Application to Personality Disorders

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Pretzer and Beck (1996) believe that cognitive therapy has particular value in the treatment of personality disorders. Interestingly, Beck is one of the very few theorists to offer an ultimate explanation for personality disorders from an evolutionary perspective and also to offer specific therapeutic interventions for their amelioration. Beck's theorizing follows the traditional evolutionary explanations (which are expanded on in Chapter 8). Simply put, Beck (1992) theorizes that the origins of many modern personality disorders developed from specific conditions in the ancestral environment that are now maladaptive in the present environment. He labeled these behaviors, which were successful in the ancestral environment, primeval strategies. For example, persons with Antisocial Personality Disorder exhibit the primeval strategy of predation. Persons with the Histrionic Personality Disorder exhibit the primeval strategy of exhibitionism. Obsessive -compulsive persons exhibit the primeval strategies of creating rituals and order. However, understanding personality disorders from a primeval perspective does not obviate the need for interventions or make these interventions any less successful. It does, however, provide a greater theoretical perspective for the understanding of personality disorders, emphasizing that something about the exhibited behavior has some possible adaptive function, at least at some point in the past. Whether the distant past or the more recent past (i.e., childhood) is a greater influence on the dysfunctional behavior is an important point of debate.

Pretzer and Beck (1996) noted that persons with personality disorders pose significant problems for therapists because the pervasiveness, chronicity, and range of their symptoms often make their problems difficult to conceptualize clearly. Because cognitive-behavioral techniques are problem focused, Pretzer and Beck note that they may be used to alleviate current stress and to accomplish deeper changes necessary for future successes.

As noted earlier, cognitive therapies are theoretically based on a phenomenological paradigm—that events themselves do not directly cause our emotions but rather that emotions are caused by our attitudes and reaction to those events. In practice, cognitive therapy is highly pragmatic and strongly emphasizes individualized effective treatments. This approach hypothesizes common underlying misperceptions in people (of all ages) with personality disorders. The identification of the patient's particular misperceptions is crucial for cognitive therapy to proceed. Commonly occurring misperceptions include (a) all-or-none thinking (i.e., seeing personal qualities or situations in absolutist black-and-white terms, and failing to see the shades of gray in between), (b) catastrophizing (i.e., perceiving negative events as intolerable catastrophes—making mountains out of molehills), (c) labeling (e.g., attaching a global label to oneself, "I am a loser," instead of referring to a specific action or event, "I did not handle that particular situation very well"), (d) magnification and minimization (i.e., exaggerating the importance of negative characteristics and experiences while discounting the importance of positive characteristics and experiences), (e) personalization (i.e., assuming one is the cause of an event when other factors are also responsible), and (f) "should" statements (using should and have-to statements to provide motivation or to control behavior).

Underlying these specific logical errors or cognitive distortions are schemas or core beliefs held by people that influence their perceptions and thoughts at the conscious level. Schemas are often expressed as unconditional evaluations about the self and others, including beliefs that "I am incompetent," "I am defective," "I am unlovable," "I am special," "Others are hurtful and not to be trusted," "Others need to take care of me," and "Others must love and admire me." Schemas are generally thought to be formed early in life and tend to persist if no conscious effort is made to identify, examine, and challenge them (Dozois, Frewen, & Covin, 2006). Some examples of cognitive distortions and schema relevant to personality disorder pathology include:

■ An individual with Paranoid Personality Disorder is prone to habitually and chronically perceive others as deceitful, abusive, and threatening.

■ An individual with Borderline Personality Disorder is prone to sort people into categories of either "all good" or "all bad."

■ An individual with Histrionic Personality Disorder often labels what another might consider a minor hassle as a real threat and also perceives him or herself as lacking the resources to cope.

■ An individual with Obsessive-Compulsive Personality Disorder tends to be a slave to "shoulds" and "oughts," which he and others must fastidiously and uncompromisingly adhere.

■ An individual with Dependent Personality Disorder sees herself as weak, incompetent, and inadequate, requiring constant reassurance, nurturance, and direction.

A cognitive therapist will evaluate his or her patient for their specific misperceptions, attitudes, assumptions, schemas, and interpersonal strategies and generally use a different intervention strategy with each type of personality disorder and person with a specific type of personality disorder (Beck, Freeman, & Associates, 2003).

Many cognitive therapists have developed empirically tested approaches for dealing with the various personality disorder groupings. For example, cognitive-behavioral therapist Marsha Linehan has developed an approach specifically for treating the Borderline Personality Disorder, called dialectical behavior therapy (DBT), which is discussed in Chapter 10. Other cognitive-behavioral interventions have been developed for the full spectrum of personality disorders (Beck et al., 2003; Pretzer & Beck, 1996;Young, 1999;Young, Klosko, & Weshaar, 2003) although empirical support is in the nascent stages. Interestingly, Young's approach has a developmental perspective in which he delineates five different unhealthy de-

velopmental environments in which a child might be raised, each of which contributes to creation of a discernable number of distinctive core beliefs, called Early Maladaptive Schemas. Research should address the question of whether (or to what extent) these core beliefs remain constant or change throughout the life span.

Cognitive therapies have done little to address specifically the issues associated with aging and personality disorders, although some cognitive therapists have begun to address general aging issues that may have some application to older persons with personality disorders (e.g., Reinecke & Clark, 2004). The individualized treatment approaches that cognitive-behavioral therapists have developed should, however, adapt well to the unique challenges that older persons with personality disorders present. An excellent reference for CBT approaches with older adults has recently been published (Laidlaw et al., 2003), and although the book focuses largely on treating clinical disorders and problems, some strategies can apply directly to the treatment of personality disorders among older adults.

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