We have clinically identified four major groups of beliefs of clients with personality disorders that interfere with their full engagement in and commitment to treatment. Sometimes they state these beliefs outright; more often, therapists need to use Socratic questioning when they observe clients engaging in relevant patterns of dysfunctional behavior in or between sessions. Clients may have beliefs primarily in one area or in any combination of the following four areas:
- Engaging in treatment
- Experiencing negative emotion
- Solving problems
- Getting better
The beliefs fall into the intermediate belief category of assumptions and can be understood as representing clients' concerns or fears or as the negative meaning they ascribe to their therapy experience. In terms of treatment engagement, for example, clients may believe:
If I engage in treatment, something bad will happen.
Or they may believe,
If I engage in treatment, it will mean something bad or negative.
If I engage in treatment...
I'll have to focus on my problems.
I'll find out that I've been at fault.
I'll have to do things I don't want to do.
I'll have to reveal my secrets.
my therapist will hurt me in some way.
Or they may attach an uncomfortable meaning to engagement:
If I fully engage in treatment, it will mean...
my therapist is strong and I'm weak.
my therapist is superior and I'm inferior.
my therapist is controlling me.
It would make sense, then, that clients who hold negative beliefs about engagement might display dysfunctional behavior such as continually saying, "I don't know," or choosing not to contribute to the agenda, or remaining guarded in providing information -- in short, failing to collaborate fully with their therapist.
Dysfunctional assumptions in the other categories will be described in future installments.