A look at the field of cognitive-behavioral therapy1 helps to explain the reason Young felt that the development of schema therapy was so important. Cognitive-behavioral researchers and practitioners have made excellent progress in developing effective psychological treatments for Axis I disorders, including many mood, anxiety, sexual, eating, somatoform, and substance abuse disorders. These treatments have traditionally been short term (roughly 20 sessions) and have focused on reducing symptoms, building skills, and solving problems in the patient’s current life.
However, although many patients are helped by these treatments, many others are not. Treatment outcome studies usually report high success rates (Barlow, 2001). For example, in depression, the success rate is over 60$ immediately after treatment, but the relapse rate is about 30$ after 1 year (Young, Weinberger, & Beck, 2001)—leaving a significant number of patients unsuccessfully treated. Often patients with underlying personality disorders and characterological issues fail to respond fully to traditional cognitive-behavioral treatments (Beck, Freeman, & Associates, 1990). One of the challenges facing cognitive-behavioral therapy today is developing effective treatments for these chronic, difficult-to-treat patients.
Characterological problems can reduce the effectiveness of traditional cognitive-behavioral therapy in a number of ways. Some patients present for treatment of Axis I symptoms, such as anxiety or depression, and either fail to progress in treatment or relapse once treatment is withdrawn. For example, a female patient presents for cognitive-behavioral treatment of agoraphobia. Through a program consisting of breathing training, challenging catastrophic thoughts, and graduated exposure to phobic situations, she significantly reduces her fear of panic symptoms and overcomes her avoidance of numerous situations. Once treatment ends, however, the patient lapses back into her agoraphobia. A lifetime of dependence, along with feelings of vulnerability and incompetence—what we call her Dependence and Vulnerability schemas—prevent her from venturing out into the world on her own. She lacks the self-confidence to make decisions and has failed to acquire such practical skills as driving, navigating her surroundings, managing money, and selecting proper destinations. She prefers instead to let significant others make the necessary arrangements. Without the guidance of the therapist, the patient cannot orchestrate the public excursions necessary to maintain her treatment gains.
Other patients come initially for cognitive-behavioral treatment of Axis I symptoms. After these symptoms have been resolved, their characterological problems become a focus of treatment. For example, a male patient undergoes cognitive-behavioral therapy for his obsessive-compulsive disorder. Through a short-term behavioral program of exposure combined with response prevention, he largely eliminates the obsessive thoughts and compulsive rituals that had consumed most of his waking life. Once his Axis I symptoms have abated, however, and he has time to resume other activities, he must face the almost complete absence of a social life that is a result of his solitary lifestyle. The patient has what we call a “Defectiveness schema,” with which he copes by avoiding social situations. He is so acutely sensitive to perceived slights and rejections that, since childhood, he has avoided most personal interaction with others. He must grapple with his lifelong pattern of avoidance if he is ever to develop a rewarding social life.
Still other patients who come for cognitive-behavioral treatment lack specific symptoms to serve as targets of therapy. Their problems are vague or diffuse and lack clear precipitants. They feel that something vital is wrong or missing from their lives. These are patients whose presenting problems are their characterological problems: They come seeking treatment for chronic difficulties in their relationships with significant others or in their work. Because they either do not have significant Axis I symptoms or have so many of them, traditional cognitive-behavioral therapy is difficult to apply to them.
Traditional cognitive-behavioral therapy makes several assumptions about patients that often prove untrue of those patients with characterological problems. These patients have a number of psychological attributes that distinguish them from straightforward Axis I cases and make them less suitable candidates for cognitive-behavioral treatment.
One such assumption is that patients will comply with the treatment protocol. Standard cognitive-behavioral therapy assumes that patients are motivated to reduce symptoms, build skills, and solve their current problems and that, therefore, with some prodding and positive reinforcement, they will comply with the necessary treatment procedures. However, for many characterological patients, their motivations and approaches to therapy are complicated, and they are often unwilling or unable to comply with cognitive-behavioral therapy procedures. They may not complete homework assignments. They may demonstrate great reluctance to learn self-control strategies. They may appear more motivated to obtain consolation from the therapist than to learn strategies for helping themselves.
