Cognitive Therapy of Personality Disorders
Chapter 5
General principles and specialized techniques in cognitive therapy of personality disorders

Introduction

Patients with personality disorders frequently continue to perceive themselves or their experiences in problematic ways and may acknowledge that they have ‘always’ thought this way, even though they no longer feel as depressed or anxious as the disorder subsides.

The personality disorder mode differs from the symptom disorder mode in a variety of ways: 1) the frequency and intensity of dysfunctional automatic thoughts observed during the acute disorder level off when patients return to their regular cognitive functioning 2) Although the patients may have fewer dysfunctional automatic thoughts and feel less distressed overall, their exaggerated or distorted interpretations and the associated disruptive affect continue to occur in specific situations

The most plausible explanation for the difference between the syndromes and the personality disorders is that the extreme faulty beliefs and interpretations characteristic of the symptomatic disorders are relatively plastic. The more persistent dysfunctional beliefs of the personality disorder are structuralized, built into the ‘normal’ cognitive organization and embedded in primal schemas.

The dysfunctional beliefs remain operative because they form the substrate for patients’ orientation to reality. People rely on their beliefs to interpret events, so they cannot relinquish these beliefs until they have incorporated new adaptive beliefs and strategies to take their place.

When patients return to their premorbid level of functioning, they rely on their customary strategies, keeping the underlying beliefs activated through interconnected networks.

Data-based case conceptualization

Specific individual conceptualization that is data based and collaborative in nature is essential for understanding the patient’s maladaptive behaviour, selecting effective treatment strategies, and modifying dysfunctional attitudes.

The therapist should engage the patient early on in codeveloping a formulation to explain the nature and source of the patient’s difficulties. Much of the data will come from discussions about the patient’s current life situation, and the problems that precipitated treatment consultation. The therapist also gathers data about the patient’s general developmental history. Direct interaction with and observation of the patient in the course of consultation is also an important source of data.

In a therapeutic triad model, the therapist simultaneously integrated attention to the developmental narrative, current life problems, and the treatment relationship. Specific techniques will vary with the goals specific to the disorder and the person. The therapist can approach the work of conceptualization and intervention as a fluid movement among these spheres to assist the patient in identifying and modifying core schema.

The basic data needed for a cognitive conceptualization includes 1) core beliefs about self and others 2) one or two conditional assumptions and imperative beliefs 3) observations of underdeveloped and overdeveloped strategies (behaviour) 4) if relevant, any treatment-interfering beliefs and behaviours.

As new data are collected, the therapist modifies the formulation accordingly.

When therapists engage the patient in ongoing data gathering, they are providing a guide for the patient to learn how to isolate problem situations and to identify relevant thoughts and behaviours for a preliminary conceptualization, and make adjustments as needed.

Early on, the therapist carries much of the responsibility for advancing work, as treatment progresses, the patient acquires tools for sorting out complaints in terms of psychological and behavioural constructs, and applying strategies for change. Drawing diagrams for patients can show them how to fit experiences in the overall formulation.

The progression toward explicit mapping of core beliefs about self and others must be sensitive to the patient’s trust and ability to collaborate effectively.

The therapist can use the data that (s)he is collecting to extract patients’ self-concept, view of others, and the rules and formulas by which they live. Often, the therapist has to determine the patients’ self-concept from its manifestations in their descriptions across a variety of situations.

Similar statements can be linked to vastly different assumptions and core meaning. Schemas can overlap, so their characteristic beliefs and assumptions may reflect more than one of the typical cognitive profiles associated with different personality disorders. Asks follow-up questions about the meaning connected to the patient’s thoughts and self-appraisals.

The therapist can elicit the conditional assumptions through statements that specify the context under which the particular self-concept will express itself. Individuals with personality disorders, tend to apply expectations for relationships in an all-or-nothing fashion across all situations, even when there are alternative expectations or compelling evidence that is contradictory to this belief.

The therapist tries to elicit the patient’s views of other people. A consequent pattern of arbitrary conclusions reflects a cognitive bias and is said to be ‘schema driven’. These arbitrary conclusions trigger overdeveloped strategies or behaviours to cope with the emotions aroused by these beliefs.Overdeveloped strategies become more rigid over time, and function as safety behaviours, avoiding potentially disconfirming information and reinforcing the basic schema.

