Carl Sherman, Contributing Writer, [Clinical Psychiatry News 27(10):24,25 1999. © 1999 International Medical News Group.

Cognitive therapy might seem an unlikely choice for personality disorders.

Its focus on cognitive distortions, dysfunctional behaviors, and problem-solving deficits has been shown effective in anxiety and mood disorders.

But what can such a rational approach offer the deep, pervasive pathology seen in borderline, dependent, or antisocial patients?

It offers a good deal, according to its proponents.

Cognitive therapy (CT) was originally introduced for Axis I disorders, said Dr. Aaron Beck, University Professor of Psychiatry at the University of Pennsylvania, Philadelphia. "But the same kind of problems pervade Axis II. They may be more intractable, but without great transformation of methodology, we can extend the approach to deal with the particular features of Axis II."

In contrast to Axis I applications, relatively few data document the efficacy of CT for personality disorders. One study did find that depressed patients were more likely to drop out of therapy if they had concurrent Axis II pathology, but those who stayed in treatment responded as well as others.

Increasing interest in this area reflects trends in psychiatric practice, suggested Judith Beck, Ph.D., director of the Beck Institute for Cognitive Therapy and Research in Bala Cynwyd, Pa., and daughter of Dr. Aaron Beck.

"Most people with straightforward depression and anxiety are well treated with medication. ... Those who seek psychotherapy tend to be the ones who don't respond ..., and they often have Axis II
pathology," she said in an interview.

From a cognitive perspective, uncomplicated Axis I patients generally had a fairly healthy view of themselves before their disorder developed, but in Axis II patients, patterns are lifelong and can interfere with therapy.

"One of the first things we notice is that the patient is having a negative reaction to the therapy or the therapist," she said. A change in body language or tone of voice conveys distress.

Transference, minimized in standard CT by the active stance of the therapist, may become impossible to ignore. But this does not mean a departure from cognitive principles is necessary, Dr. Beck said. "We have the patient identify the thoughts that are connected to his distress: 'My therapist is trying to control me,' or 'I'm such a bad person [that] this will never work.' "

This material, along with a discussion of problems in daily life, facilitates the primary task of CT: defining the core beliefs and attitudes at the heart of the patient's difficulties, she said.

According to Dr. Aaron Beck, a study of 500 patients confirmed the clinical impression that characteristic themes go with specific disorders. The histrionic patient, for example, is likely to believe the following: "It's extremely important for others to recognize me. ... If I don't entertain them, they won't like me." The dependent patient's perspective is as follows: "If someone deserts me, it's the end of the world. ... To make decisions, I need the help of others."

"By focusing on these specific personality characteristics, we can make treatment more efficient," he told CLINICAL PSYCHIATRY NEWS.

This doesn't mean a cookbook approach, however. Clinicians must have an especially clear grasp of the often complex combination of attitudes and core beliefs in patients with Axis II pathology, said James Pretzer, Ph.D., director of the Cleveland Center for Cognitive Therapy, Beachwood, Ohio.

For example, a fear of freeway driving might ordinarily be addressed by cognitively exploring phobic anxiety. With a borderline or dependent patient, however, themes like the fear of losing control or relationship issues must also be taken into account, he said.

Goal setting, another basic strategy of CT, must likewise be deployed with special finesse. Some patients initially express goals broadly -- "to be all I can be" -- or try to please the therapist. Elucidating what the patient really wants out of therapy is a key to reducing power struggles and promoting a therapeutic alliance.

Logistically, it's often best to begin with problems that are likely to improve quickly, such as a fear of driving, rather than with problems that require more time, such as the consequences of sexual abuse, Dr. Pretzer said in an interview. "Generally we address Axis I issues first, and when Axis II issues interfere, we work on them. ... A depressed patient with an obsessive-compulsive personality may not want to be less perfectionistic, but if his perfectionism is making his depression worse, we can work on it in that context."

The work itself may explore another area unusual for CT -- historical material. "Axis II patients generally believe their cognitive distortions much more strongly. These themes have run all through their lives," Dr. Judith Beck said. When a patient with simple depression rationally examines a belief like "I am unlovable and incompetent," improvement is often rapid. But the Axis II individual may challenge the belief intellectually yet maintain that "in my gut I still feel it's true."

Therapy may thus require exploring the childhood roots of the attitude and tracing how it was strengthened over the years by selectively accepting experiences that confirm it and discounting evidence to the contrary. It also may involve an "experiential" approach, using imagery to return to the age when the belief got started, she said.

Not surprisingly, CT with Axis II patients rarely fits the 12- to 24-session protocol typical in simple anxiety or depression. "When problems are so stable, so encrusted, so integrated into personality, it may take much longer" to deal with them, Dr. Aaron Beck said.

While the length of therapy depends on the individual patient, and logistical factors such as insurance coverage, 1 year is average. "This doesn't necessarily mean 52 sessions," he said. The schedule may move from weekly to biweekly sessions, as patients learn to integrate what they have learned, and their daily life becomes "a laboratory" to test new ideas.

When difficulties common to working with Axis II arise -- such as phone calls between sessions or resistance -- "the therapist conceptualizes, in cognitive terms, what assumptions the patient is making and puts these on the therapeutic agenda," Dr. Judith Beck said. One example of the assumptions a patient may make is, "If I'm upset, I must call because I have no means of calming myself down."

The rigors of working with difficult patients may require the therapist to do cognitive work on himself or herself to deal with countertransference issues, she added.

The therapist-patient match, unimportant in uncomplicated Axis I treatment, may be crucial in these cases, Dr. Aaron Beck observed. "A warm, giving therapist may do better with dependent patients and a highly flexible one, with borderlines."

If transference, countertransference, and historical material sound more like psychodynamic therapy than standard CT, a key distinction must be kept in mind, he emphasized. "We observe the same phenomena. But the analytic framework decrees that [these phenomena] are driven by unconscious forces ... while we believe there's more on the surface than meets the eye."