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Tools, Not Schools, of Therapy
Part 4: The interpersonal Model

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Copyright © 2008 by David D. Burns, M.D. Any reproduction, electronic or otherwise, is strictly prohibited without expression written permission of the author.

By David Burns, M.D.

In this newsletter, I’ll focus on the Interpersonal Model.

We can't just specialize in the treatment of one type of problem, such as depression or anxiety, because the people who come to us for treatment are usually suffering in many different ways. For example, a man who asks for help with depression may also be troubled by feelings marital discord, conflicts with friends or colleagues, and feelings of loneliness.

Some experts have promoted the use of CBT in the treatment of relationship problems, but I've found that these methods usually aren't effective. Here’s why. If you're treating a patient who feels depressed and worthless, all the distorted thoughts will be directed against the self. The patient will be telling himself that he's a worthless loser, that he should be better than he is, and that things will never change. These thoughts create enormous suffering, but there’s a kind of mental con involved. He’s involved in numerous distortions, such as All-or-Nothing Thinking, Overgeneralization, Mental Filtering, Fortune-Telling, Emotional Reasoning, Labeling, Should Statements, and Self-Blame, among others. When he discovers that these negative thoughts aren't valid, he'll feel a sudden wave of relief. In fact, this discovery can be exhilarating.

When people are angry, they’re also involved in cognitive distortions. For example, a woman named Mary was mad at her husband. She recorded these negative thoughts on her Daily Mood Log, and indicated she believed each thought 100%:

• He's a jerk.

• All he cares about is himself.

• He'll never change.

• He never listens.

• Our problems are all his fault.

Use checks to indicate all the distortions you can find in these thoughts before you continue.

Answer
Her negative thoughts contain all 10 distortions. She’s thinks of him “a jerk" with no redeeming qualities (Labeling; All-or-Nothing Thinking; Overgeneralization), exaggerates all his flaws (Mental Filter; Discounting the Positive; Magnification) and concludes that all he cares about is himself (Mind-Reading). She also tells herself that he should be a better listener (Should Statement) and insists that he'll never change (Fortune-Telling). Finally, she feels like an innocent victim so she concludes that he really is to blame for all their problems (Emotional Reasoning; Other-Blame).

Now, let’s assume that you jump in with your CBT techniques to show Mary that:

1.     Her negative thoughts, rather than her husband’s behavior, are the cause of her anger and frustration.

2.     Her thoughts are distorted and wrong.

What will happen? It doesn't take a genius to answer that question. Mary will become even more upset. Now she'll have two enemies—her husband and her therapist. In fact, she’ll probably drop out of therapy, thinking that her therapist is as much of a jerk as her husband. That's what I mean when I say that treating relationship problems with CBT makes about as much sense as trying to put out a fire by throwing gasoline on it. In my experience, it’s not a very promising approach.

Do you know why? When you’re depressed or anxious, you’re suffering and want relief. Discovering that you’re thoughts are the source of your angst, and that those thoughts are not valid, is tremendously exhilarating. But when you’re angry, there’s a strong tendency to want to feel angry. It’s empowering, almost addictive. You’ll have feelings of moral superiority. So you’ll want to think about the other person in a negative manner, and you won’t care if your thoughts are distorted.

The interpersonal treatment techniques that I’ve developed are radically different from the CBT techniques that can be so helpful in the treatment of depression and anxiety.

Whenever a patient first describes a problematic relationship, I empathize and try to see the world through his or her eyes. I don't challenge the patient or try to help. Instead, I provide support and try to find truth in what she or he is saying, even if it seems exaggerated and self-serving.
Once the patient feels understood, I move to the Invitation step of Agenda Setting. I ask if she or he wants help with the problem, or if simply wants me to listen and understand how they feel. I also point out that the patient has three options. She or he can:

• Settle for the status quo.

• Leave the relationship.

• Work to make the relationship better.

I call this process Interpersonal Decision-Making. Most patients will be able to answer this question right away. The first option is the most common choice. In this case, interpersonal therapy is not indicated. This is sometimes hard for therapists to accept because we naturally want to help our patients. But jumping in and trying to help someone who’s not asking for help is the most common therapeutic error of all, and it accounts for nearly all therapeutic failures.

Some patients will choose option #2 and tell you that they want to leave the relationship. In this case, you can ask if they need some help from you. For example, they might have fears about being alone, or concerns that friends or family might look down on them if they were separated or divorced. They may have doubts about how to support themselves, or feel anxious about developing a social life and starting to date again. Once they've defined a problem, assess their motivation, and select the most appropriate treatment tools.

A few patients, but not many, will choose option #3. They’ll tell you that they want to make the relationship better. If so, I ask the patient, “Who, in your heart of hearts, do you feel is more to blame for the problems in this relationship? Who do you think is the bigger jerk? You or the other person?”

In the vast majority of cases, the patient will say that the other person is to blame. If you continue trying to help the patient, the odds are overwhelming that you’ll run into a wall of resistance. I don’t know any tools in the world that are powerful enough to help someone who’s blaming the other person for the problems in their relationships, or in their life for that matter.

