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- Herausgeber: Hogrefe Publishing
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
- Veröffentlichungsjahr: 2019
This practice-oriented guide presents a model of Personality Disorders (PDs) based on the latest research showing that "pure" PDs are due to relationship disturbances. The reader gains concise and clear information about the dual-action regulation model and the framework for clarification-oriented psychotherapy, which relates the relationship dysfunction to central relationship motives and games. Practical information is given on how to behave with clients and clear therapeutic strategies based on a five-phase model are outlined to help therapists manage interactional problems in therapy and to assist clients in achieving effective change. The eight pure Personality Disorders (narcissistic, histrionic, dependent, avoidant, schizoid, passive-aggressive, obsessive-compulsive, and paranoid) are each explored in detail so the reader learns about the specific features of each disorder and the associated interactional motives, dysfunctional schemas, and relationship games and tests, as well as which therapeutic approaches are appropriate for a particular PD. As the development of a trusting therapeutic relationship is difficult with this client group, detailed strategies and tips are given throughout. This book is essential reading for clinical psychologists, psychiatrists, psychotherapists, counselors, coaches, and students.
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Personality Disorders
A Clarification-Oriented Psychotherapy Treatment Model
Rainer Sachse
About the Author
Rainer Sachse is Head of the Institute for Psychological Psychotherapy (IPP) in Bochum, Germany. He studied psychology from 1969 to 1978 at the Ruhr University of Bochum, Germany, and went on to gain his doctorate in psychology and a postdoctoral qualification for a full professorship, and later becoming a professor of clinical psychology and psychotherapy. At the end of the 1990s, Prof. Sachse developed a dual action theory of personality disorder which led to the creation of clarification-oriented psychotherapy, a therapy approach which he continues to use and develop today. His main areas of interest are personality disorders, psychosomatics, clarification-oriented psychotherapy, and behavioral therapy, and he has written extensively about these themes.
Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number: 2019938719
Library and Archives Canada Cataloguing in Publication
Title: Personality disorders : a clarification-oriented psychotherapy treatment model / Rainer Sachse.
Other titles: Persönlichkeitsstörungen. English
Names: Sachse, Rainer, author. | Translation of: Sachse, Rainer. Persönlichkeitsstörungen.
Description: Translation of: Persönlichkeitsstörungen : Leitfaden für die Psychologische
Psychotherapie. | Includes bibliographical references.
Identifiers: Canadiana (print) 20190098422 | Canadiana (ebook) 20190098465 | ISBN 9780889375529
(softcover) | ISBN 9781613345528 (EPUB) | ISBN 9781616765521 (PDF)
Subjects: LCSH: Personality disorders. | LCSH: Personality disorders—Treatment. | LCSH:
Psychotherapy.
Classification: LCC RC554 .S23 2019 | DDC 616.85/81—dc23
The present volume is an adaptation and translation of R. Sachse, Persönlichkeitsstörungen – Leitfaden für die Psychologische Psychotherapie, published under license from Hogrefe Verlag GmbH & Co. KG, Göttingen, Germany. © 2004, 2013 by Hogrefe Verlag GmbH & Co. KG.
© 2020 by Hogrefe Publishing
www.hogrefe.com
The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.
Registered trademarks are not noted specifically as such in this publication. The use of descriptive names, registered names, and trademarks does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
The cover image is an agency photo depicting models. Use of the photo on this publication does not imply any connection between the content of this publication and any person depicted in the cover image. Cover image: © LiudmylaSupynska – iStock.com
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|v|Foreword
Personality disorder has been increasingly identified as a mental condition that influences the treatment and recovery of patients both in medical psychiatric and in psychodynamic and cognitive behavioral treatments. Despite significant research, personality disorders still remain relatively underrecognized and misperceived in both psychiatric and psychological evaluations, either due to the predominance of primary comorbid disorders, such as mood, trauma, substance misuse, or eating disorders, or because of insufficient strategies for distinguishing and integrating personality-based function into assessment and treatment. In addition, the shortage of general, effective guidelines for identifying and approaching personality disorders has left many clinicians and therapists to their own devices when facing these problems with their patients. Some personality disorders are significantly influenced by deficits in neuropsychological processing, by attachment patterns, and by trauma, in addition to cognitive and interpersonal patterns, while others can be identified primarily in terms of psychological processing and relational motivation and regulation.
This volume provides a most instructive and comprehensive outline for identifying and treating clients with these personality disorders, which first and foremost present with problems in psychological and relational functioning. It fills a significant gap through its aim to create an integrative strategy for clarification and for motivating patients to seek to change. The author presents a well-organized approach, including detailed descriptions of each disorder and their array of functional patterns, with thorough therapeutic strategies for a broad range of problems in different phases of the treatment.
The clarification-oriented psychotherapy approach focuses on self-regulation and motivation in interpersonal interactions and relationships. By identifying motives and schemas, the author provides constructive and informative strategies for therapists to understand and manage the complexity of patients’ internal and interpersonal functioning, which can otherwise easily distract therapists and invite unconnected or misguiding perceptions of patients’ mental functioning. The informative and detailed therapeutic guidelines can help direct therapists’ efforts to identify and clarify patients’ complex motives and the different behavioral and intentional aspects of their functioning, and these guidelines include specific examples that are anchored in a solid theoretical frame of reference. In addition, the author identifies the co-occurring normal aspects of personality functioning within the framework of psychopathology, as well as subcategories of disorders that present with a range of behaviors and levels of functioning. This is very important for alliance building and for engaging patients’ sense of agency and motivation toward change and improvement.
In sum, this is a very well-structured, informative, and readily accessible book that provides unique and valuable guidelines for therapists treating those with personality disorders, with a clarification- and schema-focused approach. Given the integration of empirical studies |vi|with detailed clinical descriptions of each disorder, this is a useful and inspiring resource, and it is to be hoped that this book can be made available to therapists and clinicians in many countries.
Elsa Ronningstam, PhD
Harvard Medical School, Harvard University, Cambridge, MA
Contents
Foreword
Chapter 1 Essential Basic Concepts of Personality Disorders
1.1 Introduction
1.2 The Term Personality Disorder
1.3 Style and Disorder
1.4 Making Diagnoses
1.5 Resources
1.6 Personality Disorders as Relationship Disorders
1.7 Therapist Expertise
1.8 Relevance of DSM and ICD
Chapter 2 Characteristics of Personality Disorders
2.1 Introduction
2.2 Ego-Syntony and Ego-Dystony
2.3 Motivation for Change
2.4 Clients Are Motivated to Seek a Particular Relationship
2.5 Interaction Maneuvers
2.6 Tests
2.7 Problems Encountered by Therapists
Chapter 3 What Is Clarification-Oriented Psychotherapy?
