Personality Theory in Real Life: Beck’s Cognitive Therapy and the Treatment of Personality Disorders
Aaron Beck and a number of his colleagues, as well as others, have attempted to apply cognitive therapy to the treatment of personality disorders. It is widely accepted that personality disorders are highly resistant to treatment, but aside from the problems they present by themselves, there is another important reason to continue trying to address these serious psychological disorders. Personality disorders often co-occur with other psychological conditions (Axis I disorders), and they may be the primary reason why psychotherapy does not work well with certain patients (Pretzer & Beck, 2005). Since cognitive therapy in particular requires that the therapist gain an understanding of what the client is thinking, in order to then help the client recognize their own dysfunctional cognitions so that the client may work toward change, it is necessary for the therapist to have a complete understanding of the client’s psychological make-up. As a prelude to treating personality disorders with cognitive therapy, one needs to understand personality disorders in cognitive-behavioral terms.
As with depression, or any other psychological disorder, the cognitive-behavioral perspective suggests that individuals suffering from personality disorders have formed dysfunctional schemas that create an attributional bias, which then causes the person to interpret life’s experiences in dysfunctional ways, but in ways that nonetheless support and maintain the dysfunction of the personality disorder. If this theory is accurate, one should be able to identify typical patterns of dysfunctional schemas that match the characterization of different personality disorder diagnoses. Indeed, Beck and Freeman (1990) have offered those patterns in Cognitive Therapy of Personality Disorders. What distinguishes the negative schemas that characterize personality disorders from schemas that characterize other psychological disorders reflects the basic difference between Axis II and Axis I in the DSM system:
The typical schemas of the personality disorders resemble those that are activated in the symptom syndromes, but they are operative on a more continuous basis in information processing. In dependent personality disorder, the schema “I need help” will be activated whenever a problematic situation arises, whereas in depressed persons it will be prominent only during the depression. In personality disorders, the schemas are part of normal, everyday processing of information. (pg. 32; Beck & Freeman, 1990)
What might the typical schemas associated with other personality disorders be? Beck and his colleagues offer detailed examples for all ten of the personality disorders listed in the DSM, as well as for the passive-aggressive (negativistic) personality disorder (Beck & Freeman, 1990; Pretzer & Beck, 2005). To cite just a few examples, the antisocial individual thinks that “people are there to be taken,” the narcissistic individual thinks “I am special,” and the histrionic individual believes “I need to impress.” As a result of these basic beliefs and attitudes, these individuals adopt corresponding behavioral strategies. The dependent person seeks attachment, the antisocial person attacks, the narcissist engages in self-aggrandizement, and the histrionic person performs dramatically (Beck & Freeman, 1990).
How does a personality disorder arise, according to the cognitive-behavioral perspective? First, there are inherited predispositions that may represent primeval strategies. For example, Beck has suggested that the antisocial personality reflects a predatory strategy, whereas in contrast, the paranoid personality reflects a defensive strategy (see Pretzer & Beck, 2005). Second, the characteristics of personality disorders can result from social learning, especially when the social environment enhances genetic predispositions. A child born with a shy disposition, in a household that seems threatening and/or confusing, may naturally withdraw. That withdrawal, taken to its extreme, is a strategy compatible with the avoidant personality disorder. And finally, there is the possibility of traumatic experiences during development. Personality becomes well established during childhood. If one’s experiences during this important time are dysfunctional and traumatic, the individual is likely to develop a personality that has ingrained dysfunctional schemas, thus affecting the individual’s life from that point forward. In this model, personality disorders are not necessarily any different in form than other psychological conditions, but since they directly involve one’s relationship with others, they become significant, problematic features of one’s daily life:
…The cognitive view of “personality disorder” is that this is simply the term used to refer to individuals with pervasive, self-perpetuating cognitive-interpersonal cycles which are dysfunctional enough to come to the attention of mental health professionals. (pg. 61; Pretzer & Beck, 2005)
The basic approach to treating personality disorders with cognitive therapy is not different than usual, but does require some special attention to detail:
Personality disorders are among the most difficult and least understood problems faced by therapists regardless of the therapist’s orientation. The treatment of clients with these disorders can be just as complex and frustrating for cognitive therapists as it is for other therapists…For cognitive therapy to live up to its promise as an approach to understanding and treating personality disorders, it is necessary to tailor the approach to the characteristics of individuals with personality disorders rather than simply using “standard” cognitive therapy without modification. (pp. 44-45; Pretzer & Beck, 2005)
Based on this concern, Pretzer and Beck (2005) have offered a list of twelve key elements that require attention when using cognitive therapy to treat an individual with a personality disorder:
- Interventions are most effective when based on an individualized conceptualization of the client’s problems.
