A significant number of patients have some degree of personality pathology that can interfere with treatment, whether they receive medication or some form of psychotherapy. But how can clinicians develop a strong therapeutic alliance with patients who have personality disorders? An expert explains.
Dr Judith Beck, Clinical Associate Professor of Psychology in Psychiatry at the University of Pennsylvania and President of the non-profit Beck Institute for Cognitive Behavior Therapy, is a featured presenter at this year's PsychCongress. Her talk is titled “Cognitive Behavior Therapy for Personality Disorders.”
Q: Why should psychiatrists be informed about cognitive behavior therapy (CBT)?
A: A significant number of patients have some degree of personality pathology that can interfere with treatment, whether they receive medication or some form of psychotherapy.
Q. Why did you select this topic for PsychCongress this year and what aspects of CBT do you plan to cover?
A. I’ve seen that some psychiatrists struggle to understand why their patients with personality disorders behave in self-sabotaging ways and feel frustrated that these patients seem unable to take full advantage of the help the psychiatrist is offering.
Following a brief but detailed definition of CBT and a review of research on the topic, I will discuss the cognitive formulation for various personality disorders, a method of conceptualizing individual patients; strategies to strengthen and solve problems in the therapeutic alliance; and an information processing model to explain and demonstrate how to modify patients’ core beliefs.
Q: How is this topic relevant to psychiatrists who consider themselves “medication management only” clinicians?
A: Patients with personality disorders may have beliefs that interfere with medication adherence. One set of beliefs concerns “other people.” They may think, for example, “Others (including the psychiatrist) are likely to diminish me, control me, criticize me.” Another set of beliefs reflects their basic understanding about themselves that they apply to the need for medication. “Taking medication means I’m weak; I’m crazy; I’m a failure.” Or, “Taking medication will harm me.” Identifying and modifying beliefs such as these leads to improved adherence.
Q: What is the definition of CBT?
A: CBT, as developed by Aaron T. Beck, MD, is a psychotherapy based on the cognitive model: It is not situations (internal or external experiences) that directly impact individuals’ reactions (their emotional, behavioral, and physiological responses), but rather their construal or perception of the situation.
When individuals are in emotional distress, they often display characteristic errors in their thinking. When they evaluate their thinking and appraise situations more realistically, they have an improved response. But CBT is not defined by the use of cognitive techniques. While cognitive and behavioral techniques are used most frequently, a variety of interventions from a range of psychotherapeutic modalities are used within a cognitive framework to bring about enduring changes in individuals’ thinking, moods, behavior (and sometimes physiology).
Q: How is CBT adapted for patients with personality disorders?
A: Generally we focus initially on helping patients function better in their current lives, reduce symptomatology, solve problems, and learn skills. When the personality disorder itself interferes with patients’ ability to participate fully in recovery, we conceptualize the challenges in cognitive terms.
Often patients have negative beliefs about engaging in treatment, experiencing negative emotion, solving problems, and/or getting better. We put a greater emphasis on helping them modify their negative core beliefs, their basic understanding of themselves, their worlds, and other people. We may use a wider variety of techniques, including strategies from Gestalt therapy, motivational interviewing, interpersonal psychotherapy, dialectical behavior therapy, acceptance and commitment therapy, mindfulness, psychodynamic psychotherapy, compassion therapy, and positive psychology. When patients change their beliefs at an intellectual level, but not at an emotional level, we use emotional-level techniques, such as imagery, psychodrama, and behavioral experiments.
Q: How can clinicians develop a strong therapeutic alliance with patients who have personality disorders?
A: We use a number of therapeutic relationship techniques with all patients, regardless of the presence or absence of personality pathology. Therapists act as a “team” with patients to help them reach their goals: They jointly make therapeutic decisions such as choosing which problems to focus on, share their conceptualization and treatment plan with the patient, provide rationales for interventions, elicit feedback at the end of sessions, and vary their style to suit the individual. They display solid counseling skills: accurate understanding, acceptance, positive regard, genuineness, and empathy.
While therapists strive to be attuned to the emotional experience of patients during sessions, they need to take special care with patients who have personality disorders. When therapists notice a shift in affect, they elicit patients’ thoughts and feelings. Patients with personality disorders often have overgeneralized, negative beliefs about other people, which they bring with them to the therapy session, and they may misperceive their therapist’s attitudes and intentions.
Providing patients with positive reinforcement for expressing negative feedback, apologizing when the therapist has made a mistake, and helping patients evaluate their negative cognitions and perceive the therapist more accurately-these components help build the alliance. Through the therapeutic relationship, patients can directly learn to correct distortions about themselves and others and to solve interpersonal problems.
Dr Beck reports no conflicts of interest concerning the subject matter of this article.
Beck JS. Cognitive Therapy for Challenging Problems: What to Do When the Basics Don't Work. New York: Guilford Press; 2005.
Beck AT, Freeman A, Davis DD, et al. Cognitive Therapy of Personality Disorders (2nd Ed). New York: Guilford; 2004.
Leahy RL, Beck JS, Beck AT. Cognitive therapy for the personality disorders. In: Strack S, Ed. Handbook of Personology and Psychpathology. Hoboken, NJ: John Wiley & Sons; 2005.