CBT for Personality Part 2: From a Christian Perspective

After reflecting further on my original post on CBT for personality, the New Paradigm for CBT I noticed some interesting parallels between my Christian faith and this therapy that may be relevant for both therapists and people seeking help for personality disorders that are also Christian.

In her new paradigm what I noted is that she explains old behaviour and beliefs that were held/used for “good reasons”.  Instead of challenging the old system she introduced a “new paradigm” in a very experiential manner.

It made me think of how Jesus taught about being born again to Nicodemus and how he offers the gift of eternal life to the woman at Jacob’s well.  He does not challenge the old system of sin, but acknowledged it openly and assumed that a person is already understood how the old system did not work and instead they are looking and seeking a new paradigm, this living water, or spirit life that is not based in place or a set of laws but “in spirit and in truth ” (John 4: 24).  Jesus is continuously offering images, and stories to activate the imagination of people to create a “new paradigm” to enter the kingdom of God that is “here but not yet” (common term from Kingdom theology).

Some of the people Jesus encounters, like those with personality disorders have been suffering for many years, like the woman with continuous bleeding.  Those with these physical ailments were also consequently excluded from relationships and the acceptance of society which is similar to the interpersonal difficulties and invalidation that those who have personality disorders experience.

However, unlike CBT personality that reconceptualizes  the world Jesus challenges us to imagine a new kingdom of God that is loving, beautiful, and a place for the broken.  This kingdom of God is not the world- the world is fallen- whereas the kingdom of God is good and allows people to live fully in love.  Paul for example would likely not approve of imagining the world as a good and loving place, but challenges followers to “not conform any longer to the pattern of this world, but be transformed by the renewing of your mind.”.(Romans 12:2).

Jesus does not want us to idealize ourselves in positive terms but to hold a dialectic together of both sinner and a new creation in Christ.  Loved deeply by God, though rejected by others.

We have an initial belief or experience as followers of Christ but that does not always mean that our old beliefs and habits die completely.  We struggle between paradigms slowly through steps of faith and in acting out our faith in obedience (behavioural experiments of sorts) we learn to walk in this new way. 

Ultimately what anchors us in this new life are not just the word and promises of the bible on a page (the challenging of our old system of belief through words and reason) but the discipline of living out faithfully this new life.

In this new system- or more accurately through a God that is who loves us, who is greater than ourselves – we gain the strength and new resources to cope in a new way with the struggles we face in this world.  Our old ways are no longer necessary as we live more deeply into the new way of Christ.

So if I was to use the new paradigm for CBT for personality from a Christian perspective I might initially focus the old as she does on the view of self, others and the world but conceptualize the new through replacing a focus on the world to the Kingdom of God as the new realm to live in.  This new kingdom paradigm could also be anchored through visualization, and experiential elements- encouraging one to actively enter God’s presence using imagery.

Then introducing interpersonal difficulties into this new kingdom/paradigm makes total sense because you are inviting someone to little by little start living in the kingdom of God (“let your kingdom come on earth as it is in Heaven”). For example you could say “If you are living in this new kingdom of God where God loves you, you are forgiven, you have joy, and are special…what happens when someone insults you…?” .

This new Christian interpretation of Padesky’s paradigm doesn’t just apply to those with personality disorders but I can see how it would be useful for each one of us to conceptualize in our imagination what it is like to live more fully in the kingdom of God.  It might also be helpful for those who struggle with deep shame, despite intellectually accepting that “God loves me” or “I am deeply loved”.

Kind of exciting!

Questions? Comments?

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CBT for Personality Disorders Workshop

I recently attended a workshop by Christine P., a well-known CBT therapist who has authored  Mind over Mood.

The workshop I attended was about her “New Paradigm for CBT” for personality disorder treatment.

CBT focuses on the relationships between thoughts, feelings and behaviours and specifically targets changing thoughts and behaviours as dysfunctional thinking is thought to be at the core of problems such as depression.  Automatic thoughts are challenged through thought logs and behavioral experiments to test core beliefs or “schemas”.  Behaviour is challenged through behavioral activation, skill building (assertiveness, for example) The premise is that as behavior and thinking are changed so mood will also change as a result.

This is the standard protocol treatment for most conditions as there is a lot of evidence backing up its use with many different issues (anxiety, depression, etc.).  However for personality disorders research shows therapy take a lot longer to treat, and are treated most effectively by a variety of therapies.  For example according to research, Borderline Personalty disorder is best treated by mentalization-based therapy, transference-focused therapy, dialectical behavioral therapy, and schema-focused therapy.  Classic CBT was not listed among those in a review in 2009 by Zanarini although the last two therapies are in the CBT tradition and the first two are psychodynamic in their roots.