3.1 Introduction
3.2 Aspects of Clarification-Oriented Psychotherapy
3.2.1 Relationship Formation
3.2.2 Confrontations
3.2.3 Clarification of Dysfunctional Schemas
3.2.4 Therapeutic Processing of Dysfunctional Schemas
3.3 Empirical Findings
3.3.1 Process Research Metrics
3.3.2 Process Research
3.3.3 Research on Success
Chapter 4 General Psychological Function Model for Personality Disorders
4.1 Introduction
4.2 Dual Action Regulation Model
4.2.1 Introduction
4.2.2 The Level of Authentic Action Regulation, or Motive Level
4.2.3 The Level of Dysfunctional Schemas
4.2.4 The Level of Nontransparent Behavior, or Game Level
Chapter 5 Diagnostic Features of Personality Disorders
5.1 Introduction
5.2 Relationship Motives
5.3 Dysfunctional Schemas
5.4 Compensatory Schemas
5.5 Interaction Games
5.6 General Model and Specific Disorders
Chapter 6 Therapeutic Strategies for Clients With PD: Consequences of the Model
6.1 Introduction
6.2 Therapy Phases
6.3 Therapeutic Strategies for Phase 1: Model and Relationship
6.3.1 Model Development
6.3.2 Complementary Relationship
6.3.3 Explicating the Relationship Motives
6.3.4 Directing and Internalizing
6.3.5 Understanding and Clarifying
6.3.6 Dealing With Avoidance
6.3.7 Passing the Tests
6.3.8 Resource Activation
6.4 Therapeutic Strategies in Phase 2: Game Level and Tests
6.4.1 Developing a Therapeutic Goal
6.4.2 Replenishing the Relationship Account
6.4.3 Clarification
6.4.4 Biographical Work
6.4.5 Dealing With Avoidance
6.5 Therapeutic Strategies in Phase 3: Clarification of Schemas
6.5.1 Clarification of Schemas
6.5.2 Dealing With Alienation
6.6 Therapeutic Strategies in Phase 4: Working Through Schemas
6.6.1 Client in Client Position: Working Out a Treatable Assumption
6.6.2 Client in Therapist Position: Treating the Assumption
6.6.3 Client in Client Position: Examining the Counterarguments
6.7 Therapeutic Strategies in Phase 5: Transfer
Chapter 7 Types of Personality Disorders
7.1 Introduction
7.2 Pure and Hybrid Personality Disorders
7.3 Proximity and Distance Disorders
7.3.1 Proximity Disorders
7.3.2 Distance Disorders
7.4 Differences Between Proximity and Distance Disorders
7.4.1 Trust and Building Up the Relationship
7.4.2 Affects and Processing Processes
7.4.3 Therapeutic Consequences
7.4.4 State of Research
7.5 Further Specific Therapy Approaches
7.6 Overview of Disorders
Chapter 8 Narcissistic Personality Disorder
8.1 Description and Types of NPD
8.1.1 The Former Definition: SNPD
8.1.2 Diagnostics: DSM Criteria for SNPD
8.1.3 Further Characteristics of NPD
8.2 Definition of NPD, Based on Dual Action Regulation Model
8.2.1 Definition Criteria for NPD
8.2.2 Definition Criteria for Successful Narcissists
8.2.3 Definition Criteria for Failed Narcissists
8.2.4 Definition Criteria for Unsuccessful Narcissists
8.3 Therapeutic Strategies
8.3.1 Therapeutic Strategies for NPD in General
8.3.2 Therapeutic Strategies for SNPD
8.3.3 Therapeutic Strategies for FNPD
8.3.4 Therapeutic Strategies for UNPD
Chapter 9 Histrionic Personality Disorder
9.1 Description and Types of HPD
9.1.1 Prevalence and Gender Differences
9.1.2 Progression
9.1.3 Comorbidity
9.1.4 Further Characteristics of HPD
9.1.5 Successful and Unsuccessful HPD
9.2 Definition of HPD, Based on Dual Action Regulation Model
9.2.1 Central Relationship Motives
9.2.2 Dysfunctional Schemas
9.2.3 Compensatory Schemas
9.2.4 Manipulation
9.2.5 Tests
9.2.6 Characteristics of HPD
9.2.7 Successful and Unsuccessful HPD
9.3 Therapeutic Strategies for HPD in General
9.3.1 Therapeutic Strategies in Phase 1
9.3.2 Therapeutic Strategies in Phase 2
9.3.3 Therapeutic Strategies in Phase 3
9.3.4 Therapeutic Strategies in Phase 4
9.3.5 Therapeutic Strategies in Phase 5
9.4 Processing Alienation
9.5 Therapeutic Strategies for UHPD
Chapter 10 Dependent Personality Disorder
10.1 Description of DPD
10.1.1 Therapeutic Problems
10.1.2 Criteria for DPD
10.1.3 Gender Bias
10.1.4 Helplessness and Interactional Behavior
10.1.5 Partner Reactions
10.1.6 Emotions
10.1.7 Comorbidities
10.1.8 Further Characteristics of DPD
10.1.9 Therapeutic Work
10.2 Definition of DPD, Based on Dual Action Regulation Model
10.2.1 Relationship Motives
10.2.2 Dysfunctional Schemas
10.2.3 Compensatory Schemas
10.2.4 Manipulative Strategies
10.2.5 Tests
10.2.6 Characteristics of DPD
10.3 Therapeutic Strategies
10.3.1 Therapeutic Strategies in Phase 1
10.3.2 Therapeutic Strategies in Phase 2
10.3.3 Therapeutic Strategies in Phase 3
10.3.4 Therapeutic Strategies in Phase 4
10.3.5 Therapeutic Strategies in Phase 5
Chapter 11 Avoidant Personality Disorder
11.1 Description of AvPD
11.1.1 Differentiation of AvPD from Social Phobia
11.1.2 Criteria for AvPD
11.1.3 Further Characteristics of AvPD
11.2 Definition of AvPD, Based on Dual Action Regulation Model
11.2.1 Central Relationship Motives
11.2.2 Dysfunctional Schemas
11.2.3 Compensatory Schemas
11.2.4 Games and Tests
11.2.5 Characteristics of AvPD
11.3 Therapeutic Strategies
11.3.1 Therapeutic Strategies in Phase 1
11.3.2 Therapeutic Strategies in Phase 2
11.3.3 Therapeutic Strategies in Phase 3
11.3.4 Therapeutic Strategies in Phase 4
11.3.5 Therapeutic Strategies in Phase 5
Chapter 12 Passive-Aggressive Personality Disorder
12.1 Description of PAPD
12.1.1 Description and Empirical Results
12.1.2 Further Characteristics of PAPD
12.1.3 Prevalence and Comorbidity
12.2 Definition of PAPD, Based on Dual Action Regulation Model
12.2.1 Central Relationship Motives
12.2.2 Dysfunctional Schemas
12.2.3 Compensatory Schemas
12.2.4 Manipulation
12.2.5 Tests
12.2.6 Characteristics of PAPD
12.3 Therapeutic Strategies
12.3.1 Therapeutic Strategies in Phase 1
12.3.2 Therapeutic Strategies in Phase 2
12.3.3 Therapeutic Strategies in Phase 3
12.3.4 Therapeutic Strategies in Phase 4
12.3.5 Therapeutic Strategies in Phase 5
Chapter 13 Schizoid Personality Disorder
13.1 Description of SzPD
13.1.1 Description
13.1.2 Prevalence and Comorbidities
13.1.3 Further Characteristics of SzPD
13.2 Definition of SzPD, Based on Dual Action Regulation Model
13.2.1 Central Relationship Motives
13.2.2 Dysfunctional Schemas
13.2.3 Compensatory Schemas
13.2.4 Manipulation
13.2.5 Tests
13.2.6 Characteristics of SzPD
13.3 Therapeutic Strategies
13.3.1 Therapeutic Strategies in Phase 1
13.3.2 Therapeutic Strategies in Phase 2
13.3.3 Therapeutic Strategies in Phase 3
13.3.4 Therapeutic Strategies in Phase 4
13.3.5 Therapeutic Strategies in Phase 5
