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The current state of schema and cognitive therapies for Persaonality Disorders: long!
Jeff Young · 07/19/03 at 1:32 PM ET
Jim, I think you have a legitimate point of view, but perhaps misunderstand my own. I agree that, if the "orthodox" version of cognitive therapy is working for you with longer-term cases, there is no reason to adopt elements of schema therapy. Many cognitive therapists, like me, have adopted some or all elements of ST, because they were not fully satisfied with the results of the original CT model with long-term cases in actual clinical practice. The reality is that the way CT is being practiced has changed over the years, and now incorporates many elements of ST. For example, CT originally focused on underlying assumptions, not core beliefs (and these are very different concepts!). More recently, cognitive therapists have begun focusing much more on core beliefs, which is essentially a renaming of the schema concept. (Of course, the schema concept was part of Beck's original conceptual model anyway, except that the concept was essentially ignored in CT treatment until recently, because there were no unique, specific techniques to change schemas or core beliefs). Cognitive therapists like Merv Smucker have incorporated some of the experiential elements of ST, such as "imagery rescripting." Many cognitive therapists have begun writing more about the therapy relationship as a vehicle of change, including Bob Leahy and others. Judy Beck, to name just one CTist, has expanded the original case conceptualization approach to include what we call coping styles in ST (e.g., avoidance, overcompensation). As the person who developed the original training materials for CT in 1979, and the Cognitive Therapy Rating Scale (with Dr. Beck) that is still is being used to rate cognitive therapists, I know for a fact that these expansions of cognitive therapy were not a significant part of the original, orthodox CT approach. Given that I began writing and teaching schema concepts to cognitive therapists in 1982, it would be naive to assume that many of these changes in CT have not in some significant way been influenced by ST. Without being grandiose or complaining, I think that there has been a reluctance on the part of many cognitive therapists to concede publicly that they have broadened how they do CT so that it now incorporates many aspects of ST. I'm not sure why this is. It is disappointing to me that, while Tim and Judy Beck have both been very supportive of me in my expansion of CT by developing ST, so many other cognitive therapists seem threatened, rigid, or even hostile in their reactions to ST. Cognitive therapists also have to acknowledge that CT is no longer one standardized, orthodox, monolithic protocol. It is practiced very differently depending on which practitioner you talk to. Some CTists are more "orthodox" and some are more integrative. This a healthy development, since no model of therapy should remain static. Just a couple of more comments. There still remain many significant differences in the practices of CT and ST, such as the new schema mode techniques and concepts that we've developed for BPD and NPD. That's why I believe that differentiating them as two models is still worthwhile, at least for now. I'd also like to put in a "plug" for my new textbook for therapists,"Schema Therapy: A Practitioner's Guide," just published by Guilford Press, which explains ST in great detail, and reviews some of the major differences compared with CT. The book has been endorsed by both Dr. Beck and David Barlow, who are both pioneers in CBT. The question of which approach is more effective for personality disorders is, as you say, open to question. No one is doing a controlled study comparing the two, that I know of. And such a study might prove difficult now, since there are fewer and fewer orthodox cognitive therapists, and many more who integrate techniques from schema therapy or other approaches, especially with personality disorders. And, furthermore, a comparison would be confounded by the fact that CBT has always been an important component of ST. I agree that it makes sense to maintain some caution about making claims about either CT or ST with personality disorders, since there are still not large-scale, well-controlled studies establishing either of these as "empirically-validated" approaches to personality disorders. I know that many larger-scale studies are nearing completion, however, and that such studies will begin to appear over the next 2 or 3 years. I think it's time to call a truce and to acknowledge that, for the time being, we do not know the relative efficacy of the two treatments for PD's. But that ST explicitly began with, and still incorporates, many CT concepts and techniques, and CT (implicitly) is incorporating many elements of ST. Practitioners should not have to be "at war" regarding CT and ST. They are "cousins," although each has a unique, characteristic emphasis.
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