The Relationship Cost-Benefit Analysis can help you with this, and you can complete it with your patient during a therapy session. First, ask your patient this question: "How will blaming the person I'm not getting along with help you? What are some of the rewards and benefits of this mindset?" Ask your patient to list all the advantages of blame in the left-hand column of the Relationship Cost-Benefit Analysis (CBA) on page 7. You can do the same thing, using your own copy of this form. It’s really important to do the CBA on paper, and not in your head.

You can probably think of quite a few advantages of blame, such as:

• You can feel morally superior.

• You won't have to change.

• You won't have to examine your role in the problem.

• You'll feel convinced that truth is on your side.

• You can do nasty things and get back at the other person without having to feel guilty.

• You can get friends and colleagues to side with you and agree that the other person really is a self-centered loser.

There are also many potential disadvantages, as you can see in the Relationship CBA on page 7.Once you and your patient have written down all the advantages and disadvantages you can think of, ask the patient to balance the lists against each other on a 100-point scale. Do the advantages or disadvantages feel greater? You don't need to get too obsessive about the ratings. Sometimes, one strong advantage will outweigh numerous disadvantages, or vice versa.

Ask the patient to put two numbers that reflect his or her ratings in the circles at the bottom. Make sure the numbers add up to 100. For example, if the advantages feel considerably greater than the disadvantages, she might put a 75 in the circle on the left, and a 25 in circle on the right. If it's a draw, she might put 50 – 50 in the two circles. If the disadvantages of blame feel somewhat greater, as in the example on page 7, she might put 40 – 60 in the circles.

If the advantages of blame outweigh the disadvantages, I tell the patient that I probably don't have any tools that are powerful enough to help them. I explain that as long as they blame the other person, the prognosis for developing a close, trusting relationship is close to zero, at least in my experience. I reassure them that I want to work with them, and ask if there's some other problem they might want to focus on instead. This is a paradoxical intervention. We're telling the patient, "As long as you set the problem up like that, I can't help you." The patient may need a referral to another therapist, or may have another problem she or he wants help with.

Relationship Cost-Benefit Analysis
List all the advantages and disadvantages of blaming other people for the problems in your relationships with them.

However, there’s another possibility. The patient may simply need more time to vent his or her angry feelings while you listen and provide support. You may have jumped into the problem-solving mode prematurely. After you've empathized for a period of time, without trying to “help” the patient, you can attempt to set the agenda again.

There's a chance that patients who are in the blaming mode will change their minds and decide that they really do want to work on the problem. But if the patient is determined to remain in the role of victim, and refuses to give up the idea that the problem is all the other person’s fault, I have found that it’s not productive to try to help the patient using any interpersonal therapy techniques, since the resistance will nearly always defeat your efforts, and you and the patient will both end up feeling frustrated with each other. Over and over you’ll hear some version of this statement: “Why should I have to change when it’s all her fault (or his fault)?”

Let's say that you and your patient have completed the Relationship CBA. If the patient decides that the costs of blame outweigh the benefits, you can show them how to develop greater intimacy with the use of the Relationship Journal. A woman named described a conflict with her ex-husband, Don:

"Don and I are basically good friends, but he can be loud and controlling. He always gives me advice that I haven't asked for and tells me what to do. I find it irritating. We had exactly the same problem when we were married. I enjoy spending time with him, but I don't like it when he gives me advice. We met for coffee the other day and I told him I was way behind on things and felt overwhelmed, and then he started in on me."

Cognitive Interpersonal Therapy based on the idea that the entire conflict will nearly always be embedded in any brief interaction between two people who aren’t getting along. Once you understand why you were locking horns with the other person at that particular moment, you'll discover the cause of all the problems in your relationship with him or her. And when you learn how to resolve the conflict you were experiencing at that one moment, you'll see how to resolve all the conflicts in your relationship with that person.

With these ideas in mind, I ask the patient to record one thing the other person said to them, and exactly what they said next, as Steps 1 and 2 on the Relationship Journal. You can see the first two steps of Alyson’s Relationship Journal on page 8.

Let's do Step 3. Would you say that Alyson's response in Step 2 was an example of good or bad communication? Of course, we can't answer this question until we've defined what we mean by "good communication" and "bad communication." To make this step simple, patients can simply turn the Relationship Journal over and use either the EAR checklist or the Bad Communication Checklist to analyze what they wrote down in Step 2.

Here's how Alyson analyzed her response:

"My response to Don was an example of bad communication because I didn't acknowledge Don’s feelings. He was probably feeling frustrated with me. In addition, I didn't express my own feelings. I was also feeling anxious and frustrated because I felt like he was trying to control me and I just wanted him to listen. Instead of telling him how uncomfortable I felt, I got defensive. I didn't convey any respect or warmth, either.”

Allyson’s Relationship Journal
Step 1 – Don said: You just need to take care of things. Go home. Get things done! Make those calls!
Step 2 – I said: I'm doing the best I can. I can't do any more. I feel like I'm already under too much pressure.
Step 3 – Good vs. Bad Communication. Was your response an example of good or bad communication? Why? Use the EAR Checklist or the Bad Communication Checklist to analyze what you wrote down in Step 2.

