Complex mental illness needs prolonged therapy — not very surprising, perhaps. Traditional CBT is short-term, and extending its scope is not just a matter of keeping at it for longer. Extended variants of CBT apply core elements of therapy in a more concentrated way, and broaden it by introducing elements of other therapies.
Axis I and Axis II
There is a conventional, but not entirely helpful, division of mental illness into Axis I conditions that were felt to develop as a result of life events, and Axis II conditions that were felt to be disorders of underlying mental function.
So-called Axis I conditions include the common mental illnesses like anxiety, depression and schizophrenia, and also bipolar disorder, which it now seems might be associated with underlying mental function after all.
So-called Axis II conditions include the personality disorders and mental retardation. Borderline personality disorder (BPD, in this post) was for a long time felt to be one of the most difficult conditions to treat, but recent years have seen treatments emerge, based on the conventional treatments for Axis I conditions.
Thus, the Axis I/Axis II division is looking a bit ragged.
DBT and PSFT? PSCT?
The relatively well-known treatment for BPD is “dialectical behavior therapy” (DBT), a variant of CBT that concentrates on harmful behaviours.
The newer treatment is based on schema therapy, a variant of CBT that concentrates on patterns of thinking. It now looks as if this newer treatment might be acquiring the name “Prolonged Schema-Focused Therapy” (PSFT) or maybe “Prolonged Schema-focused Cognitive Therapy” (PSCT).
It’s intriguing that of the two CBT variants, one concentrates on behaviour, and the other on cognition.
So now, for patients who were only a few years ago considered to be difficult and untreatable, there are two treatment possibilities — if only there were enough skilled therapists to deliver them in the UK.
Dense but delightful
While I was trying to find out what the newer treatment is called (and I’m still not entirely sure), I came across this online document at the University of Maastricht describing the new treatment in some detail: Borderline Personality Disorder (8.5 MB Word document)
It’s a chapter from a 2004 book, Cognitive Therapy of Personality Disorders, in which Professor Doctor Arnoud Arntz of the University of Maastricht describes BPD and the new treatment for it. Parts of its 33 pages are quite dense research-based stuff, and parts are quite delightful descriptions of how therapy works.
Pointing out some limitations of the DBT approach, the chapter notes that (page 9 in the chapter, 195 in the book):
DBT might be especially effective in reducing self-damaging BPD behavior but not effective in reducing the emotional suffering of these patients. Although 1 year of DBT leads to improvement of the patient in a number of important respects, which are maintained at follow-up…, the data indicate that the average patient still suffers from a large number of problems…
And here’s the concluding paragraph (page 29 in the chapter, 215 in the book):
Although patients with BPD present with remarkable instability in many aspects of their functioning, an intensive and directed cognitive intervention can reduce this instability, modify interpersonal distrust, and alter the underlying core schemas, including the trauma-related schemas so often encountered with this challenging disorder.
The examples in the chapter feature Natasha, a 29 year old who (page 1 in the chapter, 187 in the book):
…described her relationship with her husband as characterized by lots of fights and aggressive threats. She also expressed resentment toward her family and admitted high use of cannabis and alcohol. She repeatedly stated that she found that life had no use and was very distrustful of other people. When asked what should be done in treatment she was rather vague, giving answers such as “I have to feel at home with myself.”
A couple of transcripts of dialogue between Natasha (N) and her therapist (T) illustrate, first, the way in which the therapist has to set limits on the relationship, and the unstable way in which Natasha’s mood can change from moment to moment (page 16 in the chapter, 202 in the book, much condensed here):
N: This weekend I’ll have my 30th birthday party, and I would like to invite you to be there, so that I can introduce you to my husband and friends.
T: That is very nice of you to invite me to your birthday party, but I’m afraid I don’t want to do that.
N: Why not? I so much hoped that you could be with me.
T: I like you very much, but I want to spend my leisure time with my family and friends.
N: (getting angry) So you are not considering me as a friend? …
T: You are right, I don’t think of you as a friend, though I like you a lot … I don’t want to come to your party.
N: Jesus, you don’t need to repeat that, you don’t need to pour salt into a wound. I know what you said, I heard you. (getting afraid now) Oh my God, I shouldn’t have asked it… I cannot stay here. (She stands and starts to leave the room.)
T: Don’t leave, please stay…
N: (sits again and starts to cry) OK, but I feel so ashamed…
A second transcript illustrates a technique for reprocessing painful childhood memories through imagination. The therapist enters the imagined scene and intervenes to rescue the child, confronting Natasha’s mother, and protecting and comforting Natasha, together with her sister (page 24 in the chapter, 210 in the book, much condensed here):
N: I can’t do anything. I’m too afraid.
T: Is it OK when I join you? Can you imagine me standing alongside you?
T: … Madam, you are Natasha’s mother, aren’t you? I have to tell you that you are doing terrible things to your daughter…you are humiliating her in front of the rest of the family because she is emotional…stop accusing her and apologize for having done that!
N: Take us with you.
T: OK. I take the two of you with me: imagine that you take your cuddle toys and everything else you want and that we leave the house together with your sister…
N: I’m feeling sad now. (Starts to cry.)
T: That’s OK, do you want me to comfort you? Let me take you in my arms…can you feel that?
N: (Cries even harder.)
The chapter describes a wide range of techniques — cognitive, experiential (like this one), behavioural and pharmacological — that contribute to a successful outcome. After prolonged treatment lasting a couple of years, therapy sessions gradually become less frequent to encourage independence from the therapist.
There’s a related set of DVDs illustrating all the techniques for training purposes, but I haven’t seen it.
In the UK
Professor Doctor Arntz presented on these techniques at the BABCP’s conference in 2006, and he will be in Oxford at the end of March to train experienced UK therapists. So knowledge and awareness of this kind of treatment for severe conditions is gradually increasing in the UK.