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International Journal of Behavioral Consultation and TherapyVolume 1, No. 1, 2005A Review and Empirical Comparison of Two Treatments forAdolescent Males With Conduct and Personality Disorder:Mode Deactivation Therapy and Cognitive Behavior TherapyJack A. ApscheChristopher K. BassJerry L. Jennings,Alexander M. SivThis research study compared the efficacy of two treatment methodologies for adolescent males inresidential treatment with conduct disorders and/or personality dysfunctions and documented problemswith physical and sexual aggression. The results showed that Mode Deactivation Therapy, an advancedform of cognitive behavioral therapy based on Beck’s theory of modes, was superior to CognitiveBehavioral Therapy in reducing both physical and sexual aggression. At the same time, Mode DeactivationTherapy was the only treatment of the three that significantly reduced sexual aggression for these youth.The results also showed that MDT was superior to CBT in reducing external and internal psychologicaldistress as measured by DSMD and CBCL.Keywords: CBT, MDT, Conduct Disorder, AggressionAdolescents with conduct disorders and personality traits have proven to beextremely difficult to conceptualize and treat effectively. Many of these youth typicallycome from deprived environments with multiple stressors and often extensive histories ofphysical, emotional and sexual victimization and neglect. As a group, conduct disorderedyouth present with an complex array of recurrent behavioral problems, includingaggression, bullying, violence, intimidation, delinquency, rule violations, recklessness,property destruction, callous disregard for others, substance abuse, sexual abuse and otherdisruptive and anti-social behaviors (Kazdin and Weisz, 2003). In fact, the prevalencerate for conduct disorder is 6% to 16% for males under age 18 and it is one of the mostfrequent problems diagnosed in outpatient and inpatient mental health programs.Moreover, 80% of these youth are likely to meet criteria for psychiatric disorders in thefuture (Kazdin and Weisz, 2003). For example, a longitudinal study by Johnson, Cohen,Brown, Smailes, and Bernstein (1999) showed a clear connection between childhoodmaltreatment and the development of cluster B personality disorders in later adolescence.Moreover, conduct disorder is by far the most frequent psychiatric diagnosis given toyouth involved in the juvenile justice system with rates as high as 81% to 91% ofincarcerated youth (Boesky, 2002).Dodge, Lochman, Harnish, Bates and Petti (1997) have contributed a usefuldistinction between two types of conduct disordered youth: “Reactive aggressive” youthshow extremely strong emotional responses to perceived threats and then reactaggressively. The second type, “proactive aggressive” youth, initiate or use violence andaggression in an instrumental fashion to gain an objective or “pay-off.” The formercategory appear to share a common characteristic pattern of “emotional dysregulation,” inwhich the youth is overwhelmed by a sudden surges of intense emotions, sensations andirrational thoughts that are occur in combination and are disproportionate to the situation.27

International Journal of Behavioral Consultation and TherapyVolume 1, No. 1, 2005Koenigsberg, Harvey, Mitropoulou, Antonia, Goodman, Silverman, Serby, Schopick andSiever (2001) found that many types of aggression, including self-destructive behavior,are linked to the personality disordered traits of affective instability and impulsivity (i.e.,emotional dysregulation). Our research and clinical experience with violent and sexuallyaggressive youth suggests that this common phenomenon of “emotional dysregulation” isthe same process that Aaron Beck (1996) has described as “modes” and that treatmentmust be modified to accommodate and address this process in order to be effective.Need for Effective TreatmentGiven the prevalence of conduct disorders and its major contribution to juvenilecrime, societal violence, delinquency and sexual violence, there is a urgent need foreffective treatment methods for such youth. While Kazdin and Weisz (2003) delineatessome evidence-based treatment practices for children with Conduct Disorder, the samehas been not achieved for adolescents over 14 years old. In recent years, MultisystemicTreatment has shown promise for antisocial youth (Henggeler, Schoenwald, Borduin,Rowland and Cunningham, 1998) and for adolescent sex offenders (Swenson, Henggeler,Schoenwald, Kaufman, and Randall, 1998), but it requires a resource-rich combination ofservices, one of which is psychotherapy, and it is not a realistic option