Step 4 – Consequences. Did your response in Step 2 make the problem better or worse? Why?

Step 5 – Revised Response. Revise what you wrote down in Step 2. Use the "Five Secrets of Effective Communication." If the revised response is still ineffective, try again.

Alyson was surprised to see that she'd failed on all three counts. Most patients will discover that they're not listening, sharing their feelings openly, or conveying respect. Instead, they're arguing, blaming and counterattacking. This realization can be unnerving, since the patient suddenly has to face the fact that they're fueling the fire of conflict and making every conceivable type of communication error.

If the patient gets angry or upset at this point, empathy is the only thing that works. After you’ve empathized for a period of time, you'll also have to renegotiate the therapeutic agenda. You'll discover that many patients don't really want to get close to the person they're at odds with and are still heavily committed to the idea that it's the other person's fault. When I get this message, I suggest that we might do better to focus on some other problem that they want help with.

If patients negotiate Step 3 successfully, and can accurately pinpoint their own communication errors, you can go on to Step 4. Ask them to examine the consequences of the statement they wrote down in Step 2. Will it make the situation better or worse? How will the other person feel? What will she or he conclude? What will the other person say or do next?

Here's what Alyson wrote for Step 4:

"When I sound overwhelmed and helpless, it inspires Don to give me advice. Then I make lame excuses and argue with him. This frustrates him, because I'm not listening. He gets louder and keeps pushing his ideas and giving me more advice. In other words, I'm encouraging him to be controlling. It's like putting a line of fresh cocaine under an addict's nose, and then acting surprised when he snorts it!"

Step 4 of the Relationship Journal can be intellectually exciting, because patients suddenly see for the first time that they've been triggering the exact behavior that they've been complaining about, and that they're not helpless victims after all. Instead, they're the puppeteers who've been pulling the strings.

This step is based on the Buddhist notion of oneness, or circular causality. In other words, we get back exactly what we put out. We create our own interpersonal reality at every minute of every day. This insight is potentially enlightening, but may feel painful because it shatters our conviction that someone else is to blame.

This type of analysis takes a lot of courage, and many patients will find it disturbing. Once again, if you run into resistance, you’ll have to empathize and renegotiate the therapeutic agenda. Some patients are not willing to pay the price of intimacy. They’re unwilling to examine their own role in the problem. The good news is that once patients have completed steps 3 and 4, which can be so painful, they’re ready for their reward.

In Step 5, you can help them write out a more effective response to the person they're not getting along with, using the Five Secrets of Effective Communication on page 12. Tell the patient to indicate which techniques they used in parentheses after each sentence they write down in Step 5. That way, they'll learn how to use the five communication techniques, rather than simply memorizing a few formulaic statements they can use during conflicts and arguments. For example, if the sentence is an example of Thought Empathy and the Disarming Technique, the patient can put (TE; DT) at the end of the sentence.

Remember that Don said this to Alyson: "You just need to take care of things. Go home. Get things done! Make those calls!"

Here's what Alyson wrote down for Step 5: "You make a good point, Don. (DT; ST) I've noticed that when I tackle these things head on, I usually feel a lot better. (DT)" This response will probably end the discussion. Don will relax and lose his urge to keep giving Alyson helpful advice.

Alyson liked this response because it was radically different from her normal style, and she could see that it would probably be effective. This Revised Response is based on the assumption that Alyson may not especially want Don's advice. If she simply says something flattering, they won't get trapped in a power struggle and can talk about something more rewarding.

However, there are many other approaches that Alyson could use in Step 5. For example, she could say something like this:

"Don, you've always got a lot of helpful suggestions, but I sometimes feel like you play the role of the parent, and I end up in the role of the child who needs to be told what to do. (ST; IF) Then I feel resentful and frustrated because I'm not really asking for any help or advice. (IF) Sometimes I just want you to listen, so I get defensive when you try to help me. (IF) Have you also noticed how we fall into this pattern from time to time? (IN) I don't want to sound overly critical or unappreciative, because I think I set you up when I complain that I'm so far behind on everything (DT). Furthermore, I value your friendship a lot, and want you to know that you're very important to me. (ST)"

This response will probably lead to a more meaningful discussion about their relationship. If it's conveyed with respect, humility and affection, and not with an attitude of blame, it could be effective. Alyson can decide on the type of response that makes the most sense to her.

Learning to use the Five Secrets of Effective Communication takes time and practice. Your patients will need lots of help and encouragement because they'll make lots of mistakes at first. In fact, these techniques are also difficult for therapists to learn and master, so they're definitely going to be challenging for our patients.

This has been an overly brief introduction to CIT. It’s a sophisticating and challenging form of therapy that requires a high degree of therapeutic skill because the patient’s resistance to forming warm, loving relationships will nearly always be intense. To keep things simple, I’ve provided an example of working with one patient in individual therapy, but you can also work with couples using a modified version of this approach. If you’re interested in learning more about the new Cognitive Interpersonal Therapy, you may want to check out my latest book, Feeling Good Together, which was released in hardcover in January of 2009 (New York: Broadway Books.)

Five Secrets of Effective Communication (EAR)*

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