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Overcoming Challenging Issues in Cognitive Behavioral Therapy
SAN ANTONIO—Mental health professionals may encounter a number of patient behaviors that can interfere with cognitive behavioral therapy (CBT), particularly in patients with personality disorders. During a featured session at Psych Congress, Judith Beck, PhD, provided a framework for identifying and understanding such challenges and offered strategies for delivering more effective treatment.
Dr. Beck is President, Beck Institute for Cognitive Behavior Therapy, and Clinical Associate Professor of Psychology in Psychiatry, University of Pennsylvania, both in Philadelphia. She opened the session discussing the importance of specifying the behaviors that may be interfering with therapy.
“It is too difficult, if not impossible, to figure out how to work with patients who are labeled challenging, unmotivated, or resistant,” Dr. Beck explained in an interview with Psych Congress Network. She said it is easier to know how to solve the problem when clinicians ask themselves “What is this patient doing that’s the problem in session or between sessions?” or “What is this patient saying or not saying in session or between sessions that is a problem?”
Diagnosing Therapeutic Problems
Clinicians also need to assess which therapeutic factors may be contributing to the difficulties. Dr. Beck addressed 2 possibilities: (1) factors external to therapy and (2) therapist error. Factors external to therapy include receiving an appropriate amount of treatment, receiving the appropriate format of therapy, medication issues, and whether the patient needs adjunctive treatment.
While it can be difficult for therapists to identify their own mistakes, Dr. Beck posed 8 questions that therapists can ask themselves:
- Do I have a strong therapeutic alliance with the patient?
- Did we set concrete, achievable behavioral goals that are under the patient’s control and that he/she really wants to achieve?
- Does the patient really agree with all parts of the cognitive model?
- Have I varied treatment according to the cognitive fomulation of the patient’s disorder?
- Do I have a valid conceptualization of the patient and do I base treatment on this conceptualization?
- Did I structure the session adequately?
- Did I socialize the patient to therapy adequately?
- Am I implementing techniques effectively?
Core Beliefs
Patients with personality disorders may exhibit 3 core beliefs about themselves: (1) helplessness, (2) being unlovable, and (3) worthlessness, according to Dr. Beck. “Being aware of patients’ core beliefs helps clinicians collaboratively decide with patients which problems and cognitions to focus on in treatment,” she said.
“When patients have a core belief of helplessness, they believe that they are incompetent and/or they are vulnerable and/or they are inferior; they don’t measure up to other people. Patients who believe they are unlovable may use a variety of descriptors: I’m unlikeable, there’s something wrong with me (so no one will love me), I’m ugly, I have nothing to offer other people, etc.,” Dr. Beck explained.
“They may or may not have beliefs in the helpless category; rather, they are very concerned that they’ll never get or maintain love and intimacy from others. When patients have beliefs in the worthless category, they believe they are immoral sinners.”
Cognitive Conceptualization
Dr. Beck also discussed using cognitive conceptualization with patients, utilizing the Cognitive Conceptualization Diagram. The approach was described in her 2005 book Cognitive Therapy for Challenging Problems, What to Do When the Basics Don’t Work.
“The Cognitive Conceptualization Diagram helps the clinician take a great deal of information about a patient, look for patterns in trigger situations, cognitions, and emotional and behavioral responses, and identify the patient’s key cognitions and behavioral coping strategies,” she explained.
“The recurrent themes in their thoughts always make sense once we understand their core beliefs: the basic way they see themselves, others, and the world,” Dr. Beck added. “Their dysfunctional patterns of behavior always make sense once we realize they are coping with negative core beliefs.”
Patients’ Behavioral Strategies
Patients with personality disorders use a wide range of dysfunctional strategies in session and between sessions, according to Dr. Beck. These include being overly aggressive or overly withdrawn, criticizing others, using substances, and self-harm.