Chapter 14 Obsessive-Compulsive Personality Disorder
14.1 Description of OCPD
14.1.1 Description
14.1.2 Biographical Experience
14.2 Definition of OCPD, Based on Dual Action Regulation Model
14.2.1 Central Relationship Motives
14.2.2 Dysfunctional Schemas
14.2.3 Compensatory Schemas
14.2.4 Manipulation
14.2.5 Tests
14.2.6 Characteristics of OCPD
14.3 Therapeutic Strategies
14.3.1 Therapeutic Strategies in Phase 1
14.3.2 Therapeutic Strategies in Phase 2
14.3.3 Therapeutic Strategies in Phase 3
14.3.4 Therapeutic Strategies in Phase 4
14.3.5 Therapeutic Strategies in Phase 5
Chapter 15 Paranoid Personality Disorder
15.1 Description of PPD
15.1.1 Description
15.1.2 Prevalence and Comorbidity
15.2 Definition of PPD, Based on Dual Action Regulation Model
15.2.1 Central Relationship Motives
15.2.2 Dysfunctional Schemas
15.2.3 Compensatory Schemas
15.2.4 Manipulation, Images, and Appeals
15.2.5 Tests
15.2.6 Characteristics of PPD
15.2.7 Proximity, Distance, and Bonding
15.2.8 Ego-Syntony, Perspective, and Avoidance
15.2.9 Costs
15.3 Therapeutic Strategies
15.3.1 Therapeutic Strategies in Phase 1
15.3.2 Therapeutic Strategies in Phase 2
15.3.3 Therapeutic Strategies in Phase 3
15.3.4 Therapeutic Strategies in Phase 4
15.3.5 Therapeutic Strategies in Phase 5
References
List of Abbreviations
|1|Chapter 1Essential Basic Concepts of Personality Disorders
1.1 Introduction
The concept of personality disorders (PDs) has a long history, and in consequence, widely differing ideas have developed around it. These ideas vary greatly from one another and are barely compatible (e.g., see Benjamin, 1996, 2003; Clarkin & Lenzenweger, 1996; Derksen, 1995; Fiedler, 2007; Fowler et al., 2007; Magnavita, 2004; Oldham et al., 2005).
Recent developments of this concept suggest that PDs should be conceived of as based on two factors: One should first conceptualize generally what PDs in fact are in a psychological sense, and then, on the basis of this general concept, one should clearly define the characteristics of the individual disorders (see Livesley, 1998, 2001; Livesley & Jackson, 1992, 2009; Livesley & Jang, 2005; Livesley et al., 1994, 1998; Hentschel, 2013). Some considerations of this are also dealt with in the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; APA, 2013).
The concept of PDs presented here adopts an equivalent approach: A general model of the psychological functioning of PDs is introduced, with the individual disorders then being elucidated on the basis of this model. Moreover, therapeutic implications are derived from the general as well as specific models (see Döring & Sachse, 2008a, 2008b).
The purpose of this book is not to trace and discuss conceptual developments, however. Rather it is to illustrate a treatment concept of PD – that is, the concept of clarification-oriented psychotherapy (COP; in German: klärungsorientierte Psychotherapie, or KOP). For this purpose, essential basic concepts of the approach to PDs will be emphasized to reveal the ideas that are suggested for the concept described here.
1.2 The Term Personality Disorder
It was initially suggested that there were some disorders that were very comprehensive, profound, and treatment-resistant. As a result, these disorders were seen as disorders of the overall personality (see Kernberg, 1978; Kretschmer, 1921; Schneider, 1923).
According to current psychological concepts (Fiedler & Herpertz, 2016; Millon, 2011), one must still assume that these disorders are complex, and that owing to their specific psychological |2|constellations, they remain relatively difficult to treat (see O’Donohue, Fowler, & Lilienfeld, 2007). However, the disorder at issue is not necessarily considered a disorder of the personality. Instead, it has become clear that features which characterize a PD are often already present in a lighter form in almost every person and are largely considered as normal and ordinary. As a result, more severe forms appear to be only extreme forms of ordinary psychological occurrences (Fiedler, 2007) and therefore are variations of a norm that are not necessarily considered as pathological.
In this context, a tendency in psychology could be observed to depathologize and normalize PDs. However, it is still obvious that these disorders generate great costs for the person concerned and that it makes sense to treat them therapeutically. Nonetheless, it is important to refrain from stigmatizing those affected. Unlike Emmelkamp and Kamphuis (2007), we do not view PDs as a “chronic psychiatric disorder . . . characterized by pathological personality traits” (Sachse, Sachse & Fasbender, 2010, 2011; Sachse, Fasbender, Breil, & Sachse, 2012).
It is essential to see PDs as an extreme form of ordinary, normal psychological processes, which generate such great costs for the person concerned that psychotherapy is useful.
Therefore, in this book clients with PD will not be classified or designated as infantile, immature, pathological, seriously disturbed, or temperamentally deficient. It is important to get away from such negative evaluations (this is important to create a good therapeutic relationship with the client!). Furthermore, such a diagnosis may affect the therapist’s stance and interventions. Basically, it would make sense to dispense with the term personality disorder and replace it with interaction disorder. However, since the term has been adopted into the language, it is easier to stay with the term personality disorder as long as one knows what is intended by it.
1.3 Style and Disorder
Individuals with a minor personality style exhibit characteristics of a psychological entity in a mild form, whereas individuals with a major clinical disorder exhibit these characteristics in a severe form.
An important implication of this approach is the assumption that there are no distinct criteria according to which a style becomes a disorder. Basically, there are no empirically valid criteria which specify precisely when a style becomes a disorder (see Caspar et al., 2008; Foster & Campbell, 2005, 2007; Krueger et al., 2007; Livesley et al., 1994; Ronningstam, 2005; Samuel & Widiger, 2011; Watson, 2005; Widiger & Samuel, 2005; Widiger & Simonsen, 2005; Widiger et al., 2005). Thus, during the process of psychotherapy, it is sensible to negotiate with the client as to whether they consider their disorder to be so disruptive that therapy is indispensable.
