with an emphasis on positive psychotherapy in treating psychosomatic disorders. Method: A

single subject design was applied. Three patients suffering from chronic lower back and neck pain were

selected as a sample group and participated in 16 sessions of family therapy, two hours per week. Exami-

nation by a physician, X-ray and clinical interview based on DSM IV-TR along with MMPI and SCL-

90-R tests were used as instruments. Result: Almost all the subscales of MMPI and SCL-90-R and other

instruments showed significant decrease after therapy as compared with the pretest results. Discussion:

The results indicated the effectiveness of cognitive behavior family therapy based on positive psycho-

therapy. Some possible reasons could be solving conflicts and interpersonal problems by means of train-

ing certain skills such as problem solving, developing relationships with others, effective coping, asser-

tiveness and positive thinking.

Keywords: Positive Psychotherapy; Psychosomatic Disorders; Family Therapy; Cognitive Behavior

Therapy

Introduction

The relationship between body and mind has always been a

very controversial issue. Human beings are viewed as a bio-

psychosocial organism and these three aspects affect each other

interactional. This standpoint has brought about new interdisci-

plinary fields in psychology and medicine and these kinds of

treatments are widely applied for treating psychosomatic disor-

ders.

Psychosomatic disorders are psycho physiological disorders

and include physiochemical, anatomical or physiological dis-

orders (Knapp, 1985). Psychosomatic disorders like asthma,

stomach ulcer, high blood pressure, muscular and bone pains

and headache constitute a group of physical disorders which are

caused by psychological problems or are at least intensified

under the influence of psychological stressors.

Today there is a dominant view that almost all the physical

diseases are potentially related to psychological factors. Ac-

cording to DSM-IV-TR (2000), in case of any kind of psycho-

logical disorders, identification of stressors and other psycho-

logical factors that amplify the symptoms is essential for the

diagnosis of psychosomatic disorders. This group of disorders

implicates the presence of a reciprocal and meaningful organic

relationship between psychological and physical aspects of

human beings.

Findings of many controlled studies have shown that the

prevalence rate of psychosomatic disorders in industrial socie-

ties has been several times more than that in underdeveloped

and traditional societies (Wolman, 1988). Mison (1975) be-

lieved that daily stressful experiences and living in big cities

and industrial societies can be the cause of a change in the en-

docrine glands. This change can in turn affect the functions of

the immune system and increase the vulnerability of an organ-

ism to disease. Furthermore, stressful events can affect the bio-

logical function of amino-acids in the central nervous system,

prompt the decrease in the resistance of human and, cones-

quently, lead to psychosomatic disorders. Considering the role

of different environmental, cognitive and bio-chemical factors

that cause psychosomatic disorders, their treatment may also

require the combination of several professional fields.

Today, there are several approaches for ameliorating psy-

chosomatic disorders which include medical (e.g. surgical,

pharmacological) and psychological (e.g. psychoanalytical,

behavioral, cognitive and cognitive behavioral) approaches.

However, it is not possible to decide with certainty about the

type of therapy method or approach which is optimal for each

problem. Although research has shown the efficacy of pharma-

cotherapy in decreasing the symptoms of psychosomatic prob-

lems related to spinal column, joints and muscles (Woodham,

2000), treatment of psychosomatic disorders has increasingly

focused on the interaction of organic and psychological factors

(Lipowski, 1985). In fact, the aim of treatments for psychoso-

matic disorders is not only to relieve the symptoms but also to

prevent from their relapse. In treating the primary psychologi-

cal factors which have a role in causing the somatic symptoms,

psychotherapy can help beyond the efficacy of pharmacological

treatments.

Applying cognitive behavioral techniques, whether in the

form of individual or family therapy, is very common in treat-

ing psychosomatic disorders. Jay et al. (1987) compared cogni-

tive behavioral family therapy, use of medicine and attention-

control techniques in relieving marrow bone pain. The results

showed that cognitive behavioral family therapy was the most

efficient method in decreasing this pain. It has been also

M. KHODAYARIFARD, S. A. ZARDKHANEH

observed that family therapy based on cognitive behavioral

techniques can be effective in treating children who have psy-

chosomatic disorders. Leibman et al. (1974) used cognitive

behavioral techniques for treating a group of children who had

severe asthma. In this psychosomatic disorder, the primary

allergic tendency in the patient can be combined with emotional

factors and, particularly with family problems and conflicts.

