Part V

Treatment

17

Cognitive Behavioral Approaches

M. Zachary Rosenthal, Kristin P. Wyatt, and Kibby McMahon

Introduction

Cognitive and behavioral psychotherapies for the treatment of personality disorders have been developed and evaluated for over 30 years. Although some of the better established treatments are manualized interventions with specific brand names (e.g., dialectical behavior therapy; Linehan, 1993), others more generally have been labeled as cognitive, behavioral, or cognitive-behavioral. In this chapter, we refer collectively to these treatments as cognitive behavioral therapies (CBTs). Despite being commonly used to denote a particular kind of psychotherapeutic approach, cognitive behavioral therapy (CBT) is not a single or uniform treatment protocol for psychiatric disorders in general, or personality disorders specifically. Instead, the plural form of CBT (i.e., CBTs) refers to a family of interventions bound together by empirically supported principles of behavioral, emotional, and cognitive change grounded in learning theories and basic science. There are hundreds of randomized controlled trials using different CBT protocols to treat individuals across the lifespan, in different cultures and treatment settings, using varying formats (e.g., group, couples, and individual) and technologies (e.g., apps, virtual reality, telephone), and for a long list of specific psychiatric disorders. CBT is not one intervention. The family of CBTs form a class, type, or category of related treatments.

When conceptualized this way, CBTs for all psychiatric disorders refer to a group of interventions including traditional or so-called first-wave behavior therapies (e.g., those that discount the causative role of changing cognition and other private unobservable events, such as systematic desensitization; Wolpe, 1961), as well as second-wave (e.g., those that emphasize the importance of changes in the content of cognition as causative, such as cognitive therapy; Beck, 1991) and “third-wave” therapies (e.g., those that emphasize the importance of changing the context of how one experiences cognition and other private events, without relying on changing the content of such experiences, such as acceptance- and mindfulness-based therapies; Hayes, Strosahl, & Wilson, 1999, 2012; Linehan, 1993). There are important differences among the first, second, and third waves of CBTs. For example, traditional cognitive therapy is based on information processing theory, which asserts that cognitive schemas develop as a means of organizing experiences in normal cognitive development, and that such schemas will reflect key concepts of self and others, thereby influencing decisions and actions (Beck, 1991). Therapists using this approach help patients develop skills to identify and change maladaptive patterns of learned schemas and related behaviors. In contrast, interventions in acceptance and commitment therapy do not include direct skills training procedures to change cognition and behavior, but instead are designed to disrupt verbal relationships among stimuli through experiential learning (ACT, Hayes et al., 1999, 2012). Despite the particulars in the differences among CBT protocols, these approaches arguably are more similar than different, and can be considered together as a collection of modern or contemporary CBTs used across psychiatric disorders and other problems related to mental health.

In this chapter, we begin by providing a detailed overview of the CBTs that have been developed, manualized, and investigated for the treatment of individuals with personality disorders. These treatments have been variably labeled as empirically supported or evidence-based and have a specific brand name referring to a specific set of interventions. Accordingly, we refer to these as “branded” cognitive and behavioral treatments.

Unfortunately, there are very few branded CBTs for personality disorders. This could be due to a host of factors. Chief among them may be the lack of research that has been conducted to develop, evaluate, and disseminate psychotherapies for personality disorders. Such psychotherapy outcome research takes a long time and is expensive. However, this is not unique to CBTs and generally is true for the treatment of most mental health problems. Several additional considerations may help to explain why there are so few well-studied and established treatments for personality disorders in particular. Personality disorders are characterized by longstanding patterns of dysfunctional intra-personal and interpersonal behavior pervasive across contexts. Accordingly, it may take longer to treat patients diagnosed with personality disorders than those with many other conditions, irrespective of the treatment approach. Individuals with personality disorders commonly are diagnosed with other co-occurring disorders (e.g., such as anxiety, mood, and substance use disorders; Grant et al., 2005; Trull, Jahng, Tomko, Wood, & Sher, 2010) and are high utilizers of mental health resources (Bender et al., 2001), making it costly and difficult to develop treatment protocols for personality disorders that can be applied across co-occurring conditions. In addition, personality disorders and related interpersonal dysfunction are associated with poor response to traditional psychotherapies (for a discussion on this, see Beck, Davis, & Freeman, 2015). Taken together, a primary reason for so few well-studied treatments for personality disorders may be the prohibitive amount of time and costs associated with conducting such research.

