Re: Empirical support for CT with personality disorders and Schema Therapy

It might seem as though I contradict myself if I say in one paper "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." yet argue elsewhere that there is some empirical support for the effectiveness of CT with personality disorders. However, I believe that those quotes come from one of my earlier papers, published when there was little empirical support for CT with personality disorders. Most of the studies that provide empirical support have been published in the past decade so my current conclusions (at the beginning of this thread) are a bit different from the conclusions I drew in the 80's and early 90's.

I agree that the empirical support for CT with PDs is limited. However, CT's support is pretty decent if you consider the level of empirical support that most approaches to treating PDs have. DBT has been generating a fair amount of outcome data but most of the other approaches have little evidence regarding their effectiveness. For example, none of the other approaches covered in Major Theories of Personality Disorder (Clarkin and Lenzenweger, 1996) had much to say about the effectiveness of treatment even though Clarkin asked all of us to address that issue. CT needs more outcome data, as do all the approaches to treating PDs.

You make an excellent point in observing that a number of studies suggest that CT can be effective with PD clients who are motivated to change, in those cases by depression, and is less effective with clients who are not motivated to change. Just about every approach to therapy is more effective with clients who are motivated to change. If Schema Therapy is effective with unmotivated clients, that would be really valuable. I'd love to see data to that effect.

The studies that suggest that lack of motivation for change is an impediment to the effectiveness of CT with PDs didn't do anything specific to increase motivation for change when that was a problem. My current suggestion for dealing with unmotivated PD clients is to use a Motivational Interviewing approach to generate motivation for change. However, this suggestion is based on clinical experience, we do not yet have data to support it as far as I know.

Hopefully we'll have some outcome data on Schema Therapy in the foreseeable future. Then it will be easier to tell how ST compares with CT as a treatment for individuals with personality disorders. If discussing schema maintainance, schema avoidance and schema compensation increases the effectiveness of treatment, I'll start doing it. However, my bet is that CT will turn out to be at least as effective as ST.

Replies:

A case study supporting Schema Therapy, by Jim Pretzer, 04/05/02

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