Aaron T. Beck – Cognative Therapy of Personality Disorders (2nd edition)

Автор: Aaron T. Beck
Название книги: Cognative Therapy of Personality Disorders (2nd edition)
Формат: PDF
Жанр: Психология
Страницы: 433
Качество: Изначально компьютерное, E-book

In the more than two decades since Aaron T. Beck and his colleagues
published Cognitive Therapy of Depression, cognitive therapy has developed
in an almost exponential fashion. From the early work of treating
depression, the model has been advanced and applied to the treatment of
all the commonly seen clinical syndromes, including anxiety, panic disorder,
eating disorders, and substance abuse, as well as disturbances of
thinking associated with psychoses. Outcome studies have demonstrated
its efficacy in a wide range of clinical disorders. In addition to its application
to practically all the clinical populations, with modifications, cognitive
therapy has been applied to all ages (children, adolescents, geriatric
patients) and has been used in a variety of settings (outpatient,
inpatient, couples, groups, and families).
The interest in and development of the clinical work in treating
those patients with personality disorders have grown with the clinical
sophistication and skill of the cognitive therapists. The first edition of
this volume was the first cognitive approach to focus specifically on this
diverse and difficult group. Our second edition reflects both our growing
clinical sophistication and the expanding potential of cognitive therapy
to effectively treat these disorders that often have been regarded as untreatable.
The work in cognitive therapy has drawn interest from around the
world, and centers for cognitive therapy (or cognitive therapy study
groups) have been established on every continent except Antarctica.
Prochaska and Norcross (2003) stated the following in the fifth edition
of their Systems of Psychotherapy:
Probably the safest prediction about cognitive therapy’s direction is that it
is moving up. Cognitive-behavioral therapies in general, and Beckian cognitive
therapy in particular, are the fastest growing and most heavily researched
orientations on the contemporary scene. The reasons for its current
popularity are manifest: cognitive therapy is manualized, relatively
brief, extensively evaluated, medication compatible, and problem focused.
Let us put it this way: if we were forced to purchase stock in any of the psychotherapy
systems, Beck’s cognitive therapy would be the blue-chip
growth selection for the next five years. (p. 369)
The interest in cognitive approaches among therapists has increased
600% since 1973 (Norcross, Prochaska, & Gallagher, 1989).
The original impetus for this volume came from therapists trained
at the Center for Cognitive Therapy at the University of Pennsylvania or
those who received training from these individuals. The content of the
present work has grown organically from early case discussions and
seminars led by Beck over many years. When we decided to write a book
that would allow a sharing of the understandings gained from our work,
we realized that it would be impossible for one or two people to be expert
in treating all the various personality disorders. We therefore enlisted
a distinguished and talented group of therapists trained at the Center
for Cognitive Therapy to coauthor the text, all writing in their
specific areas of expertise. We rejected the notion of an edited text that
offered a series of disparate (or redundant) presentations. In the interest
of uniformity and consistency in presentation, we decided in favor of a
volume that would represent a total collaborative production of all the
contributors.
Different authors took responsibility for different specific topics or
clinical applications. The draft material on each topic was then circulated
to stimulate cross-fertilization and facilitate consistency and was
then returned to the original author(s) for revisions and further development.
Finally, the entire manuscript was reviewed and edited by one of
the authors to ensure continuity in style, language, and content. Although
the book is the product of a team of authors, each author takes
responsibility for the content. The major authors of each of the chapters
are, however, identified below. The integration, final editing, continuity
of the volume, and management of the second edition revision project is
the work of Denise D. Davis.
As we considered the reasons to pursue a revised edition of this volume,
a number of issues influenced our decision. First, cognitive therapy
of the personality disorders has continued to expand in the 14 years
since the first edition. Our experience as cognitive therapists has grown,
as we see even more clearly both the value and the challenge of this potentially
powerful therapeutic approach. Much has been gained in the
way of new empirical evidence. Several of the authors who contributed
to the first edition were ready to add the richness and depth of an additional
decade of experience to their original clinical applications. We
were also able to enlist the help of several new authors who have made
major contributions in their areas of expertise in recent years, adding a
fresh and up-to-date perspective to enhance the core of our original
work. Finally, we wanted to expand the original offering in the areas of
clinical assessment, and through more discussion of the role of emotions
and the therapy relationship in cognitive therapy with personality disorders.
We have organized the volume into two sections. The first offers a
broad overview of historical, theoretical, and therapeutic aspects. This
section is followed by the clinical application chapters that detail the individualized
treatment of specific personality disorders. The clinical
chapters are arranged according to the three clusters described in the revised
fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR; American Psychiatric Association, 2000). Cluster
A, those disorders that are described as “odd or eccentric,” includes
the paranoid, schizoid, and schizotypal personality disorders. Cluster B
includes the antisocial, borderline, histrionic, and narcissistic personality
disorders, which are described as “dramatic, emotional, or erratic.”
Cluster C includes the “anxious or fearful persons” that fall into the categories
of dependent, avoidant, and obsessive–compulsive personality
disorders. After much consideration, the passive–aggressive personality
disorder was included in our second edition, despite being removed from
the DSM-IV-TR list of personality disorders and placed with proposed
new categories awaiting further study. We agreed on the special clinical
relevance of passive–aggressive or negativistic personality adjustment.
