Introduction

The last 15 years have seen a rapid widening of therapeutic forces from the more specific anxiety disorders and other circumscribed problem areas that first occupied the behaviourists in the 1960s and 1970s to more complex problems such as depression, generalised anxiety, panic, hypochondriasis and so on. These developments owe much to the theoretical ideas of Beck (1976), which were originally applied to the treatment of depression (Rush et al., 1977), and which have now been found to be generalisable to the treatment of wider if not all psychiatric disorders. Whilst effective for many patients (see Hollon et al., 1992 for a review of outcome efficacy in depression and Chambless and Gillis, 1993 for a review of studies in anxiety), a significant proportion of patients do not respond to Cognitive-Behavioural Therapy (CBT), and much of the outcome variance is attributable only to unexplained and uncontrolled patient factors.

Along with the expansion of the range of problems treated there has been considerable recent interest focused on the ‘difficult patient’. Developments have also occurred both in what Teasdale and Fennell (1982) called ‘the delivery system’, the way the therapeutic ideas are taught and are practiced by the patient, and in the theoretical ideas themselves and in the processes of therapy.

The present discussion will concentrate on developments in theory and therapeutic practice, presenting two approaches: the work of J. E. Young on personality disorder, and Linehan's very original therapeutic system, Dialectical Behaviour Therapy (DBT).

Schema-focused therapy (J. E. Young)

The background to Young's work (Young 1990; Young and Klosko, 1993) was his experience of working with patients with some different characteristics than those who had responded well to short-term CBT. He began encountering a group of patients whose problems were less severe or acute, who described less functional impairment, but who made little or no progress in standard CBT. These patients tended to be diagnosed as having long-term personality problems and were characterised by cognitive rigidity (a failure of beliefs to be influenced by contrary evidence), the use of avoidance strategies (cognitive, behavioural and affective) and the prominence of interpersonal problems, such as repetitive inappropriate choices of partners, overreactions to problems within the relationship, and so on.