Re:Is there empirical support for CT and CBT with personality disorders?

Although I hesitate to respond to this topic due to the firestorm I seem to have set off with my last comments about CT and CBT with personality disordered clients, I am very interested in this area and have been since I first read an article by you stating "the presence of an Axis II diagnosis greatly decreases the likelihood of treatment's being effective" and "A number of studies have found that well-established cognitive behavioral treatments are less effective with individuals who have personality disorders in addition to their Axis I diagnosis." The quotes were also in an earlier article.

I find it interesting that some of the studies that you cite at this time found that (1)subjects diagnosed as having more than one personality disorder did not show the improvement shown by subjects with a single personalty disorder diagnosis (2) a study finding good results for PD clients of Nelson-Gray, Johnson, Foyle, Daniel and Harmon, 1996 treated clients with depression (a motivating factor) (3) An outcome study with antisocial addicts found limited results with PD clients who were not depressed (again missing the motivation factor)-noting that non-depressed sociopaths did worse after treatment and (4) in the Burns and Persons study of their clients, patients with PD were more likely to drop out of treatment. The main supportive research comes from Linehan in treating borderline personality disordered clients.

Thus for clinicians working with non-motivated, non-depressed subjects with more than one personality disorder there is limited research supporting CT's effectiveness.

There is some support for CT with offenders and in fact a cognitive behavioral approach had been found to be most effective in a study of outcome research. In addition, a variant of Cognitive behavioral therapy developed by Jack Bush in Vermont found a significant drop in recidivism rates with treated offenders. Since these were persistently violent offenders, there is an assumption that many of these offenders also had antisocial personality disorders.

So I am all for using CT with offenders. However, many clients who have mixed personality disorders as you know, complicates treatment. Specifically, an antisocial often has mixed narcissistic, paranoid and/or borderline traits. Donald Dutton from Canada has documented a high prevalance of borderline traits in domestically violent men for example.

Shall I stop here or go on again as to how Young's schema focused approach is helpful with these mixed personality disordered, non-depressed clients who have limited motivation for treatment? I think I will stop. I do want to just mention the differences I see between Young's schema therapy and the schema therapy by Beck, Pretzer, and others:

1. The concepts of schema maintnance, schema avoidance and schema compensation. (MY ORIGINAL QUESTION IN THE LAST CONTROVERSY WAS ABOUT THESE PROCESSES.)
2. Not looking at specific schemas for each Personality disorder but instead beyond specific beliefs to more general and far-reaching, underlying schema. Thus, I don't have to worry about whether someone has an antisocial PD with borderline features or a Borderline PD with antisocial features or an example of a borderline spectrum subtype of borderline-antisocial/paranoid (like Layden, et al. 1993.) I can just help them look at underlying maladaptive schema and how the client either maintains, avoids or compensates for that schema.

Replies:

Re: Empirical support for CT with personality disorders and Schema Therapy, by Jim Pretzer, 03/02/02 A case study supporting Schema Therapy, by Jim Pretzer, 04/05/02

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