1.4 Making Diagnoses
An important aspect of depathologization is that one does not make diagnoses of PD to label people: If one makes an official diagnosis (i.e., one that is passed on to the authorities), one |3|should always be aware that it can certainly be used against the client, and one should be careful about this. For internal communication between professionals, that is, in supervision, diagnoses serve exclusively to help understand exactly what the client’s disorder is in order to be able to deal constructively with the client.
The sole purpose of diagnosis is to derive meaningful therapeutic measures to help the client (Sachse, 2017).
Therefore, it makes sense in principle that a therapist
gives a diagnosis,
is aware of the fact that this is always a more or less well-proven hypothesis – that is, a working hypothesis for the purposes of psychotherapy,
establishes a diagnosis as early as possible in the process (and as a first hypothesis),
never overlooks a client’s PD.
And in this case, it may well make sense to speak, for example, of narcissism as a disorder, although the client only exhibits a style: Because it can be helpful even then to be sufficiently prepared for games, motivational problems, etc.
In general, it appears to be expedient to consider a personality style or a disorder in the therapy process – that is, to diagnose it and to consider it in the therapeutic procedure if
aspects of the style or disorder cause the costs the client does not want to incur,
and/or
aspects of the style or disorder become relevant in therapeutic interaction – for example, by leading to manipulative behavior that significantly influences interactions with the therapist.
As a rule, however, even mild styles are relevant, so therapists should generally
be mindful of PDs,
be capable of quickly detecting and validly diagnosing any PD,
be able to handle the PD in a constructive manner.
1.5 Resources
When treating PDs, the focus is no longer solely on deficits, but moves toward the client’s resources. It becomes more and more obvious that PD always implicates resources: The clients are, due to their schemas, very sensitive regarding certain information, they are competent in certain actions, etc. Most of the time, the problem is not that they do not have any resources but that they are unwilling or unable to use them constructively.
These resources are good therapeutic tools, if one wants to change schemas, develop alternative action patterns, etc.: In the modification phase of the therapy, the orientation of these resources can be very helpful. Plus, the focus on resources helps to get away from the tendency to pathologize and stigmatize the client.
This approach also has consequences for the definition of therapeutic objectives. Healing as an objective is not useful (aside from not being even realistic), because clients do not have to abandon all aspects of their personality. Clients just have to learn to use their resources more |4|sensibly; they have to learn to use their structures (such as schematas, motives, manipulations etc.) more constructively and how to benefit from them.
1.6 Personality Disorders as Relationship Disorders
Scientific studies have shown that at the center of PD are problems on a relationship and interaction level (see research by Sachse, Sachse, & Fasbender, 2010, 2011; Sachse, Fasbender, Breil, & Sachse, 2011, 2012). Thus, in certain theoretical perspectives, PDs are understood as relationship or interaction disorders. This conception is also represented in the approach taken by COP. Within this approach, it is accepted that PDs are indeed psychologically complex disorders affecting many psychological functional areas; however, the central point of PD is a relationship disorder. This assumption indicates why clients with PD are difficult clients in the therapy process: They bring their interactional problems with them into the therapeutic relationship.
1.7 Therapist Expertise
Since clients with PD put significantly greater demands on therapists (Sachse, 2006a, 2006b, 2009), therapists need a much higher level of expertise for the treatment of PD clients than for the treatment of Axis I clients. The therapists need to master a highly flexible relationship structure, they have to deal with so-called tests to be able to apply confrontational interventions, to deal with manipulative interaction behavior, to be able to clarify affective schemas, etc. And above all, they must be able to quickly recognize a PD and generate a hypothesis about its type. This requires the ability to process information and model it quickly and confidently. It also requires highly strategic knowledge, rapid action planning, and intervention formulating, etc.
1.8 Relevance of DSM and ICD
In the author’s view, diagnostic systems such as those of the DSM-5 (APA, 2013) and the World Health Organization (WHO) International Classification of Diseases, 10th edition (ICD-10; WHO, 1992) do allow a diagnosis of PDs. However, clients with PDs have characteristics that make diagnosis very difficult. These include
a high degree of distrust,
a tendency to reveal very little of themselves,
a strong tendency to produce images, and
a poor understanding of their own problems.
Therefore, traditional diagnostic systems can only ever provide diagnostic hypotheses, especially at the beginning of therapy (see Sachse, 2006a, 2006d; Sachse & Breil, 2011; Sachse, Sachse, & Fasbender, 2011; Sachse, Fasbender, Breil, & Sachse, 2012).
In addition, there are other problems with the DSM and ICD:
The DSM and ICD do not even begin to take note of the state of development of psychological concepts in the field of PDs.
|5|The criteria for the disorders are minimal, with many of the criteria that have now been empirically verified not being taken into account.
No central criteria – the “core” of the disorder – are defined, although it is clear both empirically and theoretically that not all characteristics are equally relevant.
Essential in-depth characteristics, such as motives, schemas, etc., are not taken into account at all.
The criteria do not take into account the predominant position of conceiving of PDs as relationship disorders.
The criteria for determining when a disorder is a disorder are in no way empirically validated and are completely arbitrary. From a therapeutic point of view, they are in part incomprehensible.
The clusters specified by the DSM-5 are nonempirical and result in summarizing disorders that are completely heterogeneous and that form neither theoretically nor therapeutically meaningful patterns.
In this respect, the DSM-5 is hardly a step forward; and to refrain from even defining PDs can certainly not be regarded as an advance.
In the author’s opinion, a therapist can make use of the DSM and ICD criteria as heuristics. However, it is our obligation as scientific practitioners to describe, analyze, understand, and treat disorders appropriately based on our understanding and expertise. It is not our task to standardize them, to make discussions more difficult, and to inhibit developments.
In addition to the DSM, rating systems can also be used in the therapy process (Sachse, 2015a, 2015b; Sachse, Kiszkenow-Bäker, & Schirm, 2016; Sachse & Kramer, 2015a, 2015b, 2015c; Sachse & Schirm, 2015; Sachse, Schirm, & Kramer, 2015a, 2015b). The main advantage of these procedures is that they are based on the concrete interaction behavior of the client – that is, they take into account how the client acts and not only what they express in terms of content.
|6|Chapter 2Characteristics of Personality Disorders
2.1 Introduction
As a kind of advanced organizer, essential general characteristics of PDs are summarized in this section (also in distinction to Axis I disorders): Thus, the question is, what characterizes clients with PD and what are the particular features they bring into the therapy?