In addition to there being a very small number of empirically supported manualized treatment protocols for personality disorders, the majority of rigorously conducted treatment outcome research has been restricted to borderline personality disorder (BPD). Put differently, there are several established CBTs for BPD, but little to no manualized CBT protocols with strong empirical support for other personality disorders. At the same time, clinicians using CBTs are faced with the challenge of treating patients across personality disorder diagnoses, even in the absence of clearly delineated specific CBT protocols. Whether it is patients meeting criteria for paranoid, narcissistic, obsessive-compulsive, or any other personality disorder diagnosis, across all three clusters of personality disorders, clinicians need guidance even in the absence of well-established branded treatment protocols.

Still another challenge for clinicians is the absence of well-established CBTs for patients who may not meet full criteria for a personality disorder diagnosis (or other diagnosis), but may have significant impairment and distress associated with chronic and enduring personality dysfunction. Indeed, the validity of personality disorders as categorical diagnoses may be called into question due to the heterogeneity of symptoms within diagnoses, the co-occurrence of personality disorders with other disorders, and the use of a polythetic diagnostic approach. Despite several decades of research and calls for the use of dimensional models of personality dysfunction, dimensional models of treating personality dysfunction have not taken hold in mainstream clinical practice. There are no well-established CBTs for transdiagnostic patients with personality dysfunction characterized by, for example, high emotional instability, low agreeableness, and low conscientiousness.

In sum, (a) there are few branded and well-studied CBTs for personality disorders, (b) the most well-studied of them are for BPD, and (c) clinicians using CBTs need guidance in how to treat patients across personality disorder diagnoses and those with personality dysfunction who do not meet full criteria for a diagnosis. Accordingly, after first reviewing branded CBTs in detail, we outline how clinicians can use empirically supported principles of change to formulate a flexible and personally-tailored cognitive behavioral treatment for patients across personality disorders and problems with personality dysfunction not meeting full diagnostic criteria for any specific personality disorder diagnosis.

Branded Cognitive and Behavioral Treatments for Personality Disorders

Within the family of contemporary CBTs, a few treatment protocols have been specifically developed for personality disorders. These treatments include dialectical behavior therapy, schema-focused therapy, and cognitive therapy for personality disorders. The following sections include an overview of these treatments, including their rationale and structure, and their supporting treatment outcome research.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT), originally a treatment for suicidal and self-injurious behavior and with more recent support for multiple problems beyond BPD (e.g., transdiagnostic emotion dysregulation, Neacsiu, Eberle, Kramer, Wiesmann, & Linehan, 2014; bipolar disorder, Goldstein et al., 2015), has become the gold-standard treatment for BPD. At its core, DBT is a combination of traditional behavior therapy and cognitive therapy interventions, contemplative mindfulness-based spiritual practices, and a dialectical philosophy (Linehan, 1993). Using dialectics, a flexible perspective of viewing the world that allows for synthesis of the valid aspects of seemingly opposite viewpoints, DBT synthesizes acceptance- and change-focused cognitive behavioral principles and interventions. Across behavioral, cognitive, emotional, and interpersonal areas of functioning, psychopathology in BPD is viewed as the cause or consequence of pervasive problems with emotion dysregulation. In DBT, symptoms of BPD are thought to develop over time from a reciprocal and recurrent transaction between a pervasively invalidating environment and biological systems underlying emotional sensitivity, reactivity, and delayed recovery following emotional arousal (biosocial theory, Linehan, 1993; for reviews of empirical support see Crowell, Beauchaine, & Linehan, 2009; Domes, Schulze, & Herpertz, 2009; Kaiser, Jacob, Domes, & Arntz, 2017; Rosenthal et al., 2008). Like a tennis match, the back and forth of biology and environment transactionally impact each other over time. From a DBT perspective, beginning early in life, biological systems underlying emotional arousal impact and are impacted by the social environment. At the same time, the environment influences these same biological systems. Over time and with pervasive invalidation of one’s private experiences, emotional functioning becomes impaired, changing how the environment responds to the individual, which, in turn, affects the underlying emotional systems regulating emotions, reciprocally impacting how behaviors are expressed in the environment, and so on.

