How To Use Your CBT Skills To Conceptualize Relationship And Interpersonal Problems: Two New Formulations To Integrate Into Your Practice

• Interpersonal difficulties are a common reason for clients to seek therapy.
• CBT therapists can struggle or lack confidence applying their skills when conceptualizing relationship difficulties and other interpersonal problems.
• In this article we will discuss two new ways we have developed for clinicians to adapt and apply existing CBT skills to work effectively with interpersonal problems.
• We will explore what interpersonal difficulties are and why therapists can feel unskilled in dealing with these types of problems. Then we’ll look at some existing psychological formulations and outline our new tools accompanied by two case studies.

Interpersonal difficulties are a common reason for clients to seek therapy. Sometimes clients bring problems where they’re struggling in everyday situations with other people, such as feeling frustrated with the way a partner is behaving, struggling to cope with their child’s behavior, or being aggressive towards other people. Or they may be having difficulty with more ingrained patterns of relating across relationships, such as issues of not fitting in, repeatedly choosing abusive partners, or not getting their needs met.

Cognitive behavioral therapy (CBT) provides many ways for therapists to conceptualize their client’s difficulties. However, many of the more familiar cognitive models for analyzing these problems focus on an individual’s responses and it is not always straightforward to adapt them to effectively represent interpersonal dimensions. Consequently, when clients come to therapy preoccupied with difficulties in their relationships, it is easy for CBT therapists to feel unskilled.

Working as CBT supervisors we have sometimes observed trainee and qualified CBT therapists struggle to manage their own feelings of discomfort when clients are preoccupied with interpersonal problems. Therapists might suggest goals for therapy that are at odds with what those that the client is bringing, perhaps focusing on concerns that are intrapersonal even when a client’s primary concern is interpersonal. Therapists might listen quite passively – feeling like they can’t conceptualize the problem in a CBT framework ­– or feel like they have gone uncomfortably ‘off piste’ with CBT. The result is that clients and therapists can end up working at cross-purposes.

In our experience, clinicians find it more difficult to work with client’s interpersonal difficulties in situations where:

• A client’s concerns relate to other people and their behavior (e.g. “They’re so unreasonable, I hate it when they speak to me like that”).
• A client externalizes and blames others for the way that they are feeling (e.g. “If they didn’t act like this I wouldn’t have a problem”).
• A client struggles to appreciate the potential effect of their behavior on others (e.g. “Why do people keep abandoning me?”).

In this article, we will discuss some new ways for clinicians to adapt their existing CBT skills to work effectively with interpersonal problems. We have developed some simple tools to facilitate this practice. These tools weave familiar CBT components together in a way that helps clinicians explore – and visually represent – the maintenance of interpersonal difficulties. Our approaches are framed in a way that contains deliberate links to the ‘theory A versus theory B’ technique, and to the use of behavioral experiments for testing assumptions, in an effort to help clinicians and their clients to move from discussion towards action.

We’ll start by defining what interpersonal problems are and then discuss some ways that other clinicians have captured reciprocal information in CBT formulations. Then we’ll introduce our tools and give some case examples. Our aim is to help you to apply CBT skills that you already possess so that you feel able to conceptualize relational difficulties.

What is an interpersonal problem?

Successful interpersonal relationships are an essential part of human flourishing. Interpersonal problems are difficulties that involve other people, their reactions, or an individual’s ways of relating to other people.

Clients may report encountering interpersonal problems in many domains of their life, including:

• Problems at work.
• Problems in social situations.
• Problems initiating or maintaining friendships.
• Problems in intimate relationships.
• Problems in online relationships.

Interpersonal problems can play out in many different ways. Clients might report not ‘fitting in’, feeling uncomfortable in social situations, being aggressive, avoiding emotional closeness, repeatedly entering relationships that are abusive or unfulfilling.

Psychological formulations of interpersonal problems

While CBT formulations do frequently include an individual’s social environment as a trigger for their experience, interventions are often focused on intra-individual factors. For example, Padesky and Mooney’s cross-sectional ‘hot cross bun’ model [1] is both a CBT formulation tool and a helpful way of introducing the cognitive model. It captures the effect of the environment on an individual’s thoughts, feelings, body, and behavior at a given moment and helps clients to understand the links between these areas. The cross-sectional formulation can be used to capture some relational information: for example, the ‘environment’ can include other people’s behavior. However, a limitation of this type of formulation for working with interpersonal problems is that it is not explicitly reciprocal – it doesn’t easily help clients to understand the effect of their actions on other people. Accordingly, a number of clinicians have published alternative methods for formulating interpersonal problems. We have outlined some of the most useful ones below.