The members of a family are all elements of an interactive

system in which one individual constantly influences and is

influenced by all other members (Stierlin, 1977). Therefore, a

symptom can be only understood within the framework and

web of relationships in which that symptom is expressed. This

is especially true for psychic and psychosomatic illnesses. The

role that the symptom plays within the family, within its rules

of conduct and within its social context can be only understood

considering this viewpoint (Peseschkian, 1986).

Cognitive behavioral family therapy aims at reducing the

symptoms as well as changing the dysfunctional family struc-

ture and roles through cognitive behavioral approach. This

approach consists of different techniques such as training

communication skills, problem solving, relaxation and reward-

ing system management.

Psychosomatic disorders (muscular/joint) are local reflec-

tions of anxiety, tension or other emotions in an individual as a

muscular tonus. Anxiety plays an important role in the cogni-

tion, affection and behavior of the patients who have chronic

muscular/joint pains (Asmundson, 1994). Among the re-

searches who have studied the efficiency of cognitive behav-

ioral family therapy in the treatment of psychosomatic muscu-

lar-joint pains, the following examples can be pointed out:

Kendal et al. (1997) treated a group of individuals suffering

from anxiety disorders and muscular pains using a cognitive

behavioral approach. In this research, the cognitive components

of anxiety (such as recognizing physiological symptoms of

anxiety, correcting stressful conversations, compromising dif-

ferent stressful situations and self-monitoring) were applied to

the experimental group during 16 weeks. They were also

trained with some behavioral techniques (like modeling, desen-

sitization, role playing and relaxation) in order to control anxi-

ety. At the end of the treatment period, anxiety symptoms were

significantly reduced in the experimental group as compared

with the control g r o u p .

Kazdin and Weisz (1998) compared individual and family

cognitive behavioral therapy in the reduction of psychosomatic

symptoms. The results for individual and family cognitive be-

havioral therapy were 57.1% and 84% improvement, respec-

tively. Johnson and Dahl (1998) investigated the effects of a

cognitive behavioral pain control program in a group of par-

ticipants with muscular bone pains in two groups: the control

group (study 1) and a sample of patients (study 2) that were

studied during a long period. The four-week therapy programs

included instructional sessions, explaining objectives, nerve

calming, practice of social skills, reduction of the use of medi-

cines and reversion to work programs.

Clinicians have been interested in applying different methods

of psychotherapy including behavior therapy (Kazdin & Wesiz,

1998) and positive family therapy (Peseschkian, 1986) in treat-

ing psychosomatic disorders and also investigating the effi-

ciency of cognitive behavioral techniques in the treatment of

muscular and bone disorders (Johnson & Dahl, 1998). The

main goal of the present research was to study the effect of

cognitive behavioral family therapy on the treatment of psy-

chosomatic disorders (muscular and bone pains).

Method

The present research was a single-subject study using an A-B

design. In order to choose the research sample, 3 individuals (2

male and 1 female) with muscular-bone type of psychosomatic

disorders were chosen from individuals who referred to a pri-

vate psychotherapy clinic. However, since two of these partici-

pants (1 man and 1 woman) did not continue to participate in all

of their therapy sessions, they were eliminated from the original

sample and the sample was eventually consisted of three re-

maining participants.

All of the participants were diagnosed with psychosomatic

disorder like muscular-bone problems (backache-neck pain)

without physiological sources. The diagnosis was confirmed by

X-ray, clinical interview made by psychotherapist based on

DSM-IV-TR, SCL-90-R and MMPI-2 testes. Data collection

was conducted in two stages of pretest (stage A) and posttest

(stage B).

Minnesota Multiphase Personality Inventory (MMPI) has 13

subscales, 3 subscales of which are related to test validity (L, F

and K) and other 10 subscales of Hypochondria (Hs), Depres-

sion (D), Hysteria (Hy), Psychosocial Deviation (Pd), Mascu-

linity-Feminity (MF), Paranoia (P), Psychasthenia (Pt), Sc hizo-

phrenia (Sc), Hypomania (Ma) and Social Introversion (Si) are

related to personality and clinical indexes. The method of an-

swering these questions is true/false; each true answer receives

1 score while the false answer receives 0.

The validity of MMPI has been confirmed. The reliability of

all MMPI subscales was also confirmed in a meta-analysis

study and the range of reliability coefficients was reported be-

tween 0.71 for Ma scale and 0.84 for Pt scale (Marnat, 1990).

In the present research, the short form of MMPI was used

which included 71 questions. The participants’ scores in Hs

scale (or hypochondria) were considered as an index of their

physical problems.