DBT features four primary modes of treatment to target the multiple problems and skills deficits associated with emotion dysregulation: (1) individual therapy to maintain motivation in treatment and apply skills taught to clinically-relevant behavioral patterns, (2) group skills training to acquire new cognitive and behavioral skills, (3) telephone coaching to enhance the generalization of behavioral skills learned during group and individual therapy, and (4) therapist consultation team to treat the therapist and promote adherent application of DBT (Linehan, 1993).

In individual therapy, therapists use acceptance and change principles to hierarchically target: (1) life-threatening behaviors (e.g., self-injurious behavior), (2) therapy-interfering behaviors (i.e., anything interfering with the process of therapy), and (3) quality of life-interfering behaviors (e.g., problems with anxiety, mood, sleep, substance use, etc.; Linehan, 1993). Given that DBT is behavior therapy-based, individual therapy uses behavior analytic assessment and problem-solving that emphasizes directly addressing functions a problem behavior is hypothesized to serve (e.g., self-injurious behavior can function to regulate emotional arousal or communicate distress to others). In addition to function-specific targeting, change strategies of stimulus control, contingency management, exposure, and skills training are used and infused with acceptance (e.g., mindfulness) and dialectical (e.g., using a devil’s advocate approach to explore multiple perspectives and enhance cognitive flexibility) strategies.

In DBT, individual therapy sessions begin with the review of a self-monitoring sheet, called a “diary card,” in an effort to set session targets in line with the treatment hierarchy, and to efficiently review events from the past week, therapy homework, and use of skills. A behavioral analysis is typically then conducted by examining the observable events and unobservable private experiences (e.g., thoughts, feelings, physical sensations, etc.) that occurred before, during, and after the problem behavior. What emerges from these behavioral analyses, commonly called “chain” analyses, is that primary links in the chain of events surrounding problem behaviors are identified and considered as possible targets for change. Over time, chain analyses with the same patient reveal patterns of proximal causation and functions for problem behaviors. Skills are discussed and, whenever reasonable, role-played, modeled, and rehearsed in-session. The therapist uses contingency management and clarification to shape the patient’s behavior into being more skillful during session, and a collaborative plan is made to generalize the skills from individual therapy into the expected daily events in the patient’s life. As an example, if a patient self-injured in the past week, a chain analysis would be done to identify the function of the self-injury, relevant skills would be explored and practiced during session to prevent future self-injury, and the patient and therapist together would problem-solve when and how to use which specific skills to prevent self-injury over the next week.

In DBT group skills training, therapists teach new behaviors in a class format, with mindfulness practice, review of skills practice from the past week, and teaching of new skills each session. Skills modules taught are mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness, all of which correspond to skills deficits observed in BPD (Linehan, 2014). Typically, there are two DBT skills group co-leaders, with one attending during the group to therapy-interfering behaviors and other group process issues, and the other leading the mindfulness, homework review, and teaching functions. To enhance effective communication between patients and individual therapists, DBT skills group co-leaders encourage patients to speak directly with their individual therapists about how to personally tailor DBT skills learned during group, and to use DBT skills to help resolve any interpersonal problems patients might have with their therapist or others.

Telephone consultation to patients is used throughout the week to assist patients in practicing effectively asking for help in applying the skills to their real-world environments. This serves to promote generalization of behavioral skills, in conjunction with outside of session practice exercises (i.e., therapy homework) from both individual and group therapies. In this way, when DBT patients have difficulty using skills in their daily environments, they are encouraged to call their individual therapist for skills coaching. The therapist responds with brief (5–10 minutes) problem-solving and coaching on the use of specific DBT skills. If a patient calls when a therapist is not available, the therapist calls back within 24 hours, but typically much sooner. If a patient has self-harmed within the past 24 hours, the therapist invokes the “24-hour rule,” and does not assist with skills coaching in order to prevent inadvertently reinforcing dysfunctional behavior.