2.2 Ego-Syntony and Ego-Dystony
Fiedler (2007) spotlighted the aspect of ego-syntony: A disorder is ego-syntonic if the person concerned does not perceive essential aspects of the disorder as disruptive, problematic, and necessitating change; moreover, these aspects are perceived as part of the self – as part of one’s identity. By contrast, a disorder is ego-dystonic if the person perceives essential aspects of it as disruptive: The person does not want to suffer these aspects of their disorder and experiences them as foreign and necessitating change.
Contrary to Axis I disorders, which are usually ego-dystonic, PDs are usually ego-syntonic: the degree of ego-syntony depends on the type and severity of the disorder (e.g., avoidant PD is a little ego-syntonic, whereas obsessive-compulsive PD is highly ego-syntonic).
2.3 Motivation for Change
The degree of motivation to change strongly depends on the ego-syntony (motivation to change is the tendency to actively want to change aspects of oneself).
Motivation to change implies that
The person realizes that their belief system produces costs;
That these costs are relevant, and they do not want these costs;
That changing can reduce costs and make objectives attainable;
That these costs are self-produced, and that the client must actively pursue their objectives.
(Sachse, Langens, & Sachse, 2012)
|7|If a disorder is ego-syntonic, the person will be able to recognize the costs and realize that they do not want to suffer them, but the person will not realize that they produce these costs themselves. Thus, the person is motivated to cut costs, meaning they want a cost reduction, but are not inclined to do anything for it. Often these individuals are motivated to remain the same (stabilized), which means that they do not want to change their belief system, they just want to avoid the costs.
This means that at the beginning of the therapy, most of PD clients are not motivated to change concerning aspects of their PD.
In other words, motivation to change is not a basic therapy precondition for clients with PD but has to be established during therapy.
However, the clients may be therapy-motivated: They may be motivated to reduce costs or to have the costs reduced by the therapist. The problem is that therapists sometimes consider this motivation to be the same as motivation to change, which is not true.
2.4 Clients Are Motivated to Seek a Particular Relationship
Clients with PD show strong relationship motives and often come to therapy to get these desires satisfied by the therapist. Due to their high relationship motivation and high ego-syntony, PD clients rarely undergo therapy to do actual therapeutic work, therefore they do not accept therapeutic strategies, something that therapists perceive as sabotage.
The strong relationship motivation implies that clients with PD often access therapy primarily for a certain relationship offered by the therapist – in other words, they look for a certain kind of relationship.
Clients might send double messages: “I am miserable, I need help, do something!” and “I can’t do anything, I can’t collaborate, it is all too difficult!” If therapists then proceed in line with the motto “Something must be done,” they will greatly impede the therapy, because the clients are not yet motivated to actively collaborate therapeutically.
Due to the extreme relationship motivation of PD clients, a therapist must concentrate on strong complementary relationship structuring at first; only when a therapist has sufficient relationship credit may they move on to specific therapeutic strategies.
2.5 Interaction Maneuvers
Individuals with PD will very likely use so-called interaction games: They use these nontransparent, manipulative actions much more than clients without PD. With these manipulative interaction games (see Tedeschi et al., 1973, 1985; Tedeschi & Norman, 1985; Tedeschi & Riess, 1981), they often cause difficulties for their interaction partners.
|8|It is important to understand that we (Sachse, Sachse, & Fasbender, 2011) do not regard manipulative actions as such as to be problematic: According to impression management theory (see Mummendey, 1995; Tedeschi et al., 1985), manipulation is an ordinary interaction behavior and an aspect of social competence. The problem is not the manipulation per se but rather the degree of manipulation or the amount of it: With a high degree of manipulative action, one will upset long-term interaction partners.
Clients with PD are characterized by such highly manipulative actions, and they will bring these actions into the therapeutic interaction. As a result, they involve therapists in interaction games. If therapists do not recognize this and/or are unable to constructively deal with it, they will get into great therapeutic difficulty.
The degree of manipulation depends on the type of disorder – clients with histrionic PD are highly manipulative, whereas clients with obsessive-compulsive PD are less manipulative), as well as on the degree of the disorder.
2.6 Tests
Clients with PD sometimes use so-called tests (Silberschatz et al., 1989, 1990; Weiss et al., 1986): Tests are behavior patterns by which the client tries to ascertain whether the therapist is genuine, whether their relationship offer is serious, whether they are reliable, etc. To test these, the therapist will, for example, be criticized, although, for the client, it is not about criticism, it is about ascertaining how the therapist will respond. If the therapist passes the test, they gain a lot of relationship credit; however, if the therapist fails the test, the client may abandon the therapy. Thus, tests are, in a sense, acid tests for the therapy, and a therapist should know what kind of tests may lie ahead, and how they can be dealt with.
2.7 Problems Encountered by Therapists
The consequences of some client characteristics are typical problems for therapists: To start with, clients with PD show no desire to change: They do not regard their behavior as problematic and do not intend to change their structures (such as schematas, manipulations etc.). Clients are, however, often motivated to try to stabilize themselves: They access therapy to stabilize themselves with the help of the therapist, meaning they are undergoing therapy so that they need not change. Therapist often have trouble realizing this: because, on the one hand, the clients do not explain it and on the other, the therapist may not know how to analyze the client’s motivations during the process. Further, clients with PD are usually relationship motivated: They access therapy to get a certain kind of relationship. Due to their stabilization motivation and relationship motivation, they are indeed motivated for therapy, but they lack any motivation to refine their assumptions, motives, objectives, etc. If the therapist targets this refining effort, the client will very likely block the therapist, and clients have a number of strategies to systematically avoid refining and to systematically block the therapist. If the therapist does not know and understand those strategies, they will feel helpless and react angrily toward the client, and the therapist’s interventions will then exacerbate the problem. Generally, clients will not thematize their relationship issues; thus, it is hard for the therapist to conceptualize these |9|issues. The therapist will fail to understand that the client’s problem is not just panic or the like, but a massive interaction problem. Because therapists often fail to recognize the real problem and/or have no suitable interventions through which to make the problem clear, they feel helpless, blocked, and frustrated in the long term. As a result, the therapist will only concentrate on the problems and objectives the clients explicitly reports – for example, panic, addiction, somatization disorders, etc. The therapist then applies specific methods to treat these disorders and realizes that these do not work as they usually do (or do not work at all, they exacerbate the problem, new problems arise constantly, or the client does not use the approach at all). The therapist, who has only a limited conceptualization of the client’s problem, therefore does not understand these internal therapeutic problems. Even if the therapist realizes the client suffers from a PD, they often do not know which therapeutic approaches are necessary, due to the lack of specific know-how required for these clients. As a result, the clients very often cannot be helped effectively.
Clients with PD are not difficult patients just because they lack certain prerequisites which would be helpful for therapy. The main problem for the therapist is the client’s relationship issues which are brought into the therapy: The clients do not thematize or refine these issues, they act them out in therapy. As a consequence, the therapist, suddenly, without being able to prevent it and often without understanding it, goes from being part of the therapeutic team to being part of the problem.