Furthermore, our research demonstrated the unique set of dysfunctional
beliefs associated with the clinical diagnosis of this disorder.
The material in Part I was developed by Aaron T. Beck, Arthur
Freeman, Andrew Butler, Denise D. Davis, and James Pretzer. In Chapter
1, Freeman and Pretzer begin by outlining the cognitive-behavioral approach
to the general problems of referral, diagnosis, and treatment of
personality-disordered patients. A discussion of the concept of schema
formation and its effect on behavior offers the reader an introduction to
this vital issue, which is expanded in later chapters. The chapter then
discusses the clinical studies and research done to date that is relevant to
cognitive-behavioral treatment of personality.
In Chapter 2, Beck offers an explication of how personality processes
are formed and serve adaptive functions in the individual’s
life. Starting with an evolutionary focus, Beck elaborates on how the
schemas (and the idiosyncratic combinations of schemas) contribute to
the formation of various disorders. The basic strategies for adaptation
are then outlined, along with the basic beliefs/attitudes for each of the
personality disorders. The processing of information and specific types
of distortion of the available information are then tied to the schematic
characteristics, including the density, activity, and valence of the
schemas. Within each personality disorder, certain beliefs and strategies
predominate and form a characteristic profile. Beck identifies the typical
overdeveloped and underdeveloped strategies for each disorder. The
strategies may, he posits, be derivative from or compensate for particular
developmental experiences. By offering cognitive profiles, including the
view of self, view of others, core and conditional beliefs, and main compensatory
strategies, he places the disorders in a perspective that allows
the application of the broad range of cognitive and behavioral interventions.
In Chapter 3, Andrew Butler discusses assessment concerns relevant
to personality disorders, including the conceptual, methodological, and
strategic issues inherent in understanding these complex domains of psychopathology.
Cognitive measures of personality pathology are discussed,
with illustrations of the specific measure developed within recent
years, the Personality Belief Questionnaire. In Chapter 4, Beck and Freeman
review the general principles for the cognitive therapy of personality
disorders. The core schemas can be inferred by first looking at the patient’s
automatic thoughts. By using imagery and reawakening of past
traumatic experiences, therapists can also activate the core schemas. The
beliefs embedded in these schemas can then be examined within the therapeutic
context. The chapter outlines basic cognitive therapy strategies
with particular emphasis on the development of case conceptualization.
Therapeutic collaboration, guided discovery, and the importance of
transference and countertransference are discussed. The chapter concludes
with an overview of specific cognitive and behavioral techniques
for modifying schemas.
The last chapter in this section, Chapter 5, is newly formulated to
highlight the cognitive approach to the therapeutic relationship in treating
personality disorders. Building on the previous work by Beck and
Freeman concerning the various reasons for therapeutic noncollaboration,
Denise Davis adds further considerations of culture and managed
care. In addition, she discusses an expansion of the interpersonal
domain in the context of treating personality disorders and offers a conceptualization
of transference and countertransference that is grounded
in the cognitive therapy model. This chapter illustrates specific strategies
for a cognitive therapy approach to both patient and therapist emotions.
This overview of the emotional and interpersonal features of cognitive
intervention is complemented by a specific discussion of therapeutic relationship
issues and collaboration strategy within each of the subsequent
chapters on specific personality disorders in Part II.
Each of the disorder-specific chapters in Part II follows a format of
first describing the key features and ways the disorder is likely to present
in a clinical context, followed by a summary of historical perspectives on
the disorder. Key research and empirical data are noted, followed by a
brief discussion of differential diagnostic issues. From there, each author
offers a specific conceptualization to explain the disorder within the cognitive
model, followed by an overview of how treatment can be approached
with patients who present with these features. The specific beliefs
and strategies that affect collaboration, and the possible ways to
address these challenges, are elaborated within a section on collaboration
strategy, followed by abundant and detailed illustration of specific
interventions. Finally, suggestions for maintaining progress are offered.
Although each of these authors followed a similar outline, a wealth of
different ideas for applying the cognitive model are contained in these respective
chapters.
Chapter 6, revised by the original author, James Pretzer, begins the
clinical applications section with an introduction to the problem of the
paranoid personality disorder. This infrequently studied group presents
several idiosyncratic problems, not the least being a high degree of interpersonal
suspicion. The schizoid and schizotypal personality disorders
are detailed in a new Chapter 7 by Anthony Morrison and Julia Renton.
These authors offer well-grounded and practical recommendations for
differentiating these disorders, for clinically treating the thoughts and
beliefs that contribute to the characteristic odd and eccentric social adjustment
of these patients, and for engaging this typically disengaged
person in a treatment collaboration. The Cluster B disorders of the
dramatic, emotional, and erratic personality are introduced with Arthur
Freeman and Denise Davis’s reformulation of Davis’s original consideration
of the antisocial personality in Chapter 8. Specific issues of confronting
these patients’ particular tendencies toward avoidance and
manipulation, setting limits, involving patients in homework, and teaching
functional skills are elaborated.