Reciprocal CBT Formulation
CBT therapists often describe finding it difficult to apply CBT skills when clients bring relational problems to therapy. Familiar methods of visually representing CBT formulations can struggle to incorporate 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 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. 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 supervisory relationships.
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, 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. Beck’s generic cognitive model (Beck et al, 1979) can also be used to under- stand issues within relationships. Flecknoe and Sanders (2008) illustrate the use components of the CBT model to develop behavioral experiments when working with client’s beliefs about relationships.
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.
“One helpful way of thinking about what happens in relationships is to draw out what happens. Would you be willing to use this tool to look at what happens in your relationships?”
Optional step: Identify beliefs about relationships
Beliefs and assumptions about relationships are important because they influence an individual’s perceptions of situations in the here-and-now. They might include beliefs about the self which influence how one is perceived interpersonally, or they might include assumptions, attitudes and rules concerning how one expects relationships to work.
- What are some of your beliefs about relationships?
- How do you expect other people to treat you?
- What do you expect from other people?
- If you do X how do you expect other people to react?
Step 1: Identify a specific triggering event which involved other people
The first step is to identify what triggered an interpersonal problem. Clients will often identify the behavior of other people. Encourage clients to identify specific details about the event (who, what, where, when).
- Where were you?
- When did you start to feel bad?
- What was it that made you start to feel bad?
- What happened that led you to feel that way?
Step 2: Identify client appraisal of the event
The fundamental step in a CBT understanding of a problem is to identify the way in which a client interpreted a situation.
- What did you think when that happened?
- What sense did you make of it?
- What went through your mind when they did / said that?
We often like to take the explicit step of framing these initial appraisals as ‘theory a’ which can help clients to distance themselves from their appraisal, hold it more lightly, and primes them for later identifying alternative plausible theories. Depending upon what else a therapist knows about a client it can also be helpful to identify a client’s important early experiences and their beliefs which have led them to interpret a situation in this way.
Step 3: Identify how the client felt in response to appraising the situation in that way
The next step is to help the client to make links between their appraisal and their emotions and feelings.
- How did you feel when you thought that?
- What did you notice in your body then you thought that way?
- How did that make you feel?
Step 4: Identify the client’s behavior in response to their feelings
Feelings are then framed as the trigger for coping behavior.
- What did you do when you felt that way
- What did you do to cope when you felt that?
- How did you react?
- What did you do?
Step 5: Encourage the client to make educated guesses about other people’s appraisals of their behavior
The therapist encourages the client to make educated guesses about how other people interpreted their behavior.
- What do you think they made of your behavior?
- What do you think they thought when you did that?
- If you didn’t know anything about them, and someone acted in this way, how might you make sense of it?
If the client struggles to identify alternative view we often brainstorm possibilities, or make tentative suggestions:
- Let’s brainstorm some possibilities. Do you think they might have thought X or Y?
- I wonder if they a little rejected when you did that?
Step 6: Encourage the client to empathize with the other person/people
The therapist is trying to make the behavior of the other person or people understandable in the light of their appraisal.
- Assuming that’s what went through their mind, how do you think they might have felt?
- How do you think they felt when they thought you were… ?
- If they were thinking that, how do you think they would feel?
Step 7: Encourage the client to identify how the other person/people reacted, or to make educated guesses about how another might react if they felt that way
And this is another opportunity to reinforce the cognitive model – the behavior of the other person/people is understood in the context of their appraisal and emotional reaction.
- How did they react?
- What did they do?
- How do you think they would react if they felt that way?
Step 8: Encourage the client to reflect on the sense they made of the other person/people’s behavior
And to ‘close the circle’ the therapist then explores the client’s appraisals of the other person’s behavior. This is an opportunity to explore what the behavior of the other person did to the client’s appraisal or ‘theory a’ – did the behavior feed into what they already thought? It is also an important opportunity to help the client to develop alternative theories about the behavior of the other person.
- What sense did you make of their behavior?
- What did it do to your ‘theory a’?
- How does their behavior affect what you think?
- So you started off thinking X, but now they’ve done this what do you think now?
Step 9: Ask reflective questions aimed at encouraging the generation and testing of alternative behaviors
If a client has come to an alternative understanding of their problem (theory B) then an obvious next step is to ask questions to explore this tentative new understanding, which might motivate further exploration, or which might motivate new behavior. Helpful questions at this step might include:
- How do you think they would feel if you acted another way?
- That sounds like an interesting possibility, how might we find out?
- How might we find out?
A helpful next step at this point is the generation of behavioral experiments to test the new theory. We will often encourage the client to reflect on where they can intervene to make changes in the cycle (“I could talk to myself differently”, “I could do something different”).
- 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.
- 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.