Another such assumption in cognitive-behavioral therapy is that, with brief training, patients can access their cognitions and emotions and report them to the therapist. Early in therapy, patients are expected to observe and record their thoughts and feelings. However, patients with characterological problems are often unable to do so. They often seem out of touch with their cognitions or emotions. Many of these patients engage in cognitive and affective avoidance. They block disturbing thoughts and images. They avoid looking deeply into themselves. They avoid their own disturbing memories and negative feelings. They also avoid many of the behaviors and situations that are essential to their progress. This pattern of avoidance probably develops as an instrumental response, learned because it is reinforced by the reduction of negative affect. Negative emotions such as anxiety or depression are triggered by stimuli associated with childhood memories, prompting avoidance of the stimuli in order to avoid the emotions. Avoidance becomes a habitual and exceedingly difficult to change strategy for coping with negative affect.
Cognitive-behavioral therapy also assumes that patients can change their problematic cognitions and behaviors through such practices as empirical analysis, logical discourse, experimentation, gradual steps, and repetition. However, for characterological patients, this is often not the case. In our experience, their distorted thoughts and self-defeating behaviors are extremely resistant to modification solely through cognitive-behavioral techniques. Even after months of therapy, there is often no sustained improvement.
Because characterological patients usually lack psychological flexibility, they are much less responsive to cognitive-behavioral techniques and frequently do not make meaningful changes in a short period of time. Rather, they are psychologically rigid. Rigidity is a hallmark of personality disorders (American Psychiatric Association, 1994, p. 633). These patients tend to express hopelessness about changing. Their characterological problems are ego-syntonic: Their self-destructive patterns seem to be so much a part of who they are that they cannot imagine altering them. Their problems are central to their sense of identity, and to give them up can seem like a form of death—a death of a part of the self. When challenged, these patients rigidly, reflexively, and sometimes aggressively cling to what they already believe to be true about themselves and the world.
Cognitive-behavioral therapy also assumes that patients can engage in a collaborative relationship with the therapist within a few sessions. Difficulties in the therapeutic relationship are typically not a major focus of cognitive-behavioral treatments. Rather, such difficulties are viewed as obstacles to be overcome in order to attain the patient’s compliance with treatment procedures. The therapist-patient relationship is not generally regarded as an “active ingredient” of the treatment. However, patients with characterological disorders often have difficulty forming a therapeutic alliance, thus mirroring their difficulties in relating to others outside of therapy. Many difficult-to-treat patients have had dysfunctional interpersonal relationships that began early in life. Lifelong disturbances in relationships with significant others are another hallmark of personality disorders (Millon, 1981). These patients often find it difficult to form secure therapeutic relationships. Some of these patients, such as those with borderline or dependent personality disorders, frequently become so absorbed in trying to get the therapist to meet their emotional needs that they are unable to focus on their own lives outside of therapy. Others, such as those with narcissistic, paranoid, schizoid, or obsessive-compulsive personality disorders, are frequently so disengaged or hostile that they are unable to collaborate with the therapist. Because interpersonal issues are often the core problem, the therapeutic relationship is one of the best areas for assessing and treating these patients—a focus that is most often neglected in traditional cognitive-behavioral therapy.
Finally, in cognitive-behavioral treatment, the patient is presumed to have problems that are readily discernible as targets of treatment. In the case of patients with characterological problems, this presumption is often not met. These patients commonly have presenting problems that are vague, chronic, and pervasive. They are unhappy in major life areas and have been dissatisfied for as long as they can remember. Perhaps they have been unable to establish a long-term romantic relationship, have failed to reach their potential in their work, or experience their lives as empty. They are fundamentally dissatisfied in love, work, or play. These very broad, hard-to-define life themes usually do not make easy-to-address targets for standard cognitive-behavioral treatment.
Later we look at how specific schemas can make it difficult for patients to benefit from standard cognitive-behavioral therapy.