0.18 Cognitive perspectives on personality development  (Page 29/30)

5. Interventions that increase the client’s sense of self-efficacy often reduce the intensity of the client’s symptomatology and facilitate other interventions.

6. Do not rely primarily on verbal interventions.

7. Try to identify and address the client’s fears before implementing changes.

8. Help the client deal adaptively with aversive emotions.

9. Anticipate problems with compliance.

10. Do not presume that the client exists in a reasonable environment.

11. Attend to your own emotional reactions during the course of therapy.

12. 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:

1. The patient may lack the skill to be collaborative.

2. The therapist may lack the skill to develop collaboration.

3. Environmental stressors may preclude changing or reinforce dysfunctional behavior.

4. Patients’ ideas and beliefs regarding their potential failure in therapy may contribute to noncollaboration.

5. Patients’ ideas and beliefs regarding effects of the patients’ changing on others may preclude compliance.

6. Patients’ fears regarding changing and the “new” self may contribute to noncompliance.

7. The patient’s and therapist’s dysfunctional beliefs may be harmoniously blended.

8. Poor socialization to the model may be a factor in noncompliance.

9. A patient may experience secondary gain from maintaining the dysfunctional pattern.

10. Poor timing of interventions may be a factor in noncompliance.

11. Patients may lack motivation.

12. Patients’ rigidity may foil compliance.

13. The patient may have poor impulse control.

14. The goals of therapy may be unrealistic.

15. The goals of therapy may be unstated.

16. The goals of therapy may be vague and amorphous.

17. There may have been no agreement between therapist and patient relative to the treatment goals.

18. The patient or therapist may be frustrated because of a lack of progress in therapy.

19. 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: