Reciprocal CBT Formulation

A CBT formulation helps therapists and clients to understand a client’s presenting problems within the framework of the cognitive behavioral model. Persons (2008) describes how formulations are described at three levels: case, disorder or problem, and symptom. These levels can be embedded in one another: for example, a case-level formulation may contain symptom-level cycles. Therapists use a wide variety of formulation tools, from cross-sectional models, which capture the effect of the environment on an individual’s thoughts, feelings, body, and behavior at a moment in time, to longitudinal models, which also seek to understand the underlying factors that predispose a client to the problems they are experiencing.

CBT theory can be applied to interpersonal problems. For example, Teichman’s reciprocal model of depression describes the constant process by which the behaviour of others can influence one’s internal state (Teichman & Teichman, 1990; Teichman, 1992). Safran and Segal’s cognitive interpersonal model (1996) describes how an individual’s behavior within relationships arises from unhelpful interpersonal schemas, which in turn provoke others to respond in ways that reinforce beliefs and difficulties. Flecknoe and Sanders (2008) illustrate the use of components of the CBT model to develop behavioral experiments when working with client’s beliefs about relationships. Beck’s generic cognitive model (Beck et al, 1979) can also be used to understand issues within relationships and Grimmer (2013) developed a nine-part model which allows conceptualisation of dyads using the familiar five-part model (Padesky & Mooney, 1990).

Notwithstanding the examples above, CBT therapists often describe finding it difficult to apply CBT skills when clients bring relational problems to therapy. Clients might report problems such as fearing and avoiding emotional closeness, finding relationships threatening, repeatedly ending up in abusive relationships, or feeling dissatisfaction in their relationships. Familiar methods of visually representing CBT formulations can struggle to incorporate these reciprocal interactions, with the result that clients are not helped to mentalize and understand how others may perceive and react to their behaviors.

This Reciprocal CBT Formulation tool was developed to formulate reciprocal interactions using CBT principles. The purpose of this tool is:

• To help clients gain alternative perspectives on their interpersonal difficulties.
• To help clients mentalize and notice how their behaviors may be perceived by other people.
• To help clients understand that they have influence over situations where they might otherwise feel helpless.
• To empower clients to identify targets for change, by testing their beliefs and assumptions with behavioral experiments.

The tool encourages therapists and clients to explore – and visually represent – the maintenance of interpersonal difficulties. A ‘figure of eight’ or ‘infinity’ metaphor illustrates the stuck ‘vicious cycle’ nature of such problems. The method encourages clients to mentalize, understand how others might appraise their behavior, and to examine how the behavior of others influences their own beliefs. Conceptualizing interpersonal problems in this way can help clients to see that their original belief (theory A) is just one hypothesis and that there could be alternatives (theory B). This can lead naturally to interventions such as behavioral experiments to test beliefs and assumptions.

Therapists should consider using this tool when: clients want to focus on relationship difficulties in therapy; clients struggle to mentalize or externalize (minimize their role); When clients present with angry or defensive interpersonal behavior; in couples work to examine reciprocal patterns that are occurring within a dyad; or to conceptualize process issues arising in therapeutic or supervi- sory relationships. 

This pack includes three versions of the tool: a cross sectional version which focuses on thoughts, feelings, and behaviors in the here-and-now; a longitudinal version designed to elicit client beliefs about relationships (these are illustrated influencing here-and-now cognitions about triggers); and a longitudinal version designed for use with couples. It includes sections for both participants’ beliefs about relationships. Multiple case examples are also included, illustrating different dyads and process issues which might arise in therapy.

• Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). The cognitive therapy of depression. New York: Guilford Press.
• Flecknoe, P., Sanders, D. (2004). Interpersonal difficulties. In: Bennett-Levy, J., Butler, G., Fennell, M., Hackman, A., Mueller, M., & Westbrook, D. (Eds.). 2004. The Oxford guide to behavioural experiments in cognitive therapy, 393-412. New York: Oxford University Press.
• 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
• Padesky, C.A. & Mooney, K.A. (1990). Presenting the cognitive model to clients. International Cogntive Therapy Newsletter, 6, 13-14. Retrieved from http://padesky.com
• Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy (guides to individualized evidence-based treatment). New York: Guilford.
• Safran, J., & Segal, Z. V. (1996). Interpersonal process in cognitive therapy. Jason Aronson, Incorporated.
• Teichman, Y. (1992). Family treatment with an acting-out adolescent. In A. Freeman & F. M. Datillio (Eds.) Comprehensive casebook of cognitive therapy. Springer.