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