Finally, the fourth primary mode of DBT is therapist consultation team. This weekly meeting includes all members of the DBT treatment team, and has the primary function of providing support, problem-solving, ongoing learning, and feedback to therapists to enhance fidelity to the treatment model. Because DBT is a team-based intervention, in order to be conducting individual DBT one must be a part of a therapist consultation team. During team meetings, there is a clear and consistent structure, with a team leader, an observer of processes out of adherence to the DBT model, and a note-taker to record key decisions made by the team. Each meeting involves a mindfulness practice, didactics, review and problem-solving of therapist needs (e.g., feeling demoralized, tired, or cynical), and an emphasis on balancing change with validation and acceptance during review of patient care needs. Indeed, therapist consultation team is not a staffing-meeting-as-usual. If a therapist is judgmental, off-topic, or defensive, for example, the team attends to these behaviors and helps the therapist be less judgmental, more targeted, or less defensive. Therapist consultation team is a critical component to a healthy DBT program, as it is a context for therapists to regain morale, develop new approaches to recurring and seemingly intransigent patient problems, and ensure the other three primary modes of DBT are being done with fidelity to the model.

The application of DBT to BPD has been thoroughly studied. Fourteen randomized controlled trials (RCTs) of standard DBT have been conducted in six countries examining effects in individuals with BPD or BPD traits (e.g., Linehan et al., 2006; Mehlum et al., 2014), and additional less rigorous studies have been performed (e.g., Rathus & Miller, 2002; Rizvi, Hughes, Hittman, & Vieira Oliveira, 2017). In response to this extensive work, Division 12 of the American Psychological Association has labeled the empirical support for application of DBT for BPD as strong (see Chambless et al., 1998 for expanded definition of “well-established treatments”), indicating that a minimum of two independent research groups using strong group designs have found that DBT is equivalent to another established treatment and/or statistically superior to another treatment or placebo.

Amongst these RCTs, several demonstrate that standard DBT led to improvements on common outcome variables, including improvements in parasuicidal behavior (suicidal behavior and non-suicidal self-injury variables; Carter, Willcox, Lewin, Conrad, & Bendit, 2010; Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 1999, 2006, 2015; McMain et al., 2009; Mehlum et al., 2014; Pistorello, Fruzzetti, MacLane, Gallop, & Iverson, 2012; Verheul et al., 2003), depression (Clarkin et al, 2007; Koons et al., 2001; Linehan et al., 1991, 2006, 2015; McMain et al., 2009; Mehlum et al., 2014), use of hospital-based crisis services (Koons et al., 2001; Linehan et al., 1991, 2006, 2015; McMain et al., 2009), and suicidal ideation (Koons et al., 2001; Linehan et al., 1991, 2006; Mehlum et al., 2014).

However, in these randomized studies, DBT outperformed the comparison treatment condition only some of the time. For example, DBT has been shown to reduce parasuicidal behavior more than usual care treatments in some trials (Linehan et al., 1991; Mehlum et al., 2014; Pistorello et al., 2012). Other studies have found that DBT was superior to the comparison group in decreasing non-suicidal self-injury, but not suicidal behavior (Linehan et al., 2015; Verheul et al., 2003), or vice versa (Linehan et al., 2006). Lastly, several studies reported that DBT did not differ significantly from other treatment conditions on parasuicide outcomes (Carter et al., 2010; Linehan et al., 1999; Linehan et al., 2002; McMain et al., 2009). For depression outcomes, some investigators have found DBT to yield reductions superior to other treatments (Pistorello et al., 2012; interviewer-rated only: Mehlum et al., 2014; self-report only: Koons et al., 2001), whereas others found control treatments to perform similarly to DBT (Andreasson et al., 2016; Linehan et al., 1991, 2006; McMain et al., 2009). Only two (Linehan et al., 1991, 2006) of seven studies (Koons et al., 2001; Linehan et al., 1999, 2002; McMain et al., 2009; Mehlum et al., 2014) reported that DBT reduced hospitalizations significantly more than comparison treatments. Lastly, of the studies that found DBT to reduce suicidal ideation, DBT only outperformed usual care in one (Mehlum et al., 2014). DBT has also demonstrated significantly greater improvements in BPD symptoms (Pistorello et al., 2012), hopelessness (Koons et al., 2001), anger expression (Koons et al., 2001), drug use (Linehan et al. 1999, 2002), social adjustment (Pistorello et al., 2012), and therapy-interfering attendance behaviors (Linehan et al., 1991) than other treatments.