“When a patient uses a coping strategy in session, it’s helpful to ask patients what was going through their minds just before they displayed the problematic behavior,” she said. “Their thoughts are often distorted and, if so, they might benefit from an evaluation of the validity and utility of their thoughts.”
Dr. Beck also reviewed ways specific personality disorders can interfere with therapy. Patients with avoidant personality disorder, for example, may believe: “If I trust my therapist, I will get hurt;” “If I focus on problems in therapy, I will feel too overwhelmed;” and “If I try to work toward achieving interpersonal goals, I will be rejected.” Those patients may also exhibit behaviors that interfere with therapy, such as putting on a false front, changing the subject when feeling distressed, and discussing problems and cognitions at a superficial level.
Practical Takeaways
Dr. Beck concluded her presentation by focusing on practical takeaways clinicians can use with patients. She emphasized that clinicians should build a therapeutic alliance with all patients, and offered the following tips:
- Be a nice human being with all patients. Treat each patient the way you would like to be treated if you were a patient. • Take measures to help your patients feel safe.
- Use good Rogerian counseling skills.
- Have reasonable expectations for your patients; remember, they are supposed to be difficult, that is why they are patients.
- Have reasonable expectations for yourself; you should not be able to fully help every patient who walks through the door, though you should strive to develop a good therapeutic alliance with them so they will be more willing to see another provider if you cannot help enough.
“It’s important to be attuned to patients’ affect during sessions. When you notice that patients are looking more distressed, ask them what was going through their minds,” Dr. Beck said. “No matter what they say, it’s important for clinicians to positively reinforce them: ‘It’s good you told me that.’ If they give negative feedback, which you deem to be correct, model apologizing and problem solve how to avoid making this kind of mistake in the future.”
“If they express incorrect assumptions about you, you might put their cognition in the context of the cognitive model and do Socratic questioning,” she added. “Once they correct their thinking about you, ask whether they have this same perception about other people. If so, help them generalize what they learned to these other relationships.”
Dr. Beck encouraged clinicians to “recognize that the therapeutic relationship improves when patients realize they’ve had a sudden gain in treatment—they’re feeling better and working to solve their problems.” “So it’s important to get right to work on the difficulties patients will experience when they leave your office,” she said.
Clinicians also need to be on the lookout for their own negative reactions to clients with personality disorders and deal with them appropriately. She said it is helpful for clinicians to look at which patients they’re scheduled to see each day and ask themselves “Who do I wish would not come in today?”
“Most patients with personality disorders don’t feel safe in treatment initially. They have negative beliefs about other people and generally apply these beliefs to the therapist, unless strongly demonstrated otherwise,” Dr. Beck said. “Clinicians’ negative reactions toward patients invariably get transmitted.”
To avoid negative reactions, Dr. Beck recommended clinicians use basic CBT techniques on themselves, particularly modifying their own relevant core beliefs. They should also seek supervision or consultation, work toward improving their skills, and engage in good self-care.
When asked what she hopes attendees gained from her Psych Congress session, Dr. Beck said “I’m hoping they can see their patients in a less pejorative way, realizing that due to genetic and epigenetic influences interacting with childhood experiences, these patients have developed very negative dysfunctional core beliefs which they cope with in dysfunctional ways.”
“It’s not their fault that they have the problems they do and it’s only reasonable to expect that they will bring their dysfunctional way of viewing others to the therapy situation, and that they will undoubtedly use dysfunctional coping strategies in and between sessions,” she said.
“I’m also hoping that clinicians can better identify patients’ beliefs and problematic patterns of behavior and that I’ve provided some tools so they can be more effective,” Dr. Beck added. “Finally, I hope I inspired the attendees to pursue additional learning about CBT for personality disorders.”
— Eileen Koutnik-Fotopoulos
Reference
"Challenging Issues in CBT: Handling the Difficult Patient.” Presented at the 29th Annual U.S. Psychiatric & Mental Health Congress; October 21, 2016; San Antonio, TX.
