Psychoanalysis and the Cognitive Therapy of Personality Disorders
Lockwood, George, Journal of Cognitive Psychotherapy
Personality disorders, through a series of vicious cycles and self-fulfilling prophecies, usually skew interactions and events in a manner that confirms the preexisting cognitive distortions. As a result, therapy often becomes part of the problem rather than the problem part of the therapy. Cognitive therapists can benefit in dealing with this phenomenon by drawing on recent developments in psychoanalytic theory and technique. Object-relations theory views problems in the therapeutic relationship as a function of internalized representations of early child-parent interactions being projected onto the relationship (the cognitive equivalent of schemas being triggered within the therapeutic relationship.) Treatment can be enhanced by taking advantage of this process as the therapist acts as a participant-observer, helping the client clarify the projections (schemas) and then test and correct them, in part, through having a new kind of interpersonal experience with the therapist (encountering new evidence in the here-and-now), and then re-internalizing a new self-image and set of assumptions about others.
One of the most pernicious aspects of personality disorders is that they are powerfully self-perpetuating. This seems to take place through a series of vicious cycles and self-fulfilling prophesies in which others are drawn in as participants, and outcomes end up being skewed in a manner such that evidence is regularly generated that confirms the preexisting views. While this is also true to a degree with neurotic difficulties, in the case of personality disorders, this occurs to such an extent that there are far fewer situations and interactions which are free of this process. Even skilled and compassionate therapists, in attempts to help the person change, are usually drawn into the same vortex. As a result, therapy usually becomes part of the problem rather than the problem becoming part of the therapy.
For this and other reasons, interpersonal difficulties, and especially interpersonal difficulties with the therapist, are often of central concern.
The cognitive learning therapies (e.g., Cognitive Therapy and Rational-Emotive Therapy) have had relatively little to say about such problems in the therapeutic relationship, and as a result, practitioners of these approaches have been on their own when it comes to dealing with the many dilemmas of this nature which inevitably arise when working with personality disorders. The interpersonal domain (including the therapeutic relationship) has played a more central role in the models put forward by the constructivistic-cognitive therapies (Guideno & Liotti, 1983; Mahoney, 1991; Young, 1990). Correspondingly, they have begun to derive interventions from this model in which the therapeutic relationship is more pivotal. While an important and new direction within the cognitive therapy movement, this theory and the associated techniques are still in an early stage of development.
Psychoanalysis has explored similar territory for some time and, in so doing, has yielded a number of technical contributions under the heading of analysis of transference, and theoretical contributions through the development of, among others, object relations theory. These advances have moved psychoanalysis much closer to the kinds of things cognitive therapy has viewed as important. For example, Gill (1982) has made technical contributions to the analysis of transference which involve a shift in emphasis away from abstract or prolonged discussions of the past to the concrete realities of the interaction between therapist and patient that are unfolding in the here-and-now. These contributions result in an approach with its own kind of structure, and a process which involves the therapist actively looking for, bringing to light, and helping the patient explore the underlying meaning of dysfunctional aspects of the therapeutic relationship. The object relations approach focuses on internalized representations of interpersonal relationships as a way of conceptualizing psychological disorders (Kernberg 1976; Mahler, 1975. …