The Symptom Checklist-90-Revised (SCL-90-R) is a diag-

nostic and screening test used mainly for mental patients and

drug addicts and alcoholics (Mirzaei, 1980). It consists of 90

items and 9 dimensions which measure different psychological

aspects including somatization, obsessive-compulsive traits,

interpersonal sensitivity, depression, anxiety, hostility, phobia,

paranoia and psychoticism. By applying Cronbach’s alpha co-

efficient, Mirzaei (1980) reported the reliability of the SCL-

90-R as 0.70 and its concurrent validity with the MMPI-2 was

0.51. According to Hooman (1997), the internal consistency

coefficients of this instrument’s subscales, which ranged from

0.69 to 0.88, were acceptable. The construct validity and con-

current validity of this instrument were also acceptable accord-

ing to Hooman (1997) and Nadjarian and Davoodi (2001). In

the present study, the Cronbach’s alpha coefficient was 0.97 for

the whole test which ranged from 0.74 to 0.87 in the subtests.

The correlation between the two halves of the test was 0.89. In

this research, the participants’ score in the subscale of physical

complaints was considered as the index of their physical prob-

lems.

Procedure

As mentioned before, the research sample included 3 indi-

viduals diagnosed with muscular bone psychosomatic disorder.

M. KHODAYARIFARD, S. A. ZARDKHANEH

They participated in 16 sessions of family therapy, 2 h per week.

The techniques used in these sessions included training skills

such as positive thinking, behavior analysis, and problem solv-

ing, anger control, and communication, assertiveness, coping

with stress, interpersonal coping, relaxation and cognitive re-

structuring. Some of these techniques were cognitive and some

of them were behavioral.

Cognitive restructuring through positive thinking is used in

the family context to treat the client’s depression and enhance

the family members’ relationships. Positive thinking is a cogni-

tive behavioral technique that has been effective as a treatment

method for many disorders (Khodayarifard, 2000). Training

positive thinking is based on focusing on one’s own and others’

points of strength. This technique is performed in eight steps

and may be applied to families or groups:

1) Each person writes all of his/her own positive points on a

sheet of paper.

2) Each person thinks about at least five of his/her good ex-

periences or memories and writes down their titles.

3) The family members discuss their positive memories or

experiences in turn.

4) As a family member tells his/her account, others take

notes of the positive points they can find in the person who is

talking.

5) Then, each speaker listens to others who are talking about

the positive points they have identified in him/her.

6) In the next stage, the members give their lists of positive

points to each of the family members in turn. The following

lines are some samples of the positive points about a speaker,

listed by the group members participating in such a task:

An honest and loyal friend; she speaks clearly and fluently, is

independent, has good faith, is a good coordinator, is encour-

aging, is physically strong, is a true believer, provides good

leadership, is creative, helpful, flexible and conforming, prac-

tices religion, learns new things easily, is clever, patient and

tolerates severe pain, listens carefully, paints well, speaks hon-

estly, is peaceful, is brave, notices the impact of prayers in

practice.

7) The positive points are ranked on the basis of their impor-

tance.

8) Five to eight points of strength which are called the reli-

able points are selected from the collected lists of the positive

points.

Through this technique, clients developed a new awareness

about themselves according to the comments they received

from their family members. They were instructed to review

their personal memories by combining good and praiseworthy

feelings. They then selected the most significant ones and ex-

tracted their points of strength. They were able to use the com-

ments of family members for clarifying and sorting their own

list of points of strength. They were helped to obtain a more

integrated self image through this technique and further devel-

oped and maintained it throughout their sessions with the help

and support of their family members.

Findings

Participant 1: Mr. H. F. H. 45 years old, engineer, married

to a 40-year-old woman, high school education, 2 daughters

who were 13 and 19 years old and a 8-year-old son.

In the first session of psychotherapy, the participant said: “It

has been about one year that I am always restless and anxious. I

feel a deep sadness and disappointment, always think about

death and also have severe backache which specialists believe

has a psychological source instead of a physiological one.”

Figure 1 shows the participant’s high score in HS (11),

demonstrating that he was very concerned about his physical

condition and inclined to get attention through physical pains,

and his high score in D (12), implying his severe depression.

Also, his high score in Hy (15) showed his physical problems.

Dotted lines in Figure 1 demonstrate the participant’s profile

in MMPI after the intervention. As can be observed, his psy-

chological status after the intervention was within the normal

range. The low score in Hs (6) and Hy (10) showed healthy

physical situation and the participant’s satisfaction with his

physical condition and the low score in D (10) implied a

healthier mental status and absence of the previously observed

depression.

