Proposed Guidelines for CT with Personality Disorders

(Excerpt from: Pretzer, J. & Beck, A.T. (1996). A cognitive theory of personality disorders. In: J. Clarkin & M. Lenzenweger (Eds.) Major Theories of Personality Disorder. New York: Guilford.)

1. Interventions are most effective when based on an individualized conceptualization of the client's problems. Clients with personality disorders are complex, and the therapist is often faced with choosing among many possible targets for intervention and a variety of possible intervention techniques. Not only does this present a situation in which intervention can easily become confused and disorganized if the therapist does not have a clear treatment plan, but the interventions which seem appropriate after a superficial examination of the client can easily prove ineffective or counterproductive. The practice of developing a clear conceptualization of the client's problems on the basis of a detailed evaluation and then revising this conceptualization on the basis of clinical observation and the results of clinical interventions aids in the development of an effective treatment plan and minimizes the risk of the therapist being confused by the sheer complexity of the client's problems.
2. It is important for therapist and client to work collaboratively towards clearly identified, shared goals. With clients as complex as those with personality disorders, clear, consistent goals for therapy are necessary to avoid skipping from problem to problem without making any lasting progress. However, it is important for these goals to be mutually agreed upon in order to minimize the non-compliance and power struggles which often impede treatment of clients with personality disorders. It can be difficult to develop shared goals for treatment since many of these clients present numerous vague complaints and, at the same time, may be unwilling to modify some of the behaviors which the therapist sees as particularly problematic. However, the time and effort spent developing mutually acceptable goals can be a good investment.
3. It is important to focus more than the usual amount of attention on the therapist-client relationship. While a good therapeutic relationship is as necessary for effective intervention in Cognitive Therapy as in any other approach to therapy, behavioral and cognitive-behavioral therapists are generally accustomed to being able to establish a fairly straightforward therapeutic relationship at the outset of therapy and then proceed without paying much attention to the interpersonal aspects of therapy. However, this is not usually the case when working with clients who have personality disorders. The dysfunctional schemas, beliefs, and assumptions which bias clients perceptions of others are likely to bias their perception of the therapist, and the dysfunctional interpersonal behaviors which clients manifest in relationships outside of therapy are likely to manifested in the therapist-client relationship as well. While the interpersonal difficulties which are manifested in the therapist-client relationship can disrupt therapy if they are not addressed effectively, they also provide the therapist with the opportunity to do in-vivo observation and intervention (Freeman, et al., 1991; Linehan, 1987c; Mays, 1985; Padesky, 1986) rather than having to rely on the client's report of interpersonal problems occurring between sessions.

   One type of problem in the therapist-client relationship which is more common among individuals with personality disorders than among other individuals in Cognitive Therapy is the phenomenon traditionally termed "transference" when the client manifests an extreme or persistent misperception of the therapist which is based on his or her previous experience in significant relationships rather than on the therapist's behavior. This can be understood in cognitive terms as the individual over-generalizing beliefs and expectancies acquired in significant relationships. Individuals with personality disorders are typically vigilant for any sign that their fears may be realized, and are prone to react quite intensely when the therapist's behavior appears to confirm their anticipations. When these strongly emotional reactions occur, it is important for the therapist to recognize what is happening, quickly develop an understanding of what the client is thinking, and directly but sensitively clear up the misconceptions before they disrupt therapy. While these reactions can be quite problematic, it is also true that they provide opportunities to identify beliefs, expectations, and interpersonal strategies which play an important role in the client's problems and that they provide an opportunity to respond to the client in ways which tend to disconfirm his or her dysfunctional beliefs and expectancies.