Her new Paradigm, is meant to treat those with personality disorders after they have already addressed Axis I issues (depression, bulimia, etc.) using evidence-based methods.

It departs from traditional CBT in a couple of ways.

1. It does not challenge core beliefs  eg.”I am unlovable”.  This is because she had come to the conclusion that in those with personality disorders lack positive core beliefs to fall back on. Instead of challenging old beliefs the majority of time is spent on building a new system, a new set of beliefs is imagined and dreamed that are tested out through behavioral experiments.  

Core beliefs are notoriously difficult to challenge and VERY hard to dislodge in most people.  I question the need or even ability to fully challenge in general in CBT. I do not agree that those with personality disorders do not have positive schemas- I believe they do but to enact them would be feel threatening and “unsafe”, and is likely something that has not been done for a long time without getting hurt badly. 

2. Similar to attachment theory, which many people say is a major factor in personality issues, she affirms the adaptive nature of people’s strategies to get through earlier struggles and uses the phrase people do things “for good reason” .  This is fantastic and really does well to not pathologize people who are labelled and judged greatly by the psychiatric/medical system.

3. Christine P. ventures into right brain territory by capitalizing on the power of positive affect (see Diane Fosha AEDP) to encourage smiling and warmth when imagining a new “system” for new beliefs and strategies. She also uses imagery to activate the “experiential” mind (see Epstein, 1998) (rather than just the rational mind that traditional CBT focuses on) to allow a person to construct a new system.  She asks people to imagine a scene, be aware of the body sensations, a memory from the past, and a metaphor/song/image as “anchors” to engage this new system.  This is completely new territory for traditional CBT.  It seems to be crossing boundaries with a lot of experiential therapies (and EMDR) that focus on the emotional experience to create and instill change.  I love the integration myself and have been wanting to focus more of the experiential but wondering how to fit it in to my theoretical framework.  This workshop gave me an opportunity to continue ot integrate ideas together that previously appeared very separated.

4. To test out these new beliefs and strategies she uses behavioral experiments- this is not new.  But the rationale is different: to continue ot create safety and protection in this “new system”.  This really fits well with the idea of defenses in traditional psychodynamic theory; defenses are constructive for protection although they may seem extremely counterproductive on the outside; just getting rid of defenses will be futile.  I think what Padesky has conceptualized is important in that she focuses energy on building new defenses so the other ones aren’t necessary.  Like CBT in general it does not focuses on the past but on the “here and now” and immediate future.

As you can tell, I quite loved the workshop and how it seemed to breathe new life into my understanding of CBT and different theories and practices that I’m using.  Padesky’s workshop gave some solid reasons and some evidence to use some practices that I have started to use outside the usual CBT box, but that seem to work well for people along with some of the classic CBT strategies.

Trauma and Psychosis

I just attended an interesting seminar on trauma and psychosis and CBT. 

Psychosis is almost exclusively explained as a biological vulnerability.  Trauma is often assumed to be linked to depression and anxiety but causality is not openly as linked to psychosis.

One researcher and psychiatrist Dr. Bill MacEwan, found that among those in the Downtown Eastside of Vancouver in a population that is highly addicted to substances there is a higher comorbidity of psychosis and childhood trauma than anxiety and childhood trauma.  One explanation is that drug use mediates/masks the anxiety symptoms that trauma can produce and that increased drug use can trigger or exacerbate psychotic symptoms.

Notably Tony Morrison of the UK reported a study that found that in one study institutional care was especially significantly associated with paranoia and rape was associated with audio-visual hallucinations.  Physical abuse alone was significantly linked to both paranoia and audio-visual hallucinations.  Numerous other studies found the same link between psychosis and traumatic events, especially those in early childhood.  Also: people can experience psychosis itself as traumatic and may go on to develop PTSD after having PTSD from the psychosis or institutional care.

This is particularly significant because it means a couple of things.

1) Preventing abuse of children could diminish those who experience psychosis

2) Understanding this link can help someone gain insight into their illness  and through addressing trauma.

3) Our care should acknowledge this and seek to diminish further trauma and increased sense of safety.

For me going starting into a field working with people with psychosis and also with a huge passion for helping people with trauma this brought a new meaning to my work with those with psychotic illnesses and more perspective and ideas on how to understand those of my neighbors in the DTES with psychosis.