CBT for Challenging and Complex Problems

Cognitive Behavior Therapy first emerged in the late 1970s and in 1980s as a new treatment approach for depression (Beck et al 1979) and anxiety (Beck et al 1985). This was an exciting advent of a highly structure, collaborative and short-term treatment (12-16 sessions) for these disorders and an impressive literature has since emerged showing its effectiveness for depression and a number of anxiety disorders including GAD, OCD, Panic Disorder and Social Anxiety Disorder. It has also been found to be effective for eating disorders, substance misuse, anger and many other psychological problems.

However, lingering questions remained through the 1980s and later as to whether this approach would work with clients with more chronic conditions. Of particular interest was its applicability to clients who receive the diagnosis of Personality Disorder. It was felt that short-term therapy focused on symptoms or here-and-now problems might be insufficient. Subsequently, some adaptations of CBT evolved over time for using CBT with these clients with more enduring patterns of thinking and reacting which often include rigid and maladaptive behaviors which can cause significant impairment, for example a Borderline Personality Disorder client who has a history of stormy relationships and emotional over -reactivity throughout his/her adult life.

These clients, unlike those presenting with depression or an anxiety disorder, may

• Report that they have “always been this way”
• (These clients often do not recall a time when they felt/thought/acted differently unlike depressed clients, for example, who can remember a time when they were not depressed)
• See their issues as being part of their identity.
• (Related to having always been this way, they may have an ego- syntonic view of their problems believing there is nothing more to them than their characteristic and long-standing problems)
• Be ambivalent about change.
• (While not being happy with how things are for them or how they function, they may find the idea of change or being different quite scary, as it is new and unfamiliar)
• Experience problems which are often interpersonal in nature so the conditions for a normal therapeutic relationship may be challenged.
• (As an example, these clients may have trust issues and will be wary of therapists or may have always felt inadequate and relied on others to solve their problems which means they will expect this of a therapist).

So, CBT as originally described needed to be adapted. To meet this need, Beck and colleagues wrote the book CT for Personality Disorders initially in 1985 and this text and two subsequent editions (the most recent being in 2015) demonstrated an adapted form of CBT for these clients. Also, Jeff Young’s Schema Therapy (Young et al 2006) was developed as a cognitively-based treatment method for personality-disordered clients.

It should be noted that for some people in the mental health field the label personality disorder itself can be problematic. Some therapists find this unhelpful, preferring to focus on particular issues these clients have (emotional regulation, behavioral issues, interpersonal style) rather than on this diagnosis which can sometimes be pejorative. In addition, labelling clients as “difficult” or “resistant” may also create an issue where a therapy impasse is in a sense blamed on the client. But leaving these issues aside, these volumes and other related CBT texts (Leahy, 2003: Beck,J.S, 2011) have made several important suggestions regarding working with clients with more complex , longer- term and more challenging problems. Compared to working with less complex cases, there is likely to be;

• More emphasis on historical material. Therapists will often explore beliefs and behavioral strategies these clients developed early in life in response to formative events including trauma, neglect and negative messaging from adults in their life.
• Use of alternate methods beyond cognitive verbal interventions. Therapists in addition to using conventional CBT strategies such as cognitive appraisal, may also include acceptance and mindfulness and/or distress tolerance and emotion regulation strategies associated with DBT.
• Expectation of longer therapy and fluctuating response to therapy. Client progress will rarely be linear (incremental symptom improvement week by week) but more often fluctuating from week to week with alternating progress and setbacks.
• Need to factor in uncertain motivation for change/ambivalence. A client once gave voice to this ambivalence by saying “People like me stay in hell because we recognize the street signs”. This points to being nervous about change from what is familiar, even if unpleasant.
• More emphasis on therapeutic relationship and the therapeutic use of issues triggered by this. Therapists might become a target for these clients’ frustrations and anger. It is important to note and process these events as they occur in a non-defensive way.

Also, when working with clients who have long term problems, therapists may need to

• Expect difficulty in establishing or sticking to goals. With these clients it can be difficult to maintain a clear set of goals for therapy as new issues /crises may keep coming up. This requires an ability to deal with immediate issues and return to core themes on the part of a therapist.
• Have challenges in structuring sessions. These clients may, for variety of reasons, ’hijack’ the structure of a CBT session and go’ off agenda’. Gentle redirection and giving choices regarding the agenda for a session while maintaining collaboration is often required.
• Anticipate derailment and detours. It is often difficult to maintain a particular therapeutic strategy when weekly or daily crises intrude. Again, patience and an ability to deal with these issues while returning to main themes will be necessary.
• Need to monitor their own cognitions when triggered. Working with these more challenging cases can create trigger events for therapists. For example, when a client gets angry with the therapist for being five minutes late, it is not helpful to be defensive or counter-attack but important to try to conceptualize why this elicits this reaction in the client (perhaps feeling unimportant due to the slightly later start of session)
• Keep a problem- solving set rather than labeling or blaming mental set. As previously noted, giving the client a label of “resistant” or “difficult” precludes finding a solution to whatever is occurring when therapy ends up being stalled. In the same vein, self-blame (“I am not a skilled enough therapist as this client is struggling so much”) is also a dysfunctional assumption and may prevent reviewing other ways forward from an impasse.  

Some helpful resources are

• Beck .A.T. et al (Eds) (3^rd Edition) (2015) Cognitive Therapy of Personality Disorders. Guilford Press.
• Beck , J.S. (2011) Cognitive Therapy For Challenging Problems: What To Do When The Basics Don’t Work. Guilford Press.  
• Leahy R.L. (2003) Overcoming Resistance in Cognitive Therapy. Guilford Press.
• Young, J.E. et al (2006) Schema Therapy: A Practitioner’s Guide. Guilford Press.