Specification of underlying goals

People generally have broad goals that are very important to them but may not be completely in their awareness. The therapist has the job of translating the patient’s stated aspirations and ambitions into the underlying goal. Observable patterns that are overdeveloped, as well as patterns that are underdeveloped are important.

Goals are derived from the core schema.

Emphasis on the therapist-patient relationship

Collaboration

One of the cardinal principles of cognitive therapy is instilling a sense of collaboration and trust in the patient. With acute distress, the patient can usually be motivated to try out the therapist’s suggestions and is rewarded by the fairly prompt reduction of suffering. In dealing with the scope of personality disorder, the changes take place much more slowly and the payoff is less perceptible. Therapist and patient have considerable work to do on the long-term project of personality change, and agreement to work together on these intrapersonal and interpersonal objectives is critical.

Beginnings are important for setting expectations in the working relationship. Patients with personality disorders often show difficulties in trust or collaboration as an early indicator of the scope of their problems. Therapists can review their use of the basic tools for fostering treatment to ensure they are providing optimal framework: 1) Proposing and securing the patient’s agreement to work on specific goals that are personally meaningful can enhance motivation 2) Brief psychoeducation on the cognitive model can help the patient become oriented and interested in the work, and perhaps reduce uncertainty concerning what will be asked of him or her 3) Outlining and following a general structure within sessions from the start creates familiarity and predictability and sets the tone for how the time will be used 4) During each session, the therapist checks on the patient’s understanding of information shared, concepts explained, or the purpose of activities suggested in session 5) They brainstorm or create homework together as much as possible 6) therapists offer positive feedback about patient strengths 7) The therapist seeks the patient’s feedback on the impact of the session and perceived usefulness f the therapist’s effort.

Patients with personality disorder frequently have problems collaborating on homework assignments. The therapist should regard these forms of ‘resistance’ as ‘grist for the mill’ and should subject them to the same kind of analysis as that used for other forms of material or data, without giving up on the collaboration. Structure, persistence, and creativity are tools that therapists might find useful in working these challenges.

Guided discovery

Part of the artistry of cognitive therapy consists of conveying as sense of adventure. A certain lightness and judicious use of humour can also add spice to the experience.

Throughout treatment of personality disorders, the therapist spends more time with patients on unravelling the meaning of experiences, to determine the patients’ specific sensitivities and vulnerabilities and ascertain what triggers them to overact to specific situations.

Determining the meaning involves looking back through the patient’s narrative history of his or her personal and psychological development and identifying key emotional experiences that support the believability of his or her maladaptive conclusions.

Use of ‘transference’ reactions

The patient’s emotional reactions to therapy and the therapist are of central concern. The therapist is ready to explore these reactions for more information about the patient’s system of thoughts and beliefs. If brought out into the open, they often provide rich material for understanding the meanings and beliefs behind the patient’s idiosyncratic or repetitious reactions. Empathically delivered interpersonal observations and feedback may be among the most powerful interventions that the therapist provides, especially when focused on interactions that occur within the therapeutic relationship. This must always be done in a supportive and honest way, inviting further exploration rather than delivering an expert interpretation.

It is important to remain nonjudgmental, compassionate, and warm, yet objective in responding to the patient’s maladaptive patterns.

Therapists can use standard methods or improvise new ones to meet specific patient needs. A certain amount of trial and error may be necessary.

The most effective application of techniques depends on a clear conceptualization of the case, the formulation of a friendly working relationship and on the artistry of the therapist. Skilful therapists know when to draw out sensitive material, draw back when necessary, and confront avoidances. Flexibility within a session is important.

Among the most effective tools in treating personality disorders are experiential techniques, such as reliving childhood events. Dramatic techniques seem to open up the sluices for new learning. Cognitive change depends on a certain level of affective arousal.

Cognitive, behavioural, and experiential techniques interact in the treatment of personality disorders. The main thrust is to develop new schemas and modify old ones, decreasing the valence of maladaptive modes and increasing the strength and availability of more adaptive modes.