Figure 2 shows high score in physical complaints index (27)

before the intervention which revealed his dissatisfaction and

concern about his physical condition. The high scores in obses-

sion-compulsion (30), depression (34) and anxiety (30) indexes

also indicated the participant’s severe anxiety, obsession and

depression.

Dotted lines in this figure show the psychological profile of

the first participant in SCL-90-R in the posttest stage. As dem-

onstrated by the figure, the participant’s psychological and

physical state was normal after the intervention. Low score in

physical complaint index (8) implied his enhanced physical

condition and low scores in obsession-compulsion (9), depres-

Figure 1.

Psychological profile of the first participant in MMPI in pretest

and posttest stages.

Figure 2.

Psychological profile of the first participant in SCL-90-R in pretest

and posttest stages.

1106

M. KHODAYARIFARD, S. A. ZARDKHANEH

sion (8) and anxiety (10) indexes demonstrated his desirable

psychological health.

The comparison of Figures 1 with 2 shows similar findings

on MMPI and SCL-90-R before the intervention. The findings

of both tests revealed physical problems and dissatisfaction

about physical state, depression and anxiety before the inter-

vention.

According to the psychological profile of the first participant

in MMPI and SCL-90-R in the pretest and posttest, cognitive-

behavioral family therapy was effective in the treatment of

psychosomatic disorder (muscular bone) as well as anxiety and

depression of the first participant.

Participant 2: Mrs. A. B., 40-year-old, high school educa-

tion, housewife and married to a 45-year-old man with an M.A.

degree and two 13 and 19 year old daughters and one 8-year-

old son.

In her first session of psychotherapy, the participant said:

“Although we almost understand each other, my husband is a

nervous, anxious and depressed man; this has made me anxious,

too, and it is about 11 months that I suffer from a severe pain

around my knee and lower back. I visited several doctors, but it

was useless; they eventually referred me to a psychologist be-

cause they thought my physical pains have psychological

sources and are caused by high anxiety and stress.”

Figure 3 which shows the participant’s MMPI profile before

the intervention revealed a tendency to exaggerate her undesir-

able conditions (low scores in K and L scales and high scores in

F scale). Furthermore, her high score in Hs (11) showed her

dissatisfaction with her physical health and that she also tended

to receive attention through her physical pains. High scores in

Hs and Hy as well as in D scale demonstrated somatization of

her inner conflicts and her histrionic traits. The high score in Pd

(12) and in Pt (14) demonstrated her paran oia and, her a nxiety,

fear, restlessness and obse ssion, respectively.

Dotted lines show a normal posttest profile. The low score in

Hs (6) and in Hy (10) implied satisfaction with physical status.

The low score in Pd (7) and Pt (8) showed a healthier psycho-

logical condition and decrease in her anxiety and paranoia,

respectively.

Figure 4 shows the SCL-90-R profile of the second partici-

pant before and after the intervention. Before the intervention,

her high scores in physical complaint (30), obsession-compul-

sion (16), depression (18) and anxiety (19) indexes revealed her

dissatisfaction with her physical condition as well as sever

anxiety, obsession and depression. Dotted lines in the same

figure show her posttest profile, indicating that her psychologi-

cal and physical status was normal after intervention. The low

score in physical complaint index (8) showed her satisfaction

with her physical condition. Low scores in other indexes such

as obsession-compulsion (9), depression (8) and anxiety (10)

demonstrated a healthy mental state.

Comparison of Figures 3 and 4 show a similarity between

the findings of MMPI and SCL-90-R. Both tests showed unde-

sirable physical condition, anxiety, obsession and depression in

the second participant as well as a significant decrease in her

symptoms after the therapy. According to the profiles of the

second participant in MMPI and SCL-90-R tests before and

after the intervention, it can be concluded that family therapy

based on cognitive-behavioral techniques had an effective role

in treating the participant’s psychosomatic disorder (muscu-

lar-bone) and other related psychological disorders.

Participant 3: Mr. S. D. 38 years old, M.A. degree, married

Figure 3.

Psychological profile of the second participant in MMPI in pretest

and posttest stages.

Figure 4.

Psychological profile of the second participant in SCL-90-R in pre-

test and posttest stages.

to a 28-year-old woman with an MA degree who was a house-

wife with two sons (7 years and 6 months old).

In his first session of psychotherapy, the participant said: “It

has been several years that I have problems with my brother

about financial and work issues and this has made me very

sensitive and irritable. I have severe anxiety most of the time

and it is about 10 months that I am suffering from a severe neck

pain and backache. I have visited several physicians, but they-

said that my backache and neck pains are probably caused by

psychological stressors.”

