Cognitive Therapy of Personality Disorders
Chapter 1
Overview of cognitive-behavioural therapy of personality disorders

Introduction

According to the Big Five model, human personality is composed of five factors: openness, conscientiousness, extraversion, agreeableness and neuroticism.

Each factor includes a variety of more specific personality traits.

The cognitive-behavioural approach to personality disorders

The cognitive-behavioural therapy (CBT) framework/paradigm has a set of interrelated theoretical principles.

Among CBT psychological treatments there are 1) acceptance and commitment therapy 2) dialectic behaviour therapy 3) schema therapy 4) cognitive therapy 5) rational-emotive behaviour therapy.

CBT theoretical foundations

CBT doesn’t treat personality disorder symptoms as an expression of an underlying illness, but as learned human responses to specific or general stimuli. The cognitive component is often prompted as a preliminary ‘cause’ of the disorder. This doesn’t mean that the causality is unidirectional. Al types of responses are strongly interrelated, forming a multidimensional interactive psychological structure.

The general ABC model of CBT is: 1) A, activating event, whether external and/or internal   2) B, beliefs 3) C, consequences: emotional, behavioural and psychophysiological.

Once generated, a consequence can become a new activating event, thus further priming metabeliefs/secondary beliefs that generate metaconsequences/secondary consequences.

Cold cognitions are descriptions of reality and the individual’s interpretations/inferences. Hot cognitions refer to how we evaluate/appraise these descriptions and inferences about reality. Both can be more surface beliefs or core beliefs.

The sequence of CT typically focuses first on automatic thoughts and later on core beliefs. At some point, CT focuses on activating events by problem-solving strategies and/or on the consequences of the beliefs by behavioural and/or coping techniques. The interactive nature of the core elements is different for each individual.

REBT focuses on altering dysfunctional consequences by changing irrational beliefs first and then, on changing cold cognitions. The process is first focuses on the surface beliefs in forms of specific irrational self-statements and later on general irrational core beliefs. After the cognitive restructuring process, REBT would focus on the other components.

Integrative multimodal CBT framework

According to the integrative and multimodal CBT framework, there are two types of core beliefs 1) Related to core cognitions, the general core beliefs coded in the human mind as general schemas 2) Hot cognitions, general irrational core beliefs coded in the mind as evaluative schemas.

These cold and hot beliefs could come into our conscious mind in a mixed way. Various core beliefs interact to bias the information processing of events, thus generating specific automatic thoughts that lead to dysfunctional consequences.

Automatic thoughts may come to our conscious mind unintentionally and are typically related to the activating events.

The source of core beliefs is related to both environment/education and biological predisposition.

The coping mechanisms are the regular cognitive and behavioural processes that have different function, to help us cope with various feelings and experiences.

Unconscious information processing is a kind of structural cognitive unconscious, containing information coded in formats that are not usually consciously accessible. It can generate dysfunctional consequences directly and indirectly. It is embedded in the nonconscious, automatic core brain structures and cannot be directly changed on the sole bases of classical cognitive restructuring techniques. Behavioural techniques can modify this.

CBT applications to personality disorders

In the case of personality disorders, the main etiopathogenetic mechanisms should be related to our core beliefs, which are shaped through key developmental experiences and some of which might be based on biological predispositions.

The CT model is mainly focused on the cold general core beliefs and the mechanisms to cope with them. One can see the issue as one of the individual’s interpretations or parenthetic views. Focusing on altering the initial idea or core belief can be a fruitless goal. The therapeutic focus is on considering the meaning embedded in the belief, and how it impacts an individual’s adaptive functions.

REBT is mainly focused on general irrational core beliefs and their interaction to one another and on their role in the primary and secondary consequences.

Key features of the CBT clinical intervention

The CBT intervention for personality disorders typically includes: clinical assessment, cognitive conceptualization, technical interventions and building and using the therapeutic relationship.

The CBT intervention for personality disorders is typically longer than the CBT intervention for other clinical conditions and often includes more experiential techniques, creating a multimodel approach . The interventions could be delivered individually or in group.

The therapeutic relationship is characterized by collaboration, congruence, empathy and genuineness. For personality disorders the relationship must often be used as a vehicle for change, and as a modelling procedure. It is often used to generate strong experiences during and subsequent to the session related to the patient’s past experiences or current life experiences.

Empirical support for CBT in the treatment of personality disorders

Psychotherapy and personality disorders

There is strong support for the use of psychotherapy for personality disorders in terms of efficacy and effectiveness.

CBT psychological treatments for personality disorders

Systematic CBT psychological treatments

DBT has a clear theoretical model and techniques consistent with this model. It has been well validated mainly for borderline personality disorder.

ST has a clear theoretical model and techniques consistent with this model. It is effective.

CT, together with REBT, is the foundational approach of the CBT framework. Several CT-oriented psychological treatments were specifically developed for personality disorders.