Working on Relationship Problems with CBT

Many therapists who are familiar with CBT and deliver it individually are somewhat daunted seeing individuals or couples to deal with their relationship issues. Perhaps, they did not receive training in this field or feel they need to refer these clients to therapist who are more specialized in these issues. CBT has been adapted in helpful ways which will allow practitioners to apply CBT interventions to the many clients who experience relationship problems which some clinicians providing therapy may not be familiar with.

The need for therapy for interpersonal issues is considerable. It may be that individual clients who comes with a presenting problem such as anxiety for depression may subsequently identify a relationship issue which they would like to address or ,alternatively, in the initial interview this may be immediately identified as a factor in their depression or anxiety. Either way the therapist will want to focus on the relational problems and understanding the CBT model and interventions based on it for these interpersonal issues will be an important component of the treatment. Interestingly, the literature demonstrates that the outcome for clients treated for anxiety with CBT shows that the outcome is less positive if interpersonal issues which exist are not addressed during treatment.

So, the questions for a therapist who has identified a relationship issue are;

• Do I refer out to a couple or relationship expert or work on these issues myself?
  If I do not refer out, do I see just the designated client and focus on these issues or do I bring in the partner or the individual (family member, friend) the client is having relational issues with?
  If I do include another person, will it be set up as couples therapy or will the partner be included a few times to augment the individual therapy?

It is not possible to go into the pros and cons of each option, but these decisions are important in treatment planning. Depending on the severity of the relationship problems, it may be possible to bring in the partner (or family member) for relationship-focused CBT. However, it is not advisable to continue seeing a client for individual therapy while also doing couples therapy with both partners, as this can create triangulation.

Irrespective of whether this is clearly designated couples therapy or individual therapy with the partner being included, the ground rules for this relationship-focused therapy with two or more people involved need to be clearly outlined.

The following rules should be outlined:

• The relationship is the focus, not the individuals themselves.
  They agree to share responsibility for the issues experienced.
  It is Important to build positive behaviors, not just focus on negative or destructive behaviors/
  Complaints should be turned into requests. (Instead of “you never…….’ , use “I would like it if……”)
  All parties will agree not to demean, disrespect or scapegoat the other.
  Time outs/constructive pauses will be initiated, if required when there is severe conflict or emotional dysregulation in participants.
  There will not be collateral individual contacts with the therapist, unless in special circumstance.

Historically, CBT has focused on relationship or couples’ issues from the beginning, starting with an RET Approach (Ellis & Harper (1961) which was followed by early Behavior Therapy approaches (Stuart 1969: Liberman, 1970) which utilized learning principles: social exchange and operant principles. Later Cognitive Therapy approaches: Dattilio & Padesky (1990), Beck (1988) stressed the role of cognitions. More recently there has been an integration of Mindfulness, Acceptance and Commitment and DBT into couple and family treatment (Epstein & Baucom; 2002). So, there are now a number of evidence-based interventions available to clinicians.

The CBT model of relationship problems is as follows;

PERSON A                      PERSON B
Behavior -----------------> Cognitive Appraisal
Leads to                             Leads to
Negative Emotions Negative emotions
Leads to                             Leads to
Cognitive Appraisal <---  Behavior

The key issue here is that each individual’s behavior is appraised and interpreted by the other person which then leads to emotional reactions and subsequent behavior by that individual which is then a trigger for a similar sequence in the partner. This is cycle which needs to be explored by analyzing a recent episode of conflict the couple have had.

Here is an example of this which occurred in a couple I saw some time ago. On their way to my office, the following argument had occurred, which we analyzed in some detail using the CBT model.

The sequence of events, external and internal was as follows;

• The situation: Husband was driving fast
  Wife’s thoughts ” What if we get in an accident “, “He is doing this to upset me”
  Wife’s emotions: Anxiety and anger
  Wife’s behavior: Criticized husband’s driving and told him to slow down
  Husband’s thoughts ” She is trying to control me again”
  Husband’s emotions: Anger and frustration
  Husband’s behavior: Yelled at wife to stop nagging

This kind of analysis can then lead to the therapist helping the couple to examine;

• What interpretation\assumption they are making about their partner’s behavior?
  What evidence supports this interpretation?
  What evidence is contrary to this interpretation?
  Is there an alternative explanation for the behavior?
  What cognitive distortions are involved in their thinking in this instance?
  If the interpretation is correct, what does it mean for each individual and for the relationship
  Does it logically follow from their partner’s actions that he\she has the motive they are assigning to him\her?
  What can they do to check out their assumptions?

Readers will note this is similar to standard CBT interventions used to question thinking patterns in individuals but crucially here it involves both partners doing this procedure with the therapist in session and subsequently on their own in between sessions.

In CBT with couples the therapist should

• Conduct a thorough assessment of the problem from all perspectives.
  Conceptualize the problems experienced and share this framework with the clients.
  Make sure to focus on relationship, not on the individuals.
  Explore the benefits and costs of relationship change.
  Promote concept of shared responsibility.
  Prevent triangulation.
  Encourage a focus on the positive and turning complaints into requests.
  Provide rules and strategies for in-session and outside-session conflict.

Since motivation to change may be an issue for relationship issues, it is also helpful early in therapy to

To ask each partner in turn:

• Why do you want to stay together?
  What are the positives in your relationship?
  Why do you want to continue in this relationship (if you do)?
  What are the positive qualities/strengths which you bring to the relationship?
  What are your partner’s positive qualities/strengths which he/she brings to the relationship?
  What attracted you to him/her initially?
  What do you still find attractive/what positive qualities does he/she have currently?
  How would you feel if you were not together/what would you miss or how much of a loss would this be to you?
  What was good about your relationship when it was best?
  What is good about your relationship now?
  How hopeful are you that things can improve?

This series of questions, besides facilitating motivation towards change or improvement ,provides a positive focus for couples who are often locked into aversive exchanges/interactions and tend to focus only on negative behaviors or characteristics of the partner or emphasize only what is wrong with the relationship, not what might be right or positive.

In addition to the cognitive interventions alluded to above, there are many other therapeutic strategies which can be introduced including;

• DBT techniques for emotional dysregulation during conflict
  Problem-solving for day to day issues with child rearing, finances ,dealing with extended family etc
  Positive psychology to increase gratitude towards each other.
  Mindfulness and acceptance approaches to reduce evaluation and judgement.
  Effective Communication including desirable behaviors such as stating things as positively as possible, the use of “I statements”, avoiding labels or accusations and active listening with reflection.

Helpful resources for therapists.

• Baucom, D. et al (2019) Treating Relationship Distress and Psychopathology in Couples; A Cognitive-Behavioral approach. Routledge Press.
  Dattilio, F. (2010) Cognitive Behavioral Therapy with Couples and Families:
  A Comprehensive Guide for Clinicians. Guilford Press.
  Ludgate, J. & Grubr, T. (2018) The CBT Couples Workbook. Premier Publishing Inc.
  Fruzetti, A. (2006 ) The High Conflict Couple… New Harbinger Press.
  Walser, R. & Westrup, D (2009) The Mindful Couple. New Harbinger Press.