for most suchyouth. Cognitive behavioral therapy (CBT) is widely employed in the treatmentprograms for behaviorally disordered youth across many settings and is frequently usedwith aggressive youth and adolescent sex offenders. But there are clear limits to theeffectiveness of CBT in the treatment of personality disordered clients, especiallyborderline and narcissistic types (e.g., Young, Klosko and Weishaar, 2003).Apsche and his colleagues developed an advanced form of cognitive behavioraltreatment called “Mode Deactivation Therapy” (Apsche and Ward Bailey, 2004a) inorder to simultaneously address the multiple problems issues of conduct- and personalitydisordered youth, while also accommodating the particular defensive characteristics ofthe adolescent. Mode Deactivation Therapy (MDT) has been applied to adolescent sexoffenders and mentally ill adolescents alike. MDT is an evidence-based treatment thatblends key elements from Beck’s theory of “modes” (Beck, 1996); traditional CognitiveBehavioral Therapy and Schema Therapy (Alford and Beck, 1997; Beck and Freeman,1990); Dialectical Behavior Therapy (Linehan, 1993); and Functional Analytic BehaviorTherapy (Kohlenberg and Tsai, 1993; Nezu, Nezu, Friedman and Haynes, 1998).Beck’s Theory of “Modes”Recognizing that his earlier model of cognitive schemas was inadequate toexplain a number of psychological problems, Beck (1996) introduced the concept of“modes” in his article, “Beyond belief: A theory of modes, personality andpsychopathology.” Beck conceives of “modes” as sub-organizations of the personality,which are comprised of integrated networks of cognitive, affective, motivational andbehavioral components, that have developed through experience as an “automatic”response to particular types of situations, notably perceived threats (Beck, 1996; Apsche,2004). Thus, modes are consistent, coordinated, self-protective response systems for an28

International Journal of Behavioral Consultation and TherapyVolume 1, No. 1, 2005individual, which are controlled by schema. Moreover, modes are charged (or“cathected”) such that some schemas are more intensive and powerful than others indriving responses to perceived threat.In Beck’s theory, when an individual is faced with a perceived danger or potentialthreat, his orienting schema can activate a dysfunctional “mode” with all its simultaneousaspects – a particular conglomerate of beliefs, emotions, motivation, and behavior(Apsche, 2004). Dysfunctional modes are typically characterized by high levels ofanxiety, fear, irrational thoughts and feelings, and aberrant behaviors. Further, “modes”are self-reinforcing and maintained by a group of fundamental beliefs. For thispopulation, individuals have developed maladaptive orienting schemas and modes asprotective strategies in response to their traumatic and abusive life experiences.Originally these modes were useful survival strategies that protected the individual fromdistress and threat, but they have become ingrained, virtually automatic, maladaptiveresponses.As repeated victims of various trauma, neglect and abuse, these youth are ultrasensitive to learned experiential cues, often unconscious, that signal danger andvulnerability. Alford and Beck (1997) refer to this phenomenon in describing how theschema that typify personality disorders operate on a more continuous basis and are moresensitive to triggering events. Hence, such individuals are always ready to defend and/orattack at the first sign of perceived danger. In short, when faced with a perceived risk ofvictimization/vulnerability, such individuals are unable to override the primal, automatic“mode” response by employing cognitive controls because they are instantaneouslyflooded with powerful feelings, sensations and fear.Mode Deactivation Therapy (MDT)Mode Deactivation Therapy is designed to disrupt (“de-activate”) the preestablished maladaptive cognitive/affective/motivational/behavioral response set(“mode”) that is automatically triggered by the situational occurrence of the orientingschema. For example, a youth has the orienting schema that, “You can’t trust anyonebecause you will be betrayed” and he is in the situation of developing more closenesswith a peer or staff person in the treatment program. For this youth, his orienting schemawould trigger a maladaptive “mode” in which the youth may become anxious, haveintense physiological sensations, have paranoid thoughts that the person is “out to getme” and start to withdraw or act aggressively.Apsche and his colleagues in numerous studies have repeatedly found thattraditional cognitive behavioral therapy was not adequate to the instantaneous, primal andextremely powerful effects of maladaptive “modes” with conduct disordered andpersonality disordered adolescents. Similarly, in using CBT with Axis II disorders,Young, Klosko and Weishaar (2003) found that personality-disordered clients, especiallyborderline and narcissistic, continue to experience significant emotional distressfollowing treatment. Apsche observed that most aggressive and sexually aggressiveyouth tend to lose control with such sudden primal intensity that they are unable to29