Teichman’s family model of depression

Yona Teichman [2] published a ‘comprehensive reciprocal model of depression’ which  describes an “attempt to expand cognitive therapy of depression from an individual to a family modality”. Helpfully, this model assists CBT therapists to conceptualize reciprocal interactions between a patient and their family – each person is the ‘environment’ of the other. In the paper Teichman describes how behavioral models of depression focusing on social skills deficits can be integrated into the model.

Burbach’s cognitive interactional cycle

Developed in the context of family intervention in psychosis, Burbach [3] published a cognitive interactional cycle which we have found helpful as a clinical tool when formulating interpersonal difficulties. Burbach’s model explicitly identifies the beliefs that family members hold about one another, the ways that they react as a result of these beliefs, and clearly illustrates the repeating patterns or ‘vicious cycles’ in which families can become stuck. What we find particularly helpful about this model is the way in which descriptions of each individual’s appraisals of the other’s behavior are incorporated.

“When family members report their problems in a generalised (and blaming) way it is useful to explore specific situations and help the family to recognise that they are all contributing to, and are stuck in, a repeating pattern or ‘vicious cycle’. An exploration of sequences of behaviours (or ‘circularities’) regarding specific incidents (e.g. ‘Let’s look at what happened yesterday evening’) enables the identification of the feelings, beliefs and actions of the participants. The clinician, working with the family, can draw a ‘cognitive interactional cycle’ clarifying a (problem) behaviour, the circumstances leading up to it and the appraisals, emotional reactions and responses to it.”

Grimmer’s nine-part model (2013)

Grimmer [4] describes many of the same issues that we have identified when working with clients who struggle with interpersonal problems. Designed to help “a client understand the way events unfold between themselves and others that might perpetuate problems” Grimmer adapts Padesky and Mooney’s cross-sectional formulation to formulate interpersonal problems.

Lobban & Barrowclough’s interpersonal framework

Developed in the context of working with families in psychosis, Lobban and Barrowclough [5] published an “interpersonal framework for extending the more familiar cognitive behavioural model of psychosis to include the role of relatives’ behaviour in the process of recovery”. This is a very comprehensive model, and in its full form would probably be most helpful for clinicians trying to understand a family system. Our clinical experience would suggest that clients would benefit from a simplified conceptualization.

Two new CBT formulations to understand unhelpful patterns in interpersonal relationships

Drawing upon previous models, we have developed two new ways of formulating reciprocal interactions within a CBT framework. Both are designed to help clinicians represent these visually in clear ways that clients will be able to follow.

The first approach is a Reciprocal CBT Formulation. This encourages clients to consider how others may perceive their behavior in a particular situation. Cross-sectional in design, this method helps client and therapist to explore specific situations, and the thoughts, feelings, and behavior which make up a sequence. Visually, this method uses a ‘figure of eight’ or ‘infinity’ metaphor which emphasizes the self-perpetuating nature of the problem. It makes clear that other people’s perceptions and actions are a reaction to the client’s own behaviors (and vice versa), and that their problems are a repeating “vicious cylce”. Our clients report finding this formulation easy to grasp.

The second approach is the Interpersonal Beliefs and Styles worksheet. This approach is more helpful when therapists want to help their clients to explore patterns of behavior across situations. It can be used to explore a client’s beliefs about relationships, and the behaviors which they enact to keep themselves safe in relationships (their interpersonal styles). Subsequent aspects of this formulation explore the typical reactions of others, and the effect of these reactions upon the client’s beliefs about relationships.

As therapists and supervisors, what we find particularly helpful about these ways of conceptualizing interpersonal problems is the way that they can lead very naturally to understanding difficulties in ‘theory a / theory b’ terms, and subsequently conducting behavioral experiments to test the relevant beliefs. Importantly, these models help clients to feel empowered – to understand that these are problems over which they can have influence.

Case examples

John’s belief that colleagues didn’t like him

John came to therapy upset that no-one seemed to like him at work. He was struggling with depression. One of the things that bothered him was that he often felt left out at work – he felt as though he didn’t fit in. He would go whole days without speaking to people and would say that people don’t like him, ignore him, and leave him out of social occasions. He concluded that this was proof that he was worthless.

The concerns that he kept bringing up were to do with other people, and how their behavior made him feel. He would often act in extremes – so when he felt rejected he would reject back and avoid, but then felt isolated and lonely. He struggled to have friendships and described having felt suspicious of his partners when he had relationships in the past. Deep down he felt like he was unlikeable.