For the development of an effective concept of therapy for clients with PD, it is therefore of crucial importance to provide the therapist with the means to deal with these interaction problems. Thus, an effective therapy for these clients must be one that is process-oriented as well as interaction-oriented.
|10|Chapter 3What Is Clarification-Oriented Psychotherapy?
3.1 Introduction
Since both the theory of PDs and the therapeutic strategies described here are based on a concept of therapy from COP, we would like to give a brief overview here of what is meant by COP. This will make the concepts presented easier to understand. COP is a psychologically well founded, highly empirically validated form of psychotherapy that pursues two major lines of approach.
One of these lines of approach relates to clarification: On the basis of a trustful therapist–client relationship actively established by the therapist, the real motives of the client that they are presently unaware of are clarified with a view to eliminating the client’s state of alienation. Further, clarification also aims at representing and clarifying dysfunctional client schemas that are co-determining the problems encountered.
The second major task of COP deals with processing and modifying these clarified schemas therapeutically, which enables the client to behave more constructively and flexibly during their daily routines, exhibit less or no disturbing symptoms, better face up to everyday situations both cognitively and affectively, thus leading to a more satisfied self-regulative life.
The key objective of COP focuses on (re)establishing functional self-regulation (Baumann & Kuhl, 2005). The client should be put in a position that enables them to access their motives, appropriately deal with situations, and take decisions that both comply with and face reality, and which are compatible with their motives. Moreover, the client should be able to process information and make decisions without disturbances caused by any dysfunctional schemas, symptoms, or unreasonable behavioral costs.
3.2 Aspects of Clarification-Oriented Psychotherapy
To accomplish the objectives listed in the previous section, COP comprises a number of subdomains that involve tasks therapists have to cope with and that require their expertise to be brought to bear in various different fields.
|11|3.2.1 Relationship Formation
One domain of expertise in COP concerns the therapist’s active and well-directed approach to establishing a relationship. For this purpose, a therapist can adopt strategies of general relationship formation or strategies of complementary relationship formation. By adopting these strategies, the therapists can build up a trustful therapist–client relationship that forms the basis for all clarification and processing work that follows (Sachse, 1995, 1999, 2006b).
A particularly important aspect of COP is the so-called complementary relationship formation. The concept of complementary relationship design was developed by Franz Caspar and Klaus Grawe (Caspar, 1996; Caspar & Grawe, 1982a, 1982b; Grawe & Caspar, 1984). In this context, it states that with respect to the client’s interactional plans, a coach should act in a complementary way – that is, satisfying the client’s needs. The concept is based on the assumption that people in their biographies learn interactional plans (Caspar, 1996) or interactional schemas (Soygüt, Nelson, & Safran, 2001), which they as clients bring into interaction and which strongly influence the relationship behavior of the clients toward the coach.
In COP, complementary relationship formation means that a therapist recognizes and reconstructs the client’s central motives for relationships and aligns the relationship formation in such a way that these motives are satisfied as much as possible within the framework of the therapeutic rules (for the therapeutic rules, see, e.g., the subsection No Complementarity at the Game Level, in Section 9.3.1).
Like the classic motives of seeking performance, power, and affiliation, relationship motives are “internal incitements” of behavior (Atkinson, 1964; Heckhausen, 1963). They are defined by subjective goals and subjective expectations: In this case, the goals are focused on certain types of relationships an interaction partner should realize. Here, we distinguish among appreciation, importance, solidarity, reliability, autonomy, and boundaries.
It can be assumed that people have fundamental motives for relationships which they seek to satisfy through their actions (Sachse, 1997a, 1999, 2001a, 2004a, 2013a; Sachse, Sachse, & Fasbender, 2010). These motives are elementary and positive. Satisfying them also has a positive effect on the client’s system: The client is contented and feels well treated and understood.
Significant relationship motives (described in more detail below) are
Appreciation
Importance
Dependability
Solidarity
Autonomy
Boundaries
These motives are not all equally important for all people. While appreciation is central to some, it is less important to others, and there are people to whom autonomy is extremely important, while solidarity is significant to others, and so on.
Therapists who want to act in a complementary manner must first find out which relationship motive is of central importance for the respective client and then try to act complementary to that relationship motive. The motive of seeking appreciation implies the need to receive positive feedback from other people about one’s own person. The motive of seeking importance implies the need to play a significant role in another person’s life and to receive signals |12|that saying one is a source of enrichment for another person. The motive of seeking a reliable relationship is the need to receive signals that a relationship is stable, lasting and predictable. The motive for seeking a collaborative relationship is a need to get help and support when you need it. The motive of seeking autonomy is the need (even in relationships) to be able to exist and be allowed to exist as an independent person, to be able to make and be allowed to make one’s own decisions, and to be able and allowed to have one’s own spheres of life. The motive of looking for safe boundaries is the need to define your own territory, one that has safe borders, and for which you can decide yourself who is allowed to enter it and who is not!
3.2.2 Confrontations
Clients, especially clients with PDs, often generate costs for their actions and behavior without realizing that they are responsible for those costs themselves: Accordingly, they have no motivation for change, because they see no reason to change themselves or their belief system. As described in Section 2.2, PDs must be understood as ego-syntonic disorders (and the model of dual action regulation also makes clear why this is the case; see Section 4.2). Thus, these are disorders that do not disturb the person who has them, which are not considered by the person to be problematic or needing to be changed. This means that clients who come into therapy with PDs are not motivated to change, because of their PD, and as a result, they have no concrete therapeutic goal with regard to this disorder: They do not want to work on changing their PD, and they do not demonstrate any compliance with the therapist’s corresponding interventions. Without a therapeutic goal, however, a therapist cannot work on changing a disorder at all: Without a therapeutic goal, there is no meaningful therapy.
Therefore, if you want to work on changing a PD, you must first create a therapeutic goal (a motivation to change).
If clients want to take the trouble (and it is one!) to clarify and modify their system, then they urgently need to develop a therapeutic goal – that is, they need to build up a motivation for change with regard to aspects of the PD.
But they can only do this when they realize
that there are high costs, especially high interactional costs;
that they really do not want to incur these costs, which massively contradict important motives;
that they generate these costs themselves through their actions and behavior and ultimately through their own goals, assumptions, and strategies;
that they can substantially reduce their costs by changing these objectives, assumptions, and strategies;
that they can do this with the help of the therapist.
However, this is precisely what clients with PDs do not recognize on their own initiative (as the model of dual action regulation makes clear; see Section 4.2), rather this knowledge must be actively conveyed to them by the therapist. This means that a therapeutic goal is not a prerequisite for a therapy, but rather the second objective in therapy (the first being the development of relationship credit). And the second phase of the therapy serves to achieve this second therapy goal. In that second phase, the client has to build up a motivation for change and develop a therapeutic goal through the therapist’s interventions.
|13|To do this, the therapist must make it clear to the clients through appropriate interventions:
that they are actually incurring costs;
that they do not want these costs;
that they generate these costs themselves through schemas, etc.;
that they can reduce these costs by changing the schemas, etc.;
that they can do this in therapy with the therapist.
