Skills in Cognitive Behaviour Counselling & Psychotherapy FRANK WILLS (2008) London: SAGE Chapter 3 Using interpersonal skills in CBT

CBT as an interpersonal therapy In a sense, all therapies are interpersonal - the question is: can the interpersonal dimension be mobilised in the cause of the therapy? A small discordant phrase can betray a looming interpersonal issue. The core of the most salient cognitions is invariably interpersonal - see Don’s formulation map (next slide)

Don’s formulation EARLY EXPERIENCE: Alcoholic parents; inconsistent parenting; basic needs not met. CORE BELIEFS: I am unlovable; people are not trustworthy; the world owes me no favours. ASSUMPTIONS: If I only rely on myself, I’ll be okay; if I can get someone to love me, I’ll be okay (ANTAGONISTIC SCHEMAS).

Interpersonal content in CBT formulation Beliefs about the self in relation to others Rules about how people should relate to each other Behavioural strategies about how to achieve goals with and without the co- operation (and/or opposition) of others

Interpersonal triggers invariably play a part in the development of psychological problems Humans are intrinsically interpersonal - interpersonal relating is ‘wired in’ from the first hours of life. Early CT writing underplayed relationships probably because although Beck was doing couples work, his research was focused on depression. Depression both results from poor relationships (current and/or historic) and results in poor relationships. It may be better to acknowledge that depressed clients may be quite ‘unrewarding’ to their partners and even to their therapists.

Attachment, interpersonal life and therapy Concern to relate and attach to others is ‘wired in’ – without it organisms, esp. humans, will not survive (Bowlby, 1988). The capacity to be healthily alone depends on being safely dependent (Winnicott, 1965). Therapy can work as a kind of secure base from which the client can explore new ways of thinking, feeling and acting. Negative attachment can harm the rational collaboration on which CBT exploration is built (Liotti, 2007).

Interpersonal aspects of goals for CBT Guidano & Liotti (1983) make the valuable point that understanding the importance of attachment in therapy should not blind us to the value of detachment: while we can work with client attachment, our goal should be that clients should eventually detach from us and walk on their own two feet. Another important aim of therapy is for us to help clients unhook themselves from negative interpersonal patterns. In order for us to help them do that, it is often necessary for us to first become unhooked from them too.

Unhooking from negative interpersonal patterns Negative interpersonal patterns often show self- fulfilling prophecies – e.g., socially anxious people often look ‘haughty’ and this draws negative attention from others – the very thing they fear most. Such interpersonal patterns often become obvious during the assessment phase. Therapists can check to see if they operate in the therapy sessions as well.

Relationship signals and relationship breakdowns in therapy RELATIONSHIP SIGNALS are often small discordant client behaviours that seem a little off-key. Therapists should begin by just noticing them and then watch to see if they recur. RELATIONSHIP BREAKDOWNS are highly disruptive client behaviours that threaten to derail the session or even the whole therapy.

Skills for dealing with interpersonal issues in CBT CLIENTS’ PATTERNS OUTSIDE THERAPY Review the cognitions that lurk underneath relationship difficulties experienced by the client. Pay close attention to how the cognitions link to emotions. Try replaying interpersonal scenarios with different thoughts: can use a thought record or act out as a role-play.

Skills for dealing with interpersonal issues in CBT RELATIONSHIP BREAKDOWNS DURING SESSIONS (Safran & Segal, 1990) 1. The client is sceptical. 2. The client is sarcastic. 3. The client makes indirect allusions to relationship problems via a third relationship – e.g., ‘I can’t stand women who tell me what to do.’ 4. Client and therapist disagree on goals or tasks. 5. Client is over-compliant. 6. The client does not respond to an intervention. 7. The client activates ‘therapy safety behaviours’: e.g., avoids going near painful areas.

How therapists can unhook from negative interpersonal patterns First, be aware enough of own reaction to ‘catch’ oneself reacting. Second, be aware enough to step back from the reaction to avoid ‘over-reaction’ or ‘retaliation’ (some client behaviours can be quite provocative). Third, decide when to comment – may be best to discuss in supervision first. Fourth, consider and own one’s part in the interaction (sometimes the main problem can be a therapist schema reaction – e.g., the therapist’s need to be helpful or right, etc.).

IMMEDIACY: a key interpersonal skill Immediacy is the skill to use reflections on the nature of what is going on between you and the client in ways that are helpful to the client. Often useful to ‘slow things down’ and invite the client to reflect with you – ‘Can we just stop and think what happened there? It seemed to me that … How did it seem to you?’ Need to think how emotionally open I can be with this client. It can be a priceless opportunity for them to learn how they come over to others. Most social situations are not safe enough for this – therapy can be.

Using Kagan’s IPR Interpersonal Process Recall (IPR) is good way of using supervision to get into the interpersonal processes underlying therapy sessions It consists essentially of stopping session tapes to share reflections of what might be going on. One party asks ‘inquirer leads’ to help the other reflect on what is happening in the session. See Wills (2008: 50), or Inskipp (1996: 96–100).