One of the most helpful parts of John’s therapy was when his therapist helped him to understand his relationships using the reciprocal CBT formulation.

First his therapist explored a recent time when he had been upset at work. They went through the cross-sectional aspects of the formulation. When no-one said anything to him he identified that his hot cognition was “My colleagues don’t like me”. This made him feel ashamed and down. He coped by avoiding colleagues, keeping to himself and avoiding eye contact.

John thought the problem was that his colleagues don’t like him, and that he couldn’t do anything about it. He felt hopeless and helpless, and thought that he should leave work. His therapist conceptualized this as ‘theory A’: just one hypothesis.

Therapists often feel quite stuck at points like this. The problem can appear to be environmental, or all to do with the behavior of other people. Therapists can often ‘buy into’ the sense of helplessness that their clients feel.

John’s therapist encouraged him to spend more time thinking about this problem. Together they considered the impact that his behavior was having on how other people might be thinking and behaving. John noticed that his avoidance was perhaps perceived by others to think that he wasn’t interested in engaging, or that he was a private person. If other people thought this, John reasoned, then it was conceivable that they might feel indifferent towards him, and might not talk to him because they think he is not interested. John understood that this then reinforced his belief that his colleagues don’t like him, and that he was in a vicious cycle.

This helped John to see his problem in a different way. He started to recognize that his thinking was just one hypothesis, and so he was open to considering that there might be other ways of looking at this situation.

His therapist introduced the idea of Theory A vs. Theory B. They formulated a theory B of “My colleagues don’t talk to me because they think I’m not interested”. Together they started to think about ways to test which might be the more helpful way of understanding what was happening for John. They planned an experiment where John would behave in a friendly way towards his colleagues and see how they reacted. He was very anxious about what being friendly meant. They considered different options such as inviting people to lunch, but in the end what John felt most comfortable testing was just saying hello to colleagues every day for the next week.

John was surprised at the friendly response that he received. He still felt urges to withdraw and avoid, and there were times when he felt worthless, but he persevered with the experiment. At his next session he brought several examples of friendly conversations, and of colleagues being genuinely interested in him. This was enough for him to carry on with some of his new behaviors at work.

Working with client’s relational problems in this way meant that the therapist wasn’t colluding with the client’s externalizing and avoidance. The client found it a validating and helpful way of working on the problems that he was bringing. They were able to use CBT principles to understand the relationship between his behavior and how other people responded, and the vicious cycles that he found himself in.

Cara’s belief that other people would hurt her and leave

Cara came to therapy because she was struggling with anxiety and depression. She was fearful that her partner would be unfaithful and felt that she could not talk to her friends about her feelings. She felt lonely and disconnected from everyone around her. She would often bring examples to therapy where she worried that her partner was cheating on her, lying to her, or withholding information from her. She also described feeling distant from her friends as she could not confide in them.  She had previously been betrayed by ex-boyfriends and, earlier in life, had been bullied by her friends at school. She therefore struggled to trust that other people truly cared for her, and feared that in the end everyone would hurt her and leave.

In therapy she gave examples of finding it difficult when her partner turned his phone away from her, which she had interpreted as a sign of him trying to hide messages from other women. She reported feeling anxious and scared, and she would respond by making unfair accusations, and by checking her partners phone for evidence of his infidelity. With her friends she worried that they would drop her eventually, so she never revealed too much about herself and tried to keep up a ‘happy front’, which left her feeling disconnected and depressed inside.

Cara’s therapist used an Interpersonal Beliefs and Styles worksheet to help Cara consider how her beliefs were affecting her behavior, resulting in the interpersonal difficulties she was describing. She identified that she held a strong belief that “When I get close to people, they will hurt me and let me down”. She was able to recognize that some of the ways she behaved with her partner and friends were related to this belief: she was hypervigilant for signs that her partner might cheat, and she avoided getting too close to her friends or showing any vulnerability that could be used against her (her interpersonal styles).

Cara’s therapist used the worksheet to encourage Cara to think about how others might be thinking, feeling, and reacting to the way Cara was behaving. For example, when she accused her partner of cheating or checked his phone for messages from other women, he became more secretive and distant from her – which she took as confirmation of her belief that he was being unfaithful. Cara also found it helpful to think about her friend’s responses to her ‘guardedness’ – she described how they didn’t open up and confide in her and this prevented her from opening up to them and fuelled the disconnectedness she felt. With gentle exploration Cara was able to consider alternative possibilities, that perhaps her partner was withdrawing because he was hurt by her accusations, and that her friends were unwilling to open up because she didn’t open up about her feelings.

