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ORLANDO—The popular view of cognitive therapy as a method of changing thinking is an accurate but extremely narrow definition, according to Judith Beck, PhD, President of the Beck Institute for Cognitive Behavior Therapy and Clinical Associate Professor at the University of Pennsylvania.

Cognitive therapy is better described as psychotherapy based on the cognitive model, meaning that the way that people perceive their experience is more closely connected to their reaction than the situation itself. That reaction could involve an emotional, behavioral, and sometimes physiological reaction, Dr. Beck explained in a presentation at the 27th Annual U.S. Psychiatric and Mental Health Congress.

Clinicians frequently begin to treat patients at the level of automatic thoughts, helping patients to identify, evaluate, and respond to these thoughts effectively. Although this approach often assists patients in feeling well, something different is needed when treating patients with personality disorders.

“To make really enduring change in people’s mood, behavior, and sometimes physiology, we need to work at a deeper level, particularly with people who have personality disorders,” said Dr. Beck. “We need to look at their basic understanding of their selves, their world, and other people.”

Working Toward Change

Bringing about this change involves use of a variety of  techniques adapted from many different psychotherapeutic modalities.

“Cognitive behavioral therapy is not defined by its use of techniques, because we use lots of techniques. It’s defined by its reliance on a theoretical model, the cognitive model,” said Dr. Beck.

That said, therapists still often employ cognitive behavioral techniques in addition to direct problem solving techniques, environmental interventions, interpersonal techniques, mindfulness techniques, biological techniques, and psychodynamic techniques. Because cognitive therapy needs to take place in the context of a highly supportive relationship, clinicians tend to borrow techniques from compassion therapy too.

“We also make sure [patients] have a recent medical checkup to make sure they don’t have any medical problems masquerading as psychological problems,” said Dr. Beck.

However, sometimes the intellectual techniques of therapy are beneficial but not sufficient, such as when patients say they intellectually understand a false belief is wrong but still feel the belief is correct in their gut. In these cases, therapists might employ experiential techniques that more deeply challenge patients’ world view.

As an example, Dr. Beck described facilitating an imaginary dialogue between a patient’s younger and older self. The older self intellectually understood the origins of a family member’s behavior and resulting formation of a negative core belief, but the younger self did not. During the dialogue the older self spoke compassionately to the younger self, and the patient was able to take that feeling of compassion and practice it during the week when her negative core belief was activated.

Treating Challenging Patients

For patients with personality disorders, negative beliefs are much different than for the average person or for patients experiencing anxiety or depression that later remits.

When depression or anxiety lessens, patients might shed negative beliefs and go back to their older, healthier beliefs about themselves.

Not so for patients with personality disorders, said Dr. Beck. These patients lack healthy beliefs to revisit and may have harbored negative self-beliefs since childhood.

Overall, patients with personality disorders can be particularly challenging for clinicians to treat. Clinicians can cope with this challenge by remembering key points. “What helps me is to know that all patients with personality disorders come to treatment not feeling safe and what do I have to do to make them feel safe. I expect patients with personality disorders to behave in therapy-interfering ways and to say negative things about me,” said Dr. Beck.

According to Dr. Beck, patients with personality disorders might have dysfunctional assumptions that interfere with treatment.

For example, patients might assume that engaging in treatment means the therapist is superior and the patient is inferior, or that the patient will have to take responsibility for change.

Other dysfunctional assumptions occur with the experience of negative emotion, such as when patients might think that if they experience stress they will fall apart, and with problem solving having no point because they will just fail. Finally, patients have dysfunctional beliefs about getting better, assuming that recovery means going back to work, acknowledging a bad relationship, etc.

Therapists must be careful not to have a negative reaction to difficult patients, said Dr. Beck, as patients can always pick up on this reaction to some degree. “Every morning I look at the schedule of patients for that day and ask who do I wish would not come in that day. With any patient like that I could be having a negative reaction.”

She added, “If you’re having a negative reaction, chances are you’re having unrealistic expectations about the patient, such as the patient should be easy to treat, or you might have unrealistic expectations of yourself.”

To move past these reactions, therapists might have to use cognitive techniques on themselves or seek consultation for difficult patients. Dr. Beck also recommends additional training through the Beck Institute and invites clinicians to visit her blog at www.beckinstituteblog.com.

—Lauren LeBano

1. Beck J. [Psych Congress conference presentation]. September 20, 2014. Cognitive Therapy of Personality Disorders.

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