However, the therapist must make all this clear to the client, because the client will hardly be able to see this for themselves: In the case of clients with PDs, therapeutic goals do not arise automatically or on their own, but only through a targeted approach realized by the therapist! Clients with PDs recognize that they are incurring costs, but the fact that they generate those costs themselves is hardly recognizable at all due to the ego-syntony of their disorder.
All of this makes it very clear that the therapist’s task is to communicate these insights to the client, so it depends crucially on the therapist’s interventions whether a client develops a motivation for change and a therapeutic goal, or not.
If one looks at these tasks the therapist has to accomplish, it becomes clear that the therapist via their interventions must draw the client’s attention to aspects of their disorder which the client does not recognize and does not want to recognize (according to the dual action regulation model; see Section 4.2) but rather strongly wants to avoid. Therefore, this makes it clear that all interventions that a therapist can carry out here are, by definition, confrontational interventions and therefore all these interventions result in a loss of relationship credit. A therapist who carries out such confrontational interventions must have sufficient relationship credit to be able to afford such strategies. If they make such interventions without adequate relationship credit, they can badly endanger the therapist–client relationship.
Even attracting the client’s attention to costs they are incurring can be confrontational, but making it clear to the client that they generate those costs through their own actions and behavior, in particular through their own manipulative actions, is very likely to be highly confrontational: Because clients usually do not want to be exposed at this point in particular, and usually react highly aversively when someone tries to makes this a topic of discussion.
It follows, therefore, that all interventions and strategies that serve to make the disorder ego-dystonic and create a motivation for change are very likely to be confrontational.
Confrontational interventions are necessary, for without such interventions, the disorder will not become ego-dystonic, and clients will be unable to develop any motivation to change.
So, therapy cannot be limited to the creation of relationship credits. It must always use the relationship credits to carry out confrontational interventions.
Confrontational interventions are the second essential therapeutic element in therapy with PD clients.
3.2.3 Clarification of Dysfunctional Schemas
Clarification – that is, the conscious and valid representation of dysfunctional schemas, is the central part of COP. From the perspective of COP, many problems are caused by the fact that clients develop dysfunctional schemas in their biographies – that is, certain assumptions (or |14|basic beliefs) that are unfavorable and result in costs that are incurred by the client. People make a number of assumptions: assumptions about reality, assumptions about themselves, assumptions about relationships, etc. Some of these assumptions are realistic, derived from experience, and withstand everyday testing (empirical tests). But many assumptions are not realistic; they do not reflect reality well, or they are wrong. They do not stand up to examination, but unfortunately, they are no longer examined by the client; they are believed. And some assumptions are unfavorable and lead to problems, including misinterpretation of situations, giving rise to making unfavorable decisions, causing disturbing emotions, etc.
It is precisely these problem-causing or problem-determining assumptions that are tackled in COP. That involves identifying, clarifying, and changing them (Sachse, 1996, 2003, 2005, 2008a; Sachse, Breil, & Fasbender, 2009; Sachse, Breil, Fasbender, Püschel, & Sachse, 2009; Sachse & Fasbender, 2010, 2014; Sachse, Fasbender, & Breil, 2009).
Unfortunately, however, people do not retain assumptions in the same way as normal memories. Rather, assumptions form schemas, and in addition to their contents (i.e., the assumptions), there are also other important psychological characteristics of the schemas (Beck, 1979; Herrmann, 1965; Norman, 1982; Piaget, 1954; Power & Dalgleish, 1997; Rumelhart, 1980; Sachse, 2014c; Teasdale & Barnard, 1993). Schemas are automatically activated (triggered) by situations (i.e., in a bottom-up manner) – and once activated, they have a strong influence on the processing of information (top-down). Therefore, the assumptions underlying schemas will to a large extent determine current interpretations of situations and thus emotions, actions, and behavior.
If the schemas contain unfavorable (i.e., dysfunctional) assumptions, then the schemas lead to wrong and problematic interpretations of situations and thus to problematic actions and emotions. In that case, it is important
to identify and make clear that schemas are involved in a problem;
to elaborate these schemas and their contents (the assumptions) – that is, to clarify them exactly;
to work on and change these schemas.
However, everyday experience, therapy experiences, and process research studies now show that people cannot clarify (i.e., name or express in speech) large parts of their schemas without therapeutic help. Often they can name only some assumptions or indicate them in response to questionnaires, while, underlying, deeper assumptions are no longer accessible to them.
Process research studies have shown
that it is very difficult for clients to clarify schemas;
that clients need special support from therapists;
that therapists need special therapeutic techniques to encourage clarification;
that clarification processes still take time
(Sachse, 1988, 1990a, 1990b, 1990c, 1991a, 1991b, 1992a, 1992b, 1992c).
In schemas, it is possible to differentiate between contents and function: Each schema has a specific content – for example, a structure of certain assumptions – and these contents make the schema specific. These include assumptions such as: “I’m a failure,” “I’m unattractive,” “in relationships you are not taken seriously,” “I have to be the best,” and so on. And, each schema has psychological functions – for example, it is automatically activated by stimuli and it then controls information processing, etc. (Sachse, 1992a, 2003).
Schemas are activated (triggered) by activating stimuli (bottom up), and then they control a person’s information processing (top down). Schemas can influence all types of information processing: interpretations of situations, interpretations of personal relevance, coping skills, etc.
|15|Furthermore, schemas must be acknowledged to have a filtering function: They either let all the information pass through, or they reinforce those pieces of information that are consistent or compatible with the contents of the schema.
We distinguish among four types of schemas (Sachse, Breil, Fasbender, Püschel ,& Sachse, 2009; Sachse, Fasbender, Breil, & Sachse, 2011; Sachse, Püschel et al., 2008):
Two types of dysfunctional schemas:
Self-schemas
Relationship schemas
Two types of compensatory schemas:
Normative schemas
Rule schemas
We assume that a client is often unaware of the assumptions of a schema, or they are not completely clear to them, or they are not able to express them well, or that they cannot grasp them precisely. Although the schema contents are in a cognitive code, the client cannot express the contents in speech, at least not exactly, or precisely, or validly. Rather, it is necessary to translate schema contents into language, and express them in accurate and valid formulations, to communicate the contents during the therapy process so that the contents can be fully understood by the client, so the contents can be checked for coherence and problem relevance, and so the contents can be questioned, checked, and refuted if necessary, using cognitive techniques.
The conversion (or translation) of (rather implicit) schema contents into explicit verbal statements is what we call clarification or explication, and the process is called the clarification or explication process.
In this context, we assume that
The clarification or explication process is implemented by the client and must be implemented by them: Only the client has access to their schemas, and only the client can translate implicit meanings into explicit meanings in a coherent way.
