Response to Jim Pretzer's Comments

Jim, I think you're being somewhat disingenuous when you say, "I am not particularly interested in criticizing Jeff's approach." You have mentioned both my name and Schema Therapy repeatedly in several negative postings. Your critical comments have been brought to my attention on many occasions by both patients and therapists who have read "Behavior Online" over the past two years.

In fact, it was one of my patients who brought these recent postings to my attention in an e-mail she sent me last night. She may reply herself later. This is what she wrote me after reading the comments by you and Paul: "I can't believe that they would display that sort of behavior for all the world to see. At least, they should have to be concerned about having to face you at some point." She goes on to comment about "the childish and ignorant behavior of many therapists regardless of their education or reputation." If a patient reacts this way, one has to question how we treat each other.

Although you often phrase criticisms under the guise that you are merely repeating the opinions of others, I would say that this is irresponsible, unless you believe the criticisms yourself and are prepared to defend them. If you disagree, why not ask the person who has made the criticism to post it on the site, and you can indicate your own personal opinion in response? It's hard to have an exchange of ideas with an invisible critic.

I know that you are very familiar with the schema model, yet you omit information that would provide a more balanced perspective. This gives other schema therapists the idea that you are misinformed. For example, you must know from our supervision and from my writings (especially the extremely popular text edited by Barlow, "Clinical Handbook of Psychological Disorders," now in its 3rd edition) that I have always strongly advocated CT first for symptom reduction, followed by schema therapy for prevention of relapse and for characterological issues. Why did you write: "... Jeff's approach risks underemphasizing interventions which focus on achieving immediate changes in automatic thoughts and in behavior... They (and I) would argue in favor of Beck's approach which focuses on working towards immediate changes in automatic thoughts and behavior early in therapy and then focusing on schema change later in therapy"? This is exactly my view, carefully spelled out in this widely read chapter I co-authored with Tim.

Do you believe that I should summarize how to do CT first with each Axis I disorder as part of every lecture on ST for PD's? Or isn't it sufficient to say, as I do, that we introduce ST after the symptom reduction phase, which is based on CT? Furthermore, why do you repeat a criticism that in no way reflects on the schema model, but rather on practitioners who apply it inappropriately? For example, would you criticize cognitive therapy itself on the grounds that it is often applied too rigidly or without sufficient attention to the therapy relationship?

I also believe that you are exaggerating the degree to which empirical evidence supports the use of CT with a typical PD patient. I have reviewed the literature myself and cannot find a small body of well-controlled outcome studies testing cognitive therapy with PD's. I'm afraid that I do not have access to your 1998 review right now, so perhaps you could cite two or three well-designed, controlled outcome studies using CT for PD's.

Neither of the two most recent reviews of the outcome literature in major journals cites sufficient controlled data to support any particular model of psychotherapy as effective with PD's. Bateman and Fonagy (2000) conclude that: "Data on both cognitive-behavioural and psychodynamic treatment come primarily either from single-case series or from theory-oriented methods, which makes it difficult to generalise the results... It should be noted that there is relatively little compelling evidence that individuals with personality disorders and low levels of functioning can be successfully treated on an out-patient basis..."

Perry et al. (1999) could only find 15 empirical studies on the treatment of PD's, regardless of modality. Based on these very limited studies, they conclude that psychotherapy in general seems to be helpful with personality disorders. However, they only found two controlled outcome studies including a cognitive-behavioral condition: one is a strictly behavioral treatment for avoidant personality disorder, while the other is based on Linehan's DBT. On what basis do you conclude that "there is decent empirical support for the proposition that CT and CBT can be effective treatments for individuals diagnosed as having personality disorders"? You seem to be suggesting that therapists need not expand beyond traditional cognitive therapy on the basis of this tiny data base ("However, there is no need for "therapists ... to muddle around with PD's, trying existing approaches that seem promising, because patients cannot wait for empirical data to receive treatment." We have a small but growing empirical base which we can work from.")

On the question of whether schema therapy has influenced cognitive therapy, I do not in any way want to seem self-aggrandizing. I would never have written what follows if you had not stated that Judy and Chris developed their ideas totally independently of my schema work. I just want to set the historical record straight, as I remember it. Perhaps others cognitive therapists who were active in the early 80's can offer their insights as well.

I have been told by many people who attended their workshops that both Chris and Judy used to state in their presentations that many of the schema-focused ideas they were incorporating were influenced by my work. I'm not sure what they would say today, since they have both naturally followed their own independent courses. I strongly believe, though, that the initial impetus to focus more intensively on schemas and core beliefs was significantly influenced by my teaching and writing.

Although Tim proposed the concept of a schema in cognitive therapy long before I did, it was never an important part of the treatment until I began emphasizing it. Up until then, cognitive therapy had focused on underlying assumptions (conditional beliefs) rather than schemas or core beliefs. You will remember that there is no mention of how to treat schemas or core beliefs in Tim's original book, "Cognitive Therapy of Depression," or for many years thereafter.

Furthermore, many of the contributors to "Cognitive Therapy of Personality Disorders" told me at the time that they were directly influenced by my work. In fact, one of the first chapters of that book was originally going to be a chapter I contributed on schema-focused cognitive therapy as the framework for treating PD's with CT. (I later decided to withdraw the chapter and publish it as my first book.)

Regarding the claim that schema therapists do not acknowledge that cognitive therapists have developed approaches to treating PD's, you are probably referring to the section in many of our chapters in which we provide an historical overview of how I came to develop schema therapy. In this context, we are always careful to say that we are discussing how the perceived limitations of the early CT concepts and techniques were inadequate for PD patients. We carefully refer to the "original version of cognitive therapy," or "standard cognitive therapy," which we explicitly define as the version described in Tim's first major book on CT for depression.

In our new book for Guilford, we will be including a comprehensive comparison of the latest version of CT for PD's with ST. Up until now, we have never included a review of other treatment approaches to PD's; early CT was only discussed in reference to the historical development of ST.

I also want to respond to the criticism you have overheard from some analysts that ST is just a rehashing of psychoanalysis. I do not know of anyone who has studied both psychoanalysis and ST thoroughly who could possibly make such a statement. The idea of "limited reparenting" for example is repugnant to most analysts who are familiar with it. Again we are dealing with an invisible critic. Most psychoanalysts have only heard a brief overview of the conceptual model; relatively few have actually studied the treatment approach and techniques in any depth. The two approaches have only a superficial similarity.

Some analysts will say that the conceptual model does not seem that much different from theirs. But I also hear this comment from therapists from almost every therapeutic orientation: "This isn't really different from CT," "This sounds just like Sullivan (Adler, control/mastery theory, Transactional Analysis, etc.)" This is understandable, because schema therapy is integrative; thus it incorporates at least some ideas that are consistent with most other orientations.

I apologize if I seemed to be including you in my comment about "snide remarks" or attributing mercenary motives. You have never hit "below the belt" in this way, as I believe Paul did.

I agree that it is healthy for us to disagree. That's part of what makes this field exciting. But I wish that, in the future, you would try to limit yourself to criticisms that you yourself are prepared to defend; and also that you try to be objective about the limitations of both CT and ST. These are not religions, but evolving, fallible approaches.

Replies:

Re:Response to Jim Pretzer's Comments, by Jim Pretzer, 01/09/02

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