4. Consider beginning with interventions which do not require extensive self-disclosure. Many clients with personality disorders are quite uncomfortable with self-disclosure due to a lack of trust in the therapist, discomfort with even mild levels of intimacy, fear of rejection, etc. While it is sometimes necessary to begin treatment with interventions which require extensive discussion of the client's thoughts and feelings, sometimes it can be useful to begin treatment by working on a problem which can be approached through behavioral interventions which do not require extensive self-disclosure. This allows time for the client to gradually become more comfortable with therapy and for the therapist to gradually address the client's discomfort with self-disclosure (Freeman, et al., 1990, Chapter 8).
5. Interventions which increase the client's sense of self-efficacy often reduce the intensity of the client's symptomatology and facilitate other interventions. The intensity of the emotional and behavioral responses manifested by individuals with personality disorders is often due in part to the individual's doubting his or her ability to cope effectively with particular problem situations. This doubt regarding one's ability to cope effectively not only intensifies emotional responses to the situation but also predisposes the individual to drastic responses. If it is possible to increase the individual's confidence that he or she will be able to handle these problem situations if they arise, this often lowers the client's level of anxiety, moderates his or her symptomatology, enables him or her to react more deliberately, and makes it easier to implement other interventions. The individual's sense of self-efficacy, his or her confidence that he or she can deal effectively with specific situations when they arise, can be increased through interventions which correct any exaggerations of the demands of the situation or minimization of the individual's capabilities, through helping the individual to improve his or her coping skills, or through a combination of the two (Freeman, et al., 1991, Chapter 7; Pretzer, et al., 1990).
6. Do not rely primarily on verbal interventions. The more severe a client's problems are, the more important it is to use behavioral interventions to accomplish cognitive as well as behavioral change (Freeman et al., 1990, Chapter 3). A gradual hierarchy of "behavioral experiments" not only provides an opportunity for desensitization to occur and for the client to master new skills but also can be quite effective in challenging unrealistic beliefs and expectations.
7. Try to identify and address the client's fears before implementing changes. Clients with personality disorders often have strong but unexpressed fears about the changes they seek or are asked to make in the course of therapy, and attempts to induce the client to simply go ahead without addressing these fears are often unsuccessful (Mays, 1985). If the therapist makes a practice of discussing the client's expectations and concerns before each change is attempted, this is likely to reduce the client's level of anxiety regarding therapy and improve compliance.
8. Help the client deal adaptively with aversive emotions. Clients with personality disorders often experience very intense aversive emotional reactions in specific situations. These intense reactions can be a significant problem in their own right but in addition, the individual's attempts to avoid experiencing these emotions, his or her attempts to escape the emotions, and his or her cognitive and behavioral response to the emotions often play an important role in the client's problems in living. Often, the individual's unwillingness to tolerate aversive affect blocks him or her from handling the emotions adaptively and perpetuates fears about the consequences of experiencing the emotions. If the individual is willing to face the emotions long enough to handle them adaptively, he or she may well also need to acquire some of the cognitive and/or behavioral skills needed to handle the emotions effectively.
9. Anticipate problems with compliance. Many factors contribute to a high rate of non-compliance among clients with personality disorders. In addition to the complexities in the therapist-client relationship and the fears regarding change which were discussed above, the dysfunctional behaviors of individuals with personality disorders are strongly ingrained and often are reinforced by aspects of the client's environment. However, rather than simply being an impediment to progress, episodes of non-compliance can provide an opportunity for effective intervention. When non-compliance is predictable, addressing the issues beforehand may not only improve compliance with that particular assignment but also prove helpful with other situations where similar issues arise. When non-compliance arises unexpectedly, it provides an opportunity to identify issues which are impeding progress in therapy so that they can be addressed.
10. Do not presume that the client exists in a reasonable environment. Some behaviors, such as assertion, are so generally adaptive that it is easy to assume that they are always a good idea. However, clients with personality disorders are often the product of seriously atypical families and live in atypical environments. When implementing changes, it is important to assess the likely responses of significant others in the client's environment rather than presuming that they will respond in a reasonable way.
11. Attend to your own emotional reactions during the course of therapy. Interactions with clients with personality disorders can elicit emotional reactions from the therapist ranging from empathic feelings of depression to strong anger, discouragement, fear, or sexual attraction. It is important for the therapist to be aware of these responses so that they do not unduly influence or disrupt the therapist's work with the client, and so that they can be used as a source of potentially useful data. Since emotional responses do not occur randomly, an unusually strong emotional response is likely to be a reaction to some aspect of the client's behavior. Since a therapist may respond emotionally to a pattern in the client's behavior long before it has been recognized intellectually, accurate interpretation of one's own responses can speed recognition of these patterns. Careful thought is needed regarding whether to disclose these reactions to the client or not. On the one hand, clients with personality disorders often react strongly to therapist self-disclosure and may find it very threatening. However on the other hand, if the therapist does not disclose an emotional reaction which is apparent to the client from non-verbal cues or which the client anticipates on the basis of experiences in other relationships, this can easily lead to misunderstandings or distrust. Therapists may benefit from using Cognitive techniques (such as the Dysfunctional Thought Record, Beck, et al., 1979) and/or seeking consultation with an objective colleague.
12. Be realistic regarding the length of therapy, goals for therapy, and standards for therapist self-evaluation. Many therapists using behavioral and cognitive-behavioral approaches to therapy are accustomed to accomplishing substantial results relatively quickly. One can easily become frustrated and angry with the "resistant" client when therapy proceeds slowly or become self-critical and discouraged when therapy goes badly. Behavioral and cognitive-behavioral interventions can accomplish substantial, apparently lasting changes in some clients with personality disorders, but more modest results are achieved in other cases, and little is accomplished in others (Fleming & Pretzer, 1990; Freeman, et al., 1990; Turkat & Maisto, 1985). When therapy proceeds slowly, it is important to neither give up prematurely nor perseverate with an unsuccessful treatment approach. When treatment is unsuccessful, it is important to remember that therapist competence is not the only factor influencing the outcome of therapy.

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