The clarification or explication process must, however, be guided or controlled by a therapist through appropriate interventions.
That client and therapist work together on the clarification process: The client as an expert regarding the contents and the therapist as an expert in the process.
(Sachse, 1984, 1986a, 1986b, 1987, 1990a, 1990b, 1990c, 1991a, 1991b, 2003, 2008a; Sachse, Fasbender, & Breil, 2009).
At the content level, one can distinguish between five subprocesses of the clarification process (Sachse, Fasbender, & Breil, 2009):
no problems in focus;
intellectualization;
aloof reporting;
concrete reporting;
explication.
No problems in focus: The client concentrates on contents that do not personally affect them or that do not touch their problems. The topics they raise have nothing to do with them or their problems. The client thus implicitly follows the guiding question (i.e., the question steers the client within the therapeutic framework): Which topics can I use to avoid addressing my problems?
Intellectualization: Although the client has their own problems in focus, they think mainly about how they can be rationalized – that is, they search for (psychological or other) theories |16|that can explain away their problems (though the theories do not do that). The client thus implicitly follows the leading question: How can I rationalize my problems?
Abstract reporting: The client describes aspects of a problem, but does so in an unspecified, general, or abstract way, without reference to concrete problem situations. The client thus implicitly follows the leading question: What are my problems in general?
Concrete reporting: The client describes their problems and identifies them with concrete, relevant situations that illustrate their problem in a characteristic manner. The client thus follows the implicit leading question: In which situations do my problems manifest themselves and how?
Explication: The client works on the clarification of current processing processes triggered by a situation and on the clarification of their schemas. The client follows the leading questions: What situations trigger a particular schema for me? Why do those situations trigger exactly that schema in me?
All of these processes, which can be defined in terms of contents, are based on two essential psychological functions:
the perspective the client adopts in each case;
the processing mode the client uses to process information.
The individual processes of the explication process can also be understood as steps in the process, and these steps follow each other logically, are subject-related, and thus provide an ordered sequence of explication processes (see Figure 1).
Figure 1 The steps in the explication process.
In this way, a differentiation can be made between a preexplication phase and an explication phase, which follow each other and together form the entire explication process.
Based on the results of the process research studies mentioned above, we have to assume the following:
Different clients enter the explication process at different points: Some in intellectualization step, others in the concrete reporting step, etc.
All clients enter the process at one of the steps in the preexplication phase.
All clients have to go through the steps of concrete reporting and focus on the situation.
|17|A client indicates which of these process steps they are at, by the specific statements they make in the therapy process: We call that their current processing mode.
In the explication process, a client passes through the steps from top to bottom, and therefore we call each further step toward reconstruction, a deepening of the processing mode. If a client remains at the same level of the process with two successive client statements, we call this remaining at a constant level of processing mode. If the client moves from one client statement to the next away from the step of reconstruction (upwards), we call this a flattening of the processing mode.
As the process research results clearly show, therapists must control or guide the client’s explication process. They thus encourage the client to deepen their processing mode with the help of certain types of interventions.
The inducement which a therapist offers for making an intervention, we call a processing proposal (PP): The therapist makes a suggestion to the client of what the client should do, and which direction-setting question the client should follow.
Analogous to the definition on the client side, therapists can now choose
to make deepening PPs;
to make constant-level PPs;
to pursue (but unfortunately, also) flattening PPs.
The process research study results consistently show that therapists with their PPs have a strong influence on the explication process for clients.
Both the empirical results and our therapeutic experience show very clearly that therapists have to support clients in their clarification process very actively. Therapists have to be process-directive; therapists have to stimulate and incite processes, keep them running, raise questions, and guide clients back to the topic or subject and the process, etc. And therapists have to control the clarification process step by step. They have to know at which clarification step (in which subprocess) the client is at the moment, and then they have to try to bring the client into the next subprocess – that is, encourage the client to go to the next clarification step. In this way, the therapist guides the client from step to step until a reconstruction of relevant schema elements is achieved.
In practice, empirical study results and practical experience show that the progress accomplished is not linear, but if the client is at level X, several attempts by the therapist may be needed to take the client to the next level, and more often than not, clients do not remain on one level, but fall back to a lower level by themselves. Thus, it is a laborious undertaking to lead clients to a constructive clarification process. Therapists have to carry out interventions (as we say, make PPs) again and again, to help clients through the process and keep them involved in the process.
Therapists should in any case make PPs with a view to guiding the client’s process effectively. But they should also make the appropriate offers. This means that they must make different interventions – make different types of deepening PPs – depending on the phase (subprocess) in which the client is in each case.
3.2.4 Therapeutic Processing of Dysfunctional Schemas
If relevant schemas have been sufficiently clarified, they must be systematically worked on therapeutically. They must be disputed, refuted, and thus inhibited, and alternative functional schemas must be developed. COP uses the so-called one-person role play (OPRP; German: ein-personen-rollenspiel, EPR) for this purpose.
|18|OPRP is a therapy technique in which a client is instructed to act as their own therapist and in that role to question, dispute, and debate dysfunctional schemas, and develop alternative assumptions (see Sachse, Püschel, Fasbender, & Breil, 2008). In the sense of this used by Grawe, the procedure serves the purpose of schema processing, schema clarification, resource activation, and the motivation of clients (Grawe, Donati, & Bernauer, 1994). OPRP is a therapeutic framework within which a therapist can implement different techniques, in particular:
different cognitive intervention techniques for the processing of cognitive schemas;
different affective techniques for processing affective schemas;
different motivational techniques to increase the change motivation of the clients.
The method can thus always be used in a meaningful way
if cognitive and/or affective schemas contribute significantly to a client’s problem (e.g., in the case of depression, anxiety, or PDs);
when it comes to significantly strengthening the motivation to change of clients.
In OPRP, the therapist defines two positions for the client:
Client position (CP): Client as client.
Therapist position (TP): Client as their own therapist.
To make both positions apparent to the client and to make it easier for the client to move from one position to the other, the therapist arranges two chairs opposite each other (so that two persons sitting opposite to each other can look at each other) and defines on each chair one of the positions for the client. The therapist places their own chair at right angles to the two chairs.
The spatial separation of the two client positions with the help of the two chairs is advantageous because clients often have difficulty, especially at the beginning, to adopt a different perspective and to step out of their accustomed frame of reference. The spatial separation of these two positions makes it easier for the client to distance themselves from their own belief system and bring about a mental and spiritual change of position Thus, changing the chair serves to help the client,
to differentiate between aspects of their disorder;
to distance themselves from their own assumptions;
to adopt new perspectives consistently and thoroughly;
to rethink these new perspectives, and in this context activate memories as a consequence;
to try to believe these positions, to play with them, and let them have an effect on themselves.
OPRP proceeds in a series of three steps (with the therapist taking the role of “supervisor”):
First step: The client sits in the client’s position (CP) and expresses the dysfunctional assumption.
Second step:
