Building Therapeutic Alliances Essential in Cognitive Behavior Therapy for Personality Disorders

Building trust, or a “therapeutic alliance,” between the therapist and patient with personality disorder is needed to help the patient work through core beliefs of worthlessness and unlovability that affect behavior, according to Judith S. Beck, PhD, who was the featured speaker Saturday at the US Psychiatric and Mental Health Congress, being held in Orlando, Florida.

Dr Beck, the current president of the Beck Institute, in Bala Cynwyd, Pennsylvania, has taken over as the standard bearer of cognitive behavior therapy, the movement founded by her father, Aaron T. Beck, MD. The senior Dr Beck, now 93, is still active but no longer travels, his daughter said.

Techniques of cognitive behavior therapy emerged as a way to quickly understand how underlying thought patterns affected behavior; by setting goals and homework at each session, the therapist and patient could work quickly to modify behavior. Not only did the patient feel better, but the cost of therapy could also be held in check. Dr Judith Beck said this has sometimes led to confusion to those untrained in the techniques about the depth of the relationship between patient and therapist; in fact, she said, a strong alliance is key.

And that can be especially difficult when patients have personality disorders, which come in many varieties, but all boil down to the mind’s effort to overcompensate for early experiences by displaying too much of some traits and too little of others. Which traits are involved varies with each disorder, and Dr Beck offered a roster of common disorders and how they present in patients. Essentially, these patients learn perverse coping skills to deal with difficult or abusive circumstances; through cognitive behavior therapy, patients with personality disorders must learn to undo these coping mechanisms.

A person with obsessive/compulsive disorder, for example, has overcompensated in systemization and is underdeveloped in the ability to be spontaneous or impulsive. A patient with schizoid personality disorder has been repeatedly rejected and thus overcompensates by retreating from the world. This person has a hard time with intimacy.

A common element in many of these disorders is the feeling of worthlessness; the patient feels on a deep level that he or she is flawed or “bad.” Before real progress can occur, Dr Beck said, it takes time to build trust; patients cannot be compassionate toward others until the first learn to be compassionate toward themselves.

“All patients, but particularly those with personality disorders, come to treatment feeling extremely vulnerable,” Dr Beck said. “It is my responsibility to make them feel safe.”

Some steps include a checkup to rule out a medical cause for the behavior. Dr Beck also spends time on “data collection,” which involves finding out what happened earlier in a patient’s life that can explain the origins of a patient’s negative self-perception.

Dr Beck offered several examples of encounters in which her patients appeared to be angry for no reason. But when Dr Beck explored the patient’s response, there was always an explanation; often the patient misinterpreted something Dr Beck had said or done based on a past experience. This is what makes treating these patients so challenging, she said.

“Patient reactions always make sense once we understand what they are thinking,” Dr Beck said.

When a patient with good mental health or even mild depression experiences a setback, such as not getting a job, or breaking up with a partner, feelings of helplessness or worthlessness are acute initially but eventually pass. But when a person’s core belief is that he is worthless, this is not so.

Patients who have been made to feel they have no value “revert back to their old way of seeing themselves,” Dr Beck said, because they don’t have a solid emotional foundation to fall back on when setbacks happen. “Patients with personality disorder have very negative views about the world generally.”

How does cognitive behavior therapy it work? Dr Beck outlined the steps:

• Cognitive conceptualization
• Strong therapeutic alliance
• Setting an agenda
• Establishing a problem-solving orientation
• Evaluation of thoughts and core beliefs
• Behavioral change
• Homework, or assignments between weekly sessions
• Relapse prevention.

Agenda setting is collaborative, so that patients are engaged throughout. Dr Beck offered an example of tapping into a patient’s core beliefs to bring behavioral change: a patient believed that persons close to her had to be engaged “100%” in her needs or they did not care about her. Dr Beck helped the patient with dependent disorder understand that if Dr Beck took that literally, she could not see any other patients. Over time, the patient realized that a close friend and a sister did care about her, but could not respond to every call.

The concept of “homework,” Dr Beck explained, is to teach patients to carry the techniques into their everyday lives. “Our goal is to make them their own therapist,” she said.