Skills in Cognitive Behaviour

1
Skills in Cognitive Behaviour Counselling
Psychotherapy FRANK WILLS (2008) London
SAGE Chapter 3 Using interpersonal skills in CBT
2
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 Dons formulation
  map (next slide)

3
Dons 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, Ill be
  okay if I can get someone to love me, Ill be
  okay (ANTAGONISTIC SCHEMAS).

4
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

5
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.

6
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).

7
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.

8
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.

9
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.

10
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.

11
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 cant 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.

12
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 ones part in the
  interaction (sometimes the main problem can be a
  therapist schema reaction e.g., the therapists
  need to be helpful or right, etc.).

13
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.

14
Using Kagans 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 96100).