Altering the goals of therapy with personality disorders.

Shifting  the goal posts

When working with Personality Disorders in clinical practice we need to clarify the essential goals within a CBT context. The majority of clients who present with characterological difficulties don’t present with this as the actual problem. The interpersonal difficulties that emerge for the client stems from the ack of flexibility that client has in dealing with social problems. For example a client who would typically present with Narcissistic personality Disorder  would not see any difficulties emerging from his/her personality traits. These would be considered Ego Systonic  by client or consistent with his/her self concept. The problems would arise when these rigid hypertrophied beliefs concerning entitlement  behavioural interpersonal dominance would cause clinically significant distress due to the inflexibility of behavioural response sin a variety of different social situations. The articulated goal at the beginning of therapy is always explicitly verbalised that it is not necessary or possible to change the client’s basic personality. The redirected emphasis would target the habitual pattern of thinking and acting that was causing interpersonal and functional impairment. The related goal is to  help shift  the personality style from unhealthy extremes to encompassing more adaptive and healthy modes. As I frequently say to clients in practice “Its ok to be a narcissistic, as long as you are a friendly, prosocial and attuned to the needs of people narcissist”.

Empathy training

A significant part of CBT with Personality disorders is helping the client to understand how and why he/she pulls responses from people that serve then to confirm and reinforce the client’s life script  or personal and interpersonal schemas. A significant intervention in doing this is to underscore the dissonance between a client’s private version of reality and the therapist’s social appropriate version of reality. This will have the intended target of latent learning for the client and help to reduce the client’s Cognitive/Interpersonal cycle and increase  responsibility practicing and experimenting with new ways of relating to people with the hope to create therapeutic change.



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