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.