Cara began to understand that her belief that others will hurt her (her ‘Theory A’) stemmed from her past experiences of being betrayed, and that was not necessarily true in her present circumstances. This understanding helped Cara to see that there were other possible explanations for the way her partner and friends behaved. Cara and her therapist developed a ‘theory B’ which was more nuanced “Yes I’ve been hurt in the past, but not everyone will hurt me and leave. Some people can be trusted. Maybe the way I am reacting is keeping people at a distance. If I keep going it could make my worst fears come true.” Cara could see that her fear of being hurt might become a self-fulfilling prophecy – that her behavior could be pushing her partner and friends away.

Cara decided that it would be helpful to test theory B by having an honest conversation with her partner. She spoke to him about her fears and he told her that it upset him when she accuses him because he has never done anything to betray her. He also said that he finds confrontation difficult and so hides things from her, so they don’t end up in an argument. This helped Cara to open up to the possibility of Theory B. To help her to continue testing Theory B Cara’s therapist helped her to learn worry management techniques and to learn skills to tolerate uncertainty. She practiced postponing her worries and resisting the urge to accuse her partner or check his phone. She reminded herself of her values of wanting to be a kind and trusting partner, and focused on doing more meaningful things with him so that she could feel closer to her partner. They started playing tennis together, and as Cara started to feel more confident with Theory B she began doing more things independently. She also started to open up to her friends about how she had been struggling. She was surprised at how supportive and kind they were to her, and how they started to be more open with her too. This helped Cara to feel more connected and she felt she could be herself more.

One of Cara’s big setbacks was when her partner spent a weekend attending a bachelor party with his friends. She felt very insecure and her beliefs about being taken advantage of resurfaced – she worried that he would cheat on her. She reminded herself of the relationship they had worked for, and that it was a ‘hypothetical worry’. Gradually, Cara realized that by not accusing him of things he was more open and that they felt closer. She learned to manage her worries and with time they became less bothersome. As Cara changed her behaviors (her interpersonal styles), her conviction in a healthier interpersonal belief (Theory B) became stronger. She was pleased to find that as she learned to open up and trust, her relationships actually felt deeper and more genuine.

Summary

CBT therapists often struggle when conceptualizing relationship difficulties and other interpersonal problems. Our experience as supervisors is that therapists often aren’t confident applying their CBT skills when confronted with relational difficulties – perhaps because they lack the language, or the correct tools, to effectively conceptualize interpersonal issues in CBT terms. When the client “doesn’t fit the model”, one strategy is to avoid working on the relationship problems and “make the client fit the CBT box” by working on problems that are intra-individual. An unfortunate consequence of this course of action is that the problems that are worked on are not the client’s primary concern. The opportunity is missed to work on the impact that a client’s behavior is having on other people and how other people respond to them – an area ripe for behavioral intervention.

We have developed two tools to help therapists use their CBT skills to conceptualize relationship problems: one more focused on here-and-now concerns, and the other focused on patterns within relationships. With both tools we have paid careful attention to how difficulties are represented visually, and to which information clients should attend. We have found that using these tools is a helpful way of approaching interpersonal difficulties while using familiar CBT techniques. Therapists who feel stuck with clients who ‘blame’ or ‘externalize’ may find it a helpful way of refocusing their client’s attention on to their role in reciprocal interactions and how they are perceived. In our experience it can help to reduce client’s anger or frustration by increasing their empathy or mentalization, and helping clients to understand the reasons for other people’s actions can be a big step forward and can motivate helpful changes in behavior. Similarly, clients who want to understand why they experience patterns repeating across relationships can be helped to understand their interpersonal beliefs, and the consequences of these on their behavior.

References

[1] Padesky, C. A., Mooney, K. A. (1990). Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13-14.

[2] Teichman , Y. (1986) Family Therapy of Depression. Journal of Psychotherapy & The Family, 2:3-4, 9-39, DOI: 10.1300/J287v02n03_03

[3] Burbach, F. R. (2018). Family therapy and schizophrenia: a brief theoretical overview and a framework for clinical practice. BJPsych Advances, 24(4), 225-234.

[4] Grimmer, A.G. (2013). The nine-part model: A tool for sharing dyadic formulations. Retrieved from www.bristolcbt.co.uk/publications/the-nine-part-model-dyadic-formulation on 2020-01-15

[5] Lobban, F., & Barrowclough, C. (2016). An interpersonal CBT framework for involving relatives in interventions for psychosis: evidence base and clinical implications. Cognitive Therapy and Research, 40(2), 198-215.