Cognitive strategies and techniques

Some of the primary cognitive techniques that may be helpful in dealing with personality disorder are: 1) guided discovery, this enables the patient to recognize stereotyped dysfunctional patterns of interpretation 2) Psychoeduaction about cognitive processes and modes of thoughts, behaviour and normal goals and needs. 3) Thought records, worksheets, and/or in-session graphic depiction of cognitive connections. 4) Labelling inaccurate inferences or distortions, to make the patient aware of bias or unreasonableness of particular automatic patterns of thought. 5) Collaborative discovery, applying curiosity in the form of behavioural tests to help the patient assess the validity or practicality of his or her beliefs, interpretations and expectations 6) examining possible explanations for other people’s behaviour 7) scaling experiences on a continuum to translate extreme interpretations into dimensional terms and counteract typical dichotomous or catastrophic thinking 8) constructing pie charts of responsibilities for actions and outcomes to reduce attributions of overcontrol 9) brainstorming and articulating positive beliefs and options 10) examining data from schema diaries 11) defining ideas or constructs relevant to the patient’s self-concept or current situation to increase self-understanding, appreciation of multidimensionality, and self-acceptance 12) constructing coping cards to provide a memory prompt and ‘on-the-spot’ coaching of alternative interpretations when emotional distress occurs or in other targeted situations

Implementing ‘cognitive probes’

Cognitive probes are primary tools used in therapeutic discussion to bring attention to the cognitive underpinnings of emotionally arousing incidents.

If the patients fails to recover the automatic thought, (s)he might be encouraged to imagine the experience. If the patient can anticipate a particular ‘traumatic’ experience, it is useful to prepare in advance by starting to tune in to the train of thoughts prior to entering the aversive situation.

Of most importance is the ultimate meaning of the event.

Sometimes the patient is able to discern the chain reaction through introspection. Often, though skilful questioning, the therapist can arrive at the salient staring point (core schema). The therapist can use this exercise as a way of demonstrating the particular fallacy or flaw in the patient’s process of making inferences and drawing conclusions.

The arousal of a strong feeling suggests that a core schema has been exposed than that the dysfunctional thinking is more accessible to medication. This type of questioning, attempting to probe for deeper meanings and access to the core schema, has been called downward-arrow technique. At a later date, therapist and patient will want to explore further to ascertain whether there are other core schemas.

By exposing the core schema through the downward-arrow technique, the therapist is able to bring the underlying meanings to the surface and demonstrate that the belief is dysfunctional. Once the underlying beliefs are made accessible, the patient can then apply realistic, logical reasoning to modify them.

Labelling and modifying the schemas

The patient’s style can be translated into operational terms. A nonjudgmental description modified to fit the particular belief system can be offered to the patient. Therapists will need to use their judgment as to when and if to share the specific diagnostic category beyond establishing the specific problems in self-concept or relationship that are the focus of treatment.

The objective of cognitive therapy for personality disorders is schema modification and adaptive adjustment rather than striving for personality transformation. An overarching goal is to decrease the valence of dysfunctional schemas, and strengthen the availability of benevolent schemas.

Schematic reinterpretation involves helping patients to understand and reinterpret their schemas and strategies in more functional ways.

Making decisions

Joint work is required to help patients learn how to make certain important decisions that have been postponed initially.

When acute symptoms have subsided, therapy can focus on the more chronic or long-range problems. Decisions that seem to tie patients in knots, need to be tackled. The calculated procedures involved in making decisions are often blocked by the patients’ personality problems.

The therapist cannot treat the personality problems in a vacuum. The cognitive problems encroach on the way the individual is able to cope with real-life situations. New decision-making patterns can modify the personality styles of each disorder.

A method that helps people sort out their feelings about a key decision is to list the pros and cons for each option in separate columns. With the therapist’s assistance, the patient lists the advantages and disadvantages of each alternative and attempts to assign weights to each of these items.

Behavioural techniques

The goals of using behavioural techniques are threefold: 1) the patient may need to work directly to alter self-defeating behaviours 2) the patient may need support on building specific skills 3) behavioural assignments can be used as homework to gather new data for evaluating cognitions.

