Citation

Kramer U. Journal de Therapie Comportementale et Cognitive 2015; 25(3): 125-131.

Copyright

(Copyright © 2015)

DOI

10.1002/cpp.1956

PMID

unavailable

Abstract

Therapeutic interaction with patients presenting a personality disorder is describedas difficult and volatile. In recent years, cognitive-behavioral therapies (CBT) have approachedthese difficulties by formalizing treatment manuals and by proposing complex cognitive mapsand models. While this endeavor is important and accurate for a number of treatments, thesemodels tend to ignore the central actor of change in psychotherapy: the individual patient.In this present paper a number of mechanisms of change which are central to treatments ofpatients with personality disorders are discussed. A radically scientifically inductive stance hasbeen adopted: the observed interactional behavior of the patient is taken as the starting pointin understanding the actual processes of change. This contrasts with complex models trying toexplain the clinical phenomena and fundamentally failing to do so on an idiosyncratic level. Inaddition, it is demonstrated how the paradox of equivalence extends to bona fide psychologi-cal treatments for personality disorders, by discussing problems inherent in studies aimed atdemonstrating the superiority of a specific therapy model. This argument further supports emer-ging scientific interest in mechanisms of change in treatments of personality disorders. Threepatient-related processes are considered. Firstly, patients with personality disorders presentinteractional problems, sometimes summarized as interactional maneuvers (or games), whichcreate specific therapeutic challenges. For example, these patients may tend to criticize thetherapist, cross borders and use suicide threats in order to obtain interpersonal recognition. Tobe able to productively use the relationship aspects inherent in these interactional behaviors,the therapist needs a fine-tuned perception of which elements are part of an authentic inter-action and which ones are not. This differentiated understanding helps the therapist developinteractions which foster authentic exchanges, for example by using the motive-oriented the-rapeutic relationship, based on individualized case formulations. The literature also explainsthat problems related to the patient's awareness and differentiation of emotions may impedethe quality of the treatment in the area of personality disorders. If this is the case, a detailedprocess assessment of these emotional problems should be made. As a result, the therapistmay implement techniques based on emotion-focused principles, for example by using process-directivity. Process-directivity helps the patient to work on affectively charged contents in thehere and now of the therapeutic interaction; it does not imply that the therapist makes sug-gestions related to the content of the processing, but rather helps optimize the course, qualityand depth of emotional processing. In addition, techniques of affect and techniques to dee-pen understanding may be used when appropriate. Finally, patients with personality disorderssuffer from difficulties in affirming strong social identities. Again, the first step is the accurateassessment of these problems by the therapist. Then, the therapist may foster this processby using appropriate interventions aimed at developing aspects of social identity, for examplefostering assertive anger in the patient might be a useful process leading to stronger identitiesin social contexts. In conclusion, focusing on the actual observable patient behaviors-the realprocesses going on in the therapy hour-is productive. It may allow the therapist to refine,precise and deepen their case formulation and intervention which in turn is then more closelyrelated to the patient's processes. © 2015 Association française de thérapie comportementale et cognitive.

Language: fr

Keywords

Emotion; Personality disorders; Identity; Integration; Innovation; Interpersonal; Cognitive-behavioraltherapy