Figure 5 shows that the participant tried to exaggerate his

physical problems (the F score of the participant is higher than

his K score) in the pretest stage. The high score in Hs (10) and

in Hy (16) also showed the participant’s dissatisfaction with his

physical conditions and also that he tended to get attention by

means of his physical pains. The high score in D (14) implied

his isolation and depression. Also, his high score in Pa (10)

showed paranoid traits and the high score in Pt (13) expressed

his obsession, anxiety and restlessness. Additionally, in Figure

5, dotted lines indicated that his psychological status was back

to normal in the posttest stage in different scales of MMPI-2.

The low scores in Hs (7) and Hy (13) show that the participant’s

satisfaction with his physical appearance and condition. Also,

low scores in D (10), Pa (8) and Pt (11) demonstrated a de-

crease in other symptoms of isolation, depression, suspicions,

anxiety, and restlessness in this subject.

Figure 6 shows that the participant’s score in physical com-

plaint (24), obsession (14), depression (29) and anxiety (22)

M. KHODAYARIFARD, S. A. ZARDKHANEH

Figure 5.

Psychological profile of the third subject in MMPI-2 in Pretest

and Posttest stages.

Figure 6.

Psychological profile of the third participant in SCL-90-R in pre-

test and posttest stages.

indexes were very high in the pretest. Dotted lines in Figure 6

show a decrease in physical complaint (12), obsession (8), de-

pression (9) and anxiety (11) indexes demonstrating a desirable

mental and physical state.

Comparison of Figures 5 and 6 showed high similarity be-

tween the findings of MMPI-2 and SCL-90-R before the inter-

vention. The findings of both tests showed physic al dissatisfac-

tion, obsession, anxiety and depression in the third participant.

Based on the profile of this participant in MMPI-2 and SCL-

90-R in the pretest and posttest stages, it can be observed that

family interventions based on cognitive-behavioral techniques

had an effective role in reducing psychosomatic disorder (mus-

cular-bone) and other related psychological disorders in the

third participant.

Discussion

The findings showed that family interventions based on cog-

nitive-behavioral techniques can be effective in treating psy-

chosomatic disorders (backache-neck pain) and its co morbid

psychological disorders such as anxiety, depression, paranoia,

obsession and communicative problems. This finding was con-

sistent with the results obtained from the research by Jay et al.

(1987), Johansson and Dahl (1988) and Kendal et al. (1997).

Jay et al. (1987) compared cognitive behavioral family ther-

apy with pharmacotherapy and attention control methods in the

treatment of bone pains and found that family therapy based on

cognitive behavioral techniques was the most efficient therapy

in controlling these pains. Johansson and Dahl (1998) studied

the effects of cognitive behavioral interventions on a group of

individuals who had muscular-bone pains. Their findings re-

vealed that regular cognitive behavioral interventions can suc-

cessfully treat muscular-bone pains. Kendal et al. (1997) also

treated a group of individuals who had anxiety and muscular-

bone pains with cognitive behavioral techniques.

One of the reasons for the effectiveness of cognitive behav-

ioral family therapy and other related psychological disorders

may be related to the nature of psychosomatic problems. Gen-

erally, something which is common among people who suffer

from psychosomatic problems is their interpersonal problems

(such as problems with spouse, parents, siblings, etc.). Accord-

ing to the participants’ statements in their psychotherapy ses-

sions, it can be said that this issue was commonly a very pro-

minent problem among the three participants of this study.

Family therapy, therefore, seems quite suitable for these cli-

ents since it helps solve the intrapersonal conflicts using tech-

niques such as training problem solving skills, communication

skills, assertiveness training, efficient coping skills, positive

thinking and cognitive restructuring. This method helped them

to not only cope with the existing problems efficiently, but also

avoid potential new problems. In family interventions based on

cognitive behavioral techniques, there is high emphasis on the

modification of negative and damaging communicational

means, dysfunctional belief patterns, unreasonable thinking

patterns and unreal expectations.

One of the limitations in the present study was its limited

number of participants which made the results difficult for gen-

eralization. Thus, further similar studies with bigger sample

sizes are required. Another suggestion can be to compare this

therapeutic method with other therapeutic methods such as

individual cognitive behavioral therapy or other modalities and

approaches of psychotherapy. Another limitation in this study

was concerned with the lack of a control group, which calls for

further research on the effectiveness of this method in the

treatment of psychosomatic disorders based on the result of this

study.

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