Behavioural techniques that can be helpful are: 1) activity logs, which permit retrospective identification and prospective planning of changes. 2) scheduling activities, to enhance personal efficacy in targeted areas 3) behavioural rehearsal, modelling and assertiveness training for skill development to respond more effectively in challenging or stressful situations 4) Relaxation training and behavioural redirection techniques 5) In vivo exposure 6) Graded task assignment, so that the patient can experience changes as an incremental step-by-step process, during which the difficulty of each component can be adjusted and mastery achieved in stages 7) behavioural change analysis to assist the patient braining down problem sequences and developing ideas for response alternatives at each stage 8) time and routine management 9) Stimulus control, or purposeful alteration of cues to prompt desired responses or behaviours, and create conditions that will discourage maladaptive behaviours 10) contingency management, to systematically link rewards or positive reinforcement with desired efforts , and decrease the benefits associated with maladaptive responses.

Experiential methods

A variety of activities can be used in session to create an experience that blends emotional components of schema with thoughts and behaviour, to assist in building skills, altering particularly resistant schema, or building practices that the patient can continue at home to identify and regulate emotions.

Patients vary in their willingness to engage in experiential exercises, and in specific needs for altering cognitions and overdeveloped or underdeveloped strategies. Patients who tend to be inhibited and constricted, who believe it is risky or inappropriate to let their feelings show, benefit from a gradual approach that supports greater flexibility in these inhibitory barriers. Those who tend to be more disinhibited, may need expressive exercises that help them contain and effectively direct their messages.

Role play

Role play may be used for skill development in interpersonal communications.

When the role play involves an emotionally charged topic, dysfunctional schemas usually are activated and available for modification.

In reverse role playing, the therapist can ‘model’ appropriate behaviour, and assist the patient in reflecting on the impact of their schemas and behavioural strategies.

Schema origins

Use of childhood material is often important in treating personality disorders. Recalling experiences and reviewing childhood material opens up windows for understanding the origins of maladaptive patterns. This approach can increase perspective and objectivity.

The main objective is to identify a pattern in the schema and to activate the potential for changing the pattern.

Schema dialogues

Role-play dialogues between different schema modes can be a very effective way to mobilize affect and produce ‘mutation’ of the schemas or core beliefs. Recreating 'pathogenic’ situations or key interactions of the developmental period often provides an opportunity to restructure attitudes that were formed during this period.

By role-playing a figure form the past, patients can see a ‘bad’ parent in more benign terms. They can start to feel empathy or compassion for the parents who traumatized them. They might see that they themselves were not and are not ‘bad’, but that they developed a fixed image of badness because their parents were upset and vented their anger on them. Patients can soften their own attitudes toward themselves.

To ‘reality test’ the validity of childhood-originated schemas, these beliefs have to be brought to the surface. A schema dialogue can help patients to see that their core views of themselves were not based on logic or reasoning, but were products of the parents’ unreasoning reactions.

Reexperiencing the episode facilitates the emergence of the dominant structures and makes them more accessible to modification.

Imagery

Imagery may be particularly useful for salient memories.

To modify the image, it is necessary to go back in time, and re-create the situation. When the interactions are brought back to life, the misconstruction is activated, and cognitive restructuring can occur.

Expressing emotion

Behaviorual exposures might be more effective for highly inhibited individuals when facilitated by practice in altering the physiology of their temperamental bias toward inhibition prior to exposure. This can be accomplished by activating the parasympathetic or safety system through various soothing and expressive exercises. The effect of such exercises is to reduce physiological signals of distress and defence mood that tend to automatically provoke negative responses from others, thus setting more optimal conditions for new learning and success in social interactions.

Emotionally inhibited, overcontrolled patients may benefit from assistance in breaking through their inhibitory barriers with behavioural rehearsal of emotional expressions in sessions. It is important to set a rationale for such practice that explains the notion of decreasing inhibition and defence modes, and conduct a debriefing of the patient’s thoughts and self-appraisals after the exercise.

Values clarification

Beliefs about meaning and purpose in life can be brought to conscious awareness in an emotionally charged way through personal values exercises. This can help strengthen adaptive modes, as well as provide a point of entry for loosening maladaptive schemas.

Attention focus

Personality disorders involve an inordinate amount of self-focused attention. Attention-based experiences that broaden awareness of detail and context facilitate a more reflective cognitive process.

Various mindfulness practices can help the patient to disengage from the ‘pull’ of train of thought.