Sunday, 20 May 2012

10 things I learnt from Judith Beck workshop on CBT for Personality Disorders

I attended an excellent workshop given by Judith Beck on CBT for Personality Disorders in London last week. It was a really engaging workshop, with a good mix of lecture, videos and demonstration. The group was large but not overwhelmingly so, meaning that there was a reasonable amount of time for questions. Despite her eminence (Judith is the daughter of Aaron T. Beck and the author of several books including the classic Cognitive Therapy: Basics and Beyond) she came across as humble and approachable as well as extremely knowledgable.

I'm writing this blog entry to share 10 things I learnt or was reminded of in the workshop.

1) How to set an agenda in CBT
Agenda setting is very important in CBT. Like in a meeting at work, having a clear idea of what you want to talk about helps you prioritise and focus collaboratively. However, some therapists find that asking formulaic questions such as "What shall we talk about today?" or "What agenda items do you have?" is either too vague or too formal. Beck shared with us that she no longer tends to ask "What shall we put on the agenda?" but asks the more concrete "What problem or problems would you like my help in solving today?" or "What can we look at today that will help you in the next week?". I like those questions, and have already added them to my set of  standard agenda-setting questions with a positive result.

2) There are three main areas of core beliefs one can have about oneself, relating to helplessness, unloveability and worthlessness. I think this this is a useful set of categories. Less direct ways clients might express this are, respectively "I can't cope", "If people knew the real me they wouldn't care for me" and "I am nothing".Being aware of these three categories can help you be aware of a particualr clients main vulnerability. Of course, the three areas are not completely exhaustive (for example where do you put the client who says "I am broken"?) and Jeffrey Young's idea of lifetraps in Reinventing Your Life contains a  longer list of areas of concern, which also go beyond core beliefs or schemas about onself.

3) Judith Beck's template for formulation or case conceptualisation is a useful tool to use for clients with personality disorders.  It differs from  some other CBT case conceptualisation templates in that it includes compensatory strategies and has room for an example of how it plays out in a situation with automatic thoughts and  their meaning (often a core belief) and reaction (often a behaviour).Here is an example in Word format.

4) The idea of a compensatory strategy is that people understably behaviour people carry out to get round their core beliefs and assumptions. For example, someone who believes that other people are hostile might have a compensatory strategy of avoiding them or of being a people-pleaser. For those familiar with Melanie Fennell's model of low self-esteem, it's quite similar to her  notion of "unhelpful behaviours".

5) A normalising and compassionate way of helping those with personality disorders to understand their compensatory strategies  is in terms of overdeveloped and underdeveloped strategies. For example, someone with Obsessive Compulsive  Personality Disorder may have overdeveloped responsibility and systematisation (Christine Padesky calls this "too much of a good thing") and undeveloped spontaneity and impulsivity.

6)CBT can help those with personality disorders but CBT will tend to take longer and more attention needs to be given to developing and maintaining the therapeutic alliance and to developing alternative more helpful core beliefs.

7) To help maintain a good therapeutic alliance, Judith Beck's tips include
  • asking for feedback (e.g. on a scale of 1 to 10 how empathic was I, what would have made it one point higher?), 
  • helping with solving problems relevant to client (see 1 above), l
  • looking out for signs of emotional distress in session and bring them to attention of client, 
  • giving a  rationale for your treatment, 
  • using your formulation 

8) Be on the lookout for your own negative reactions to clients with personality disorders, and deal with them, for example by
  • looking at your own core beliefs being activated and looking after yourself (Beck said that she herself finds mindfulness helpful) and 
  • using supervisions (of course!). 
  • Above all, expect interpersonal issues to arise - that's why there here - and use the therapy room as a laboratory for helping the client resolve them.

9. "We don’t see things as they are, we see things as we are." Strongly held core beliefs or schemas filter out our experience in a certain way. For example,  if you think you are unloveable, you will look out for things which support this view and either fail to notice or discount examples where you appear to be lovable. Oxford-based therapists Fennell, Butler and Hackmann  refer to this process as the "mental crusher." In Judith Beck's version of this idea , you might draw a diagram showing the client's mind with space for a circle, representing an  existing core belief. Contradictory core beliefs are then shown as  squares or triangles. You can then ask the client "what do you think will happen when you come across an idea that doesn't fit?".  This can help clients be prepared for how difficult it may be for them to change their core beliefs but also that they could benefit from being more flexible in how they see themselves and the world. This sets the scene for numerous ways to modify unhelpful core beliefs.

10. There are a number of ways to modify core beliefs. I have written elsewhere about many of these. Beck adds to my list of 10 ways to change core beliefs by adding
  •   using metaphors and stories (e.g. Cinderalla story for how someone can overcome abuse) and
  •  restructuring the meaning of early experiences through imagery,
All in all it was very refreshing to hear how you could deal with more complex cases in CBT without departing too much from standard CBT practice. Whilst approaches such as Schema Therapy and  Dialectical Behaviour Therapy may seem very attractive to those who have tried CBT for those with personality disorders without success, Beck's approach suggests that such a radical change in approach may not always be necessary.

I hope this list of 10 things I learnt from the workshop gives some flavour of how CBT can help with Personality Disorders and more generally with working with more complex clients. Of course, there was much more in the workshop than is summarised above, and I thoroughly recommend you go to one of Judith Beck's workshops if you get the chance.

Further resources
Beck Institute  Website
Interview with Judith Beck
Judith Beck video on You Tube