Cognitive therapy for difficult patients—a review

Abstract

In this review cognitive therapy innovations developed to deal with difficult patients are summarized and discussed. These new approaches comprise work with severely and chronically depressed in-patients and developments in theory and method to deal with long-term personality problems. The difficulties of distinguishing Axis 1 from Axis 2 problems is highlighted and the dangers inherent in underestimating the usefulness of standard techniques and the misattribution of poor outcome to ineffective technique rather than to difficulties in therapy execution is pointed out. The importance of the activation of maladaptive schematic structures in therapy is conceived of as a unifying principle underlying all cognitive therapy. This may be a particular difficulty for individuals who have negative attitudes to emotion and who strive for total emotional control. The lack of empirical evaluation in the area of personality problems is noted and the need for the development of short-term indicators of change as utilized in the work of Linehan et al., 1991 & 1993 in their work with parasuicidal Borderline personality disorder patients.