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CT/Schema-Focused CT with Personality Disorders
Linda Nauth (e-mail · 4/6/98 at 1:58 PM ET
-snip- Young's schema-focused therapy's conceptual model seems to explain correctional clients and help treat them. To me, my clients seem very complex and seem reflective of mixed personality disorders rather than just ASPD. You have indicated that Cognitive Therapy conceptualizes each personality disorder differently with different treatment implications. This makes it difficult to use with mixed personality disorders.
Antisocial clients hold different meanings for consequences than we might anticipate. For example, for Tom, going back to prison is a better choice than following the probation rules because to him, following probation rules is an insult to his integrity as a person. Following the rules in prison is different. To Tom, going to prison is indeed less aversive than following the probation rules- at least at that moment. The thinking I find in these clients is indeed fascinating and definitely not expected!
I am working with an interesting client that I wondered if you might help me with. I have already started using some schema focused assessment with him. But I wondered if you couldn't consult with me using a the strict, traditional Cognitive Therapy model. I don't see how the work you've written about regarding antisocials would help me much. In your Flemming and Pretzer 1990 article in "Progress in behavior modification, you do talk a lot about social learning theory and residential treatment programs. What suggestions could you have for me with this client?
I have attached a short summary about Jarrad:
History: In prison with a 7 year sentence for Burglary and Theft of a Firearm. Escaped from minimum security 5/9/97 but turned self in after four days. Received a consecutive 8 month sentence for Escape. Extensive juvenile record including Burglary, Criminal Damage to Propoerty and Retail theft. In 1991, he was convicted of Conspiracy to commit murder which involved Jarrad and two other teens planning to murder their foster family, steal the car and go to Mexico. Jarrad watched as the other teen stabbed the foster mother and took no steps to prevent it. This resulted in 3 years in the juvenile correctional facility. The instant offense occured 3 months after he was released from juvenile custody at age 19. Jarrad was diagnosed with a conduct disorder at age 14 and currently meets criteria for Antisocial Personality Disorder.
In Cognitive Therapy (CGIP) (group-psychoeducational) Jarrad identified the following automatic thoughts and beliefs that led to his criminal behavior: Easy money. (Crime) is fun, exciting, I can’t stand to be told what to do, They should treat me better. I don’t care how they feel. People aren’t any good if they don’t see it my way. I don’t care how they feel. If people don’t see it my way, then they’re out to get me. Others need to suffer for what they’ve done to me. Nobody cares how I feel.
Jarrad learned the following cognitive and behavioral interventions to help him in high risk situations: Stop and think, pleasant imagery, time out, understand the feelings of others, reflect on conflict both when unresolved and resolved, remember that it takes time and effort to change. Jason learned problem-solving skills and to think “What happened in the past, what worked before and what didn’t work before.”
Presenting complaint: Jarrad is complaining of obsessive thoughts of self-harm. When questioned further, Jarrad also admits to obsessive thoughts of violence to others. At night he fantasizes about torturing and killing people and then taunting the police. He derives a great deal of pleasure from these fantasies. He wants the fantasies to stop because he knows if he acts out on them, he will be incarcerated for the rest of his life. He has no empathy for others, feels no closeness to others but he does receive some good feelings when being around “positive people” or when he was taking the CGIP class. He would like to live responsibly and have close relationships with others but has little hope that he will ever achieve these goals. He sees himself as institutionalized and incapable of a normal life.
Jarrad is currently under psychiatric care with the diagnosis of generalized anxiety disorder and antisocial personality disorder. He is currently taking Buspar but still complains of social anxiety and violent fantasies. He says that when he is around people, he becomes agitated and angry. When he gets back to his room, at night, he gets his anger out by violent fantasies.
Past psychiatric history: Jarrad has complained of psychotic symptoms in the past but now states that he did so to “play the system” and get medication for sleep. After his return to prison after the escape, he was placed in clinical observation status due to suicidal ideation. It is possible that he was attempting to secure a transfer to the correctional mental health hospital which is seen as a more pleasant way to “do time.”
Current status: Jarrad has signed a waiver of confidentiality and knows that this clinician will be reporting his violent fantasies. Thus, he is currently sharing problems that go against his best interest. He believes that the parole board will read this clinician’s report and he has no chance for parole. Still, he indicates motivation to try and change. He seems to become easily discouraged and sees no real hope for his future.
The main intervention attempted thus far is to teach Jarrad aversive imagery/covert sensitization to help him extinguish the violent fantasies. I have also tried to figure out what pleasure he derives from the violent fantasies. Jarrad has denied power and control issues even though his thoughts of taunting the police appear very controlling.
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