- It is important for therapist and client to work collaboratively toward clearly identified, shared goals.
- It is important to focus more than the usual amount of attention on the therapist-client relationship.
- Consider beginning with interventions which do not require extensive self-disclosure.
- Interventions that increase the client’s sense of self-efficacy often reduce the intensity of the client’s symptomatology and facilitate other interventions.
- Do not rely primarily on verbal interventions.
- Try to identify and address the client’s fears before implementing changes.
- Help the client deal adaptively with aversive emotions.
- Anticipate problems with compliance.
- Do not presume that the client exists in a reasonable environment.
- Attend to your own emotional reactions during the course of therapy.
- Be realistic regarding the length of therapy, goals for therapy, and standards for therapist self-evaluation.
Despite these straight-forward steps toward effective cognitive therapy, it seems clear from looking at them that there are going to be challenges when dealing with clients who have a personality disorder. Indeed, the very process of collaborative empiricism can be quite difficult with these clients. Beck & Freeman (1990) have identified nineteen problems associated with establishing an effective collaboration with clients who have a personality disorder:
- The patient may lack the skill to be collaborative.
- The therapist may lack the skill to develop collaboration.
- Environmental stressors may preclude changing or reinforce dysfunctional behavior.
- Patients’ ideas and beliefs regarding their potential failure in therapy may contribute to noncollaboration.
- Patients’ ideas and beliefs regarding effects of the patients’ changing on others may preclude compliance.
- Patients’ fears regarding changing and the “new” self may contribute to noncompliance.
- The patient’s and therapist’s dysfunctional beliefs may be harmoniously blended.
- Poor socialization to the model may be a factor in noncompliance.
- A patient may experience secondary gain from maintaining the dysfunctional pattern.
- Poor timing of interventions may be a factor in noncompliance.
- Patients may lack motivation.
- Patients’ rigidity may foil compliance.
- The patient may have poor impulse control.
- The goals of therapy may be unrealistic.
- The goals of therapy may be unstated.
- The goals of therapy may be vague and amorphous.
- There may have been no agreement between therapist and patient relative to the treatment goals.
- The patient or therapist may be frustrated because of a lack of progress in therapy.
- Issues involving the patient’s perception of lowered status and self-esteem may be factors in noncompliance.
Although Beck and his colleagues offer more details and specific clinical examples in their writings (Beck & Freeman, 1990; Pretzer & Beck, 2005), the preceding lengthy list of problems a therapist is like to encounter clearly suggests that working with these clients is difficult at best. So, is cognitive therapy effective in the treatment of personality disorders? Numerous uncontrolled clinical reports suggest that it is, but the small number of controlled studies have offered equivocal results. More important, however, is the reality of “real-life” clinical practice:
In clinical practice, most therapists do not apply a standardized treatment protocol with a homogenous sample of individuals who share a common diagnosis. Instead, clinicians face a variety of clients and take an individualized approach to treatment. A recent study of the effectiveness of cognitive therapy under such “real world” conditions provides important support for the clinical use of cognitive therapy with clients who are diagnosed as having personality disorders… (pg. 102; Pretzer & Beck, 2005)
So what can we conclude from this discussion? There is consensus that personality disorders are prevalent in our society and they are resistant to treatment. Cognitive therapy, and the theory underlying it, has offered a promising avenue for further research. Given the significant impact of personality disorders on both individuals and society as a whole, any promising line of research deserves to be pursued vigorously.