International Journal of Behavioral Consultation and TherapyVolume 1, No. 1, 2005tolerate the traditional procedures of cognitive restructuring. Moreover, cognitivebehavioral therapy itself needed to be modified to accommodate the adolescent’s naturaldevelopmental sensitivities to resisting authority in the therapeutic relationship.Consequently, Apsche and his colleagues blended methods from three proventreatment models – Cognitive Behavioral Therapy, Dialectical Behavior Therapy, andFunctional Analytic Behavioral Therapy – to create an advanced form of cognitivebehavioral therapy called “Mode Deactivation Therapy” (MDT).Elements from Cognitive Behavioral Therapy: As described above, the term“mode de-activation” itself derives from Beck’s (1996) term “modes” and uses hiscognitive behavioral theoretical formulation of “modes.” MDT shares the basic tenets ofclassic cognitive behavior therapy, including “Schema Therapy,” which holds thatinternal schemas are at the core of the personality disorders (Young, Klosko andWeishaar, 2003). MDT agrees that aberrant behavior derives from dysfunctional schemathat trigger “modes,” but it takes a radically different approach to correcting suchschema. Unlike cognitive therapy, MDT does not directly challenge the irrationality ofthe orienting schema by “arguing” the concepts of cognitive distortions. Even when thetherapist has a good rapport, such youth are acutely sensitive to the power dynamic ofbeing in a one-down position. Given their histories of victimization, they typically haveserious difficulties with interpersonal trust. Challenging the reality of a youth’s beliefsand perceptions is negatively experienced as an attack on his esteem, his world-view andhis fragile sense of self. Developmentally, such youth perceive the cognitive therapist asanother adult trying to impose their authority and force him to change. Adolescentsbristle and respond poorly to direct cognitive corrections – even when such interventionsseem to be delivered in the most gentle and collaborative fashion. Cognitive therapythen, as it is normally practiced, can trigger a negative response that undermines progress(Apsche and Ward Bailey, 2004a).Elements from Dialectical Behavior Therapy: To accommodate thisdevelopmental and clinical barrier to traditional cognitive therapy, MDT uses two keyprinciples from Dialectical Behavior Therapy (Linehan, 1993), which was originallydeveloped to treat extremely unstable and volatile patients with severe personalitydisorders. Dialectical Behavior Therapy (DBT) uses the technique of radical acceptancein which the therapist elucidates and validates the unique “truth” in each individual’sperceptions. Rather than directly challenging the validity or empirical support for theyouth’s beliefs and perceptions, MDT uses radical acceptance in fully validating the“grain of truth” of the individual adolescent’s beliefs based on his life experiences andtrauma history. The goal is to join with the youth in order to discover how the beliefsystem is a legitimate reflection of the youth’s life experience, relationships, sense of selfand world view. Subsequently, given radical acceptance and increased trust, the therapistcan use the therapeutic relationship as well as the youth’s direct experiences in thetreatment program to show how beliefs can be modified based on corrective therapeuticexperiences. MDT also adopts the technique of balancing from Dialectical BehaviorTherapy. This is an interactive method of introducing increasing flexibility or balance in30

International Journal of Behavioral Consultation and TherapyVolume 1, No. 1, 2005the individual’s rigid and maladaptive dichotomous (either/or) beliefs by redirecting theperson to considering a continuum of truth or a continuum of possibilities.Elements from Functional Analytic Behavioral Therapy: MDT alsoincorporates principles from Functional Analytic Behavioral Therapy (Kohlenberg andTsai, 1993). First, MDT aligns with FAB in affirming that perceptions of reality andunconscious motivations evolve from past contingencies of reinforcement, such asfamilies of origin. Second, MDT uses an assessment and Case Conceptualizati