From Beck’s cognitive therapy to long-standing patients

Could you tell us how you came to develop this model for the treatment of patients with personality disorders, and in particular borderline and narcissistic disorders?

Originally, I was trained by Aaron Beck; I was one of the first people he trained in cognitive therapy (CT). At that time, CT was not what it later became. I started at his center, running one of the first outcome studies carried out with depressed patients. I treated a lot of depressed patients in that study, and we found that CT was very, very good for people who had depression without any other associated problem; the striking finding of that study was that, when the depression came with other disorders, the more serious these were, the fewer results it produced. We were working there with a particular population, and we were very excited about the good results we were getting: between 65 and 70% of patients improved with CT.

At that time, I left Dr Beck’s center to pursue my own practice, and when I began to see patients who had not been selected for research, it turned out that those who came to consult presented, in addition to depression, problems of all kinds, and not just simple depression. They came with depressions they had been dragging along for ten years or more, or they were depressed now but had previously had anxiety problems or eating disorders. Many patients, more than half of those I was seeing, had long-standing psychological problems, and I discovered that the more persistent these problems were over time, the less effective CT was with them, whereas the simpler the depression, the better it worked. The fact that this percentage of patients did not improve led me to look for other models or therapies to integrate into CT, in order to be effective with patients presenting long-standing problems. With these patients, whether or not they had a personality disorder, even if we resolved their depression or their anxiety, they went on having problems in their lives. I began by including Gestalt therapy with them, which I had known as a patient, and I found in it several techniques that proved extremely useful for working with deep emotions, which I could not reach with CT. That was the first step in this search, which I continued with the new psychoanalytic approaches I had always been interested in, such as attachment theory, in particular the work of Bowlby. There were aspects of psychoanalysis that worked very well with these patients, such as those that placed the emphasis on the “therapeutic relationship”, and also the idea of “defense mechanisms”, which was not a concept I had available in CT. The models of Kohut, Kernberg, Guidano and Liotti, and others such as attachment theory and object relations theory, brought an interesting perspective that I included with these patients; so I decided to integrate these aspects into my conceptual model.

An entirely new integrative model

These points of view that I began to integrate into the cognitive model built what I first called “schema-focused cognitive therapy”, which involved an integration, in equal parts, of other models: 25% cognitive, 25% behavioral, 25% Gestalt and 25% psychoanalytic attachment theory. At that point, saying that it was a cognitive model was no longer adequate, since it was only 25% cognitive; that is why, today, to indicate that it is not just a slightly different therapy, but a totally new integrative model, in that it integrates techniques in a systematized way into a new conceptual model, we call it “schema therapy”.

In your new book, Schema Therapy: A Practitioner’s Guide, you address particularly difficult disorders such as borderline disorder and narcissistic disorder. Does it develop only the current model, or does it include what came before and worked very well with other personality disorders?