Several meta-analyses have been conducted to synthesize these findings across studies. Four meta-analytic reviews examined DBT specifically and outcomes for BPD, whereas others have examined samples beyond personality disorders (the interested reader is referred to Hawton et al., 2016; Ost, 2008; and Ougrin, Tranah, Stahl, Moran, & Asarnow, 2015). Two groups of researchers compared DBT to treatment-as-usual (TAU) across studies, each using five RCTs (Panos, Jackson, Hasan, & Panos, 2014; Stoffers et al., 2012). Stoffers and colleagues (2012) reported that DBT outperformed TAU on parasuicidality, general mental health, and anger, with significant moderate to large effect sizes, whereas DBT did not differentially reduce attrition compared to TAU. Panos et al. (2014) found that DBT led to significantly better outcomes than TAU in reducing suicide attempts and suicidal behavior, though effects on depression symptoms were not superior to TAU and impact on attrition was only marginally better in DBT. In addition, Cristea and colleagues (2017) examined 12 DBT RCTs in a review of psychotherapies for BPD. They found that among psychotherapies, DBT and psychodynamic approaches were the only treatments with significantly better outcomes than control treatments for all BPD-relevant outcomes, including suicidal and parasuicidal behaviors and BPD symptoms, with DBT demonstrating small to moderate effect sizes. In another meta-analytic study examining DBT for BPD, eight RCTs and eight non-randomized and/or non-controlled studies were used to compare pre- and post-treatment outcomes (Kliem, Kröger, & Kosfelder, 2010). DBT was observed to yield moderate global effects, with significant moderate effects for suicidal and parasuicidal behaviors. One conclusion that can be made when synthesizing the results from these meta-analytic reviews is that the most consistent effects of DBT have been in the reduction of parasuicidal and suicidal behaviors.

Notably, recent studies highlight the importance of the skills training component of DBT in the treatment of BPD. Specifically, in BPD samples, DBT skills use mediates improvements in non-suicidal self-injury and depression (Neacsiu, Rizvi, & Linehan, 2010). Additionally, DBT interventions with active skills components (i.e., standard DBT and DBT skills group with case management) have been found to yield significantly greater reductions in self-injury and quicker improvements in depression and anxiety during treatment than DBT individual therapy only without any skills (Linehan et al., 2015).

Three RCTs have been conducted examining the effects of DBT in personality disorders, including but not limited to BPD. Feigenbaum and colleagues (2012) examined the effects of DBT as compared to TAU in Cluster B personality disorders. In each treatment group, over 90 percent of participants met full criteria for BPD, and over 35 percent met criteria for avoidant personality disorder. Paranoid personality disorder was observed in 40 percent of subjects in the DBT group, as compared to 13 percent in TAU, and all other PDs represented less than 15 percent of sample. Both groups demonstrated significant improvements in general clinical outcomes, parasuicidal behavior, and anger expression. Priebe et al. (2012) also examined DBT versus TAU in individuals with any personality disorder and self-harm behavior, in a clinic with a high rate of BPD diagnoses. The authors did not report data on personality disorder diagnoses. DBT was found to yield significantly faster reductions in self-harm behavior than TAU, though other comparisons were non-significant. Lastly, a study of older depressed adults with a personality disorder compared 24 weeks of DBT with medication management to medication management only, with obsessive-compulsive personality disorder best represented in this sample, followed by avoidant and borderline personality disorders, respectively (Lynch et al., 2007). The DBT group demonstrated more cases of and faster rates of remission, and demonstrated greater decreases in interpersonal sensitivity and aggression compared to medication management alone. Given the paucity of data from controlled clinical trials examining personality disorders in general (and not BPD specifically or primarily), firm conclusions cannot be drawn about the efficacy of DBT for all personality disorders.

Schema Focused Therapy

Schema focused therapy (SFT), sometimes referred to as schema focused cognitive therapy, is a treatment protocol specifically developed for personality disorders or other difficult-to-treat problems that do not respond to traditional cognitive behavioral therapies (Young, 1990; Young, Klosko, & Weishaar, 2003). The focus of this therapy is addressing early maladaptive schemas (EMS), which are conceptualized as longstanding emotional and cognitive patterns that cause maladaptive behaviors. An overarching goal of treatment is insight related to schemas in order to engage in adaptive ways of coping with daily life events. The following discussion gives a brief overview of maladaptive schemas, coping styles, and their etiology.

Within the model used in SFT, EMS are longstanding maladaptive patterns of thoughts, behaviors, and emotions thought to have originally developed to help individuals cope with unmet needs in their childhood environment. In this conceptual model, the basic emotional needs in childhood are: (1) secure attachment to others, (2) autonomy, (3) freedom to express valid needs and emotions, (4) spontaneity and play, and (5) realistic limits and self-control. Consistent frustration of these needs in childhood leads to patterns of thinking, feeling, and behaving that may have been functional within the childhood environment, but are no longer effective in adulthood. In SFT, there are 18 schemas classified into five categories, based on the hypothesized unmet needs in childhood: (1) disconnection and rejection, (2) impaired autonomy and performance, (3) impaired limits, (4) other-directedness, and (5) overvigilance and inhibition. For example, a schema within the disconnection and rejection category is “abandonment/instability,” which stems from a chronic frustration of the need for secure attachment in childhood. Due to this unmet need for secure attachment, it is hypothesized that the individual develops a belief that emotional support from others is unreliable. When this individual encounters signs of instability in adulthood, this schema will be activated, triggering intense negative emotions and maladaptive coping behaviors. Such coping behaviors are further categorized into three broad maladaptive coping styles: (1) schema surrender, which refers to accepting the schema as true and behaving in ways that are consistent with the schema, (2) schema avoidance, which refers to avoiding contexts or stimuli that would activate the schema, or (3) schema overcompensation, wherein the individual behaves in ways that are opposite of the schema. These coping behaviors are thought to manifest as the personality disorder traits or maladaptive interpersonal behaviors that interfere with the quality of patients’ lives.

SFT is delivered through individual therapy in the assessment phase and change phases of treatment. The goal of the assessment phase is to gain awareness and insight into the origin and associated maladaptive coping styles relevant to key EMS. Assessment is achieved through thorough discussions with the therapist and the use of self-report questionnaires. These assessments ultimately inform the case conceptualization developed collaboratively between the therapist and patient.

After a case conceptualization is formulated, the treatment proceeds to the change phase, which includes cognitive, experiential, and behavioral pattern-breaking techniques. Cognitive techniques guide patients through challenging thoughts and beliefs related to their schemas. The goal of these techniques is to train patients to learn that dysfunctional thoughts and beliefs are not true. Experiential techniques, such as imagery and role-play with the therapist, are designed to activate the schemas during the therapy session and trigger the emotional responses typically associated with schemas. The function of these techniques is to help patients emotionally confront the figures that did not meet their needs in childhood. For example, therapists lead patients through exercises where they imagine difficult memories from childhood and bring awareness and effective communication of their anger towards neglectful or abusive caregivers. These exercises facilitate externalizing of schemas, so that it is easier for patients to be aware of and challenge schemas instead of passively believing them. Behavioral pattern-breaking involves helping patients identify and modify maladaptive coping behaviors so that they can engage in healthier coping behaviors when schemas are activated. For example, the therapist will help patients target problems expressing emotions to others, generate alternative methods of expressing emotions that are more effective, and guide the patients through practicing these new behaviors through imagery or role-play exercises.

The therapeutic relationship between the patient and the therapist has an important role in the change phase of SFT. For example, there is an emphasis on meeting the patient’s frustrated childhood needs through empathy and limited reparenting from the therapist, which the patient is encouraged to internalize as an adaptive healthy adult schema. Using the case conceptualization, the SFT therapist provides empathy, emotional support, and appropriate interpersonal boundaries that help redress the patient’s unmet needs. The therapist provides limited reparenting through the therapeutic relationship (e.g., responding contingently to observe limits around patient and therapist behaviors during sessions) and through imagery, in which patients may imagine themselves as vulnerable children while the therapist engages in an empathetic, supportive dialogue with those figures. Through these dialogues, SFT aims to help patients learn to relate to their schemas with insight and compassion and to regulate their behaviors, thoughts, and emotions more effectively when elicited by such schemas.

Techniques in SFT are generalized outside of the therapy setting into the patients’ lives through behavioral homework assignments and flash-cards that remind patients of their schemas and their planned responses (e.g., the evidence against their schemas or adaptive coping behaviors). Ultimately, the goal of SFT is a change in schemas, in which EMS are activated less frequently or intensely and patients engage in healthier coping behaviors when schemas are activated.

Previous research has demonstrated the efficacy of SFT for BPD (Farrell, Shaw, & Webber, 2009; Gisen-Bloo et al., 2006). For example, a study in the Netherlands treated 86 patients with either SFT or transference focused psychotherapy (TFT) twice a week for three years. Throughout the treatment period, 45 percent of the patients in the SFT condition recovered fully from BPD, compared to only 24 percent of those who received TFT (Gisen-Bloo et al., 2006). In a one-year follow up after treatment, 52 percent of the patients in the SFT condition fully recovered from BPD compared to 29 percent in the TFT condition (Gisen-Bloo et al., 2006).

SFT has some empirical support as a treatment for personality disorders more broadly. For example, a multi-center randomized controlled trial in the Netherlands compared the effects of SFT to clarification oriented therapy and TAU in 323 patients with mixed personality disorders (Bamelis, Evers, Spinhoven, & Arntz, 2014). This study found that more patients in the SFT condition compared to the two control conditions recovered from personality disorders three years after treatment began. Other empirical studies have found that SFT delivered in a group format is efficacious in treating BPD (Farrell et al., 2009), as well as other Cluster B (Zorn, Roder, Thommen, Müller, & Tschacher, 2007) and Cluster C (Hoffart, Versland, & Sexton, 2002) personality disorders. Across studies, research has provided preliminary evidence that SFT is efficacious for treating personality disorders in both individual and group formats. However, because the strongest evidence for this treatment is within BPD, more empirical research is needed to conclusively determine the efficacy of SFT across all personality disorders. In addition, given the limited amount of research conducted using SFT for BPD, definitive conclusions cannot yet be made about SFT compared to DBT, a more rigorously studied and well-established treatment for BPD.

Cognitive Therapy and Other CBTs

DBT and SFT are two branded CBTs that were specifically developed and tested as treatments for personality disorders. However, other researchers have adapted the broad framework of cognitive therapy to treat personality disorders. In 1990, Aaron Beck and colleagues developed a cognitive approach for personality disorders at a time when there were no manualized and empirically supported treatments for personality disorders (Beck , 1991). Beck’s framework is based on the model that personality traits develop to fulfill important survival functions in specific environments. Similar to the model in SFT, in order to fulfill these functions, individuals develop core schemas, which refer to cognitive structures or sets of beliefs that include attitudes, assumptions, or expectations. These schemas are nested within networks of learned emotional, cognitive, and behavioral patterns that determine specific responses to challenges in the environment to fulfill survival goals. In personality disorders, these schemas and modes are adaptive for survival in certain environments, such as within childhood, but are overdeveloped and too rigid to adapt over time to different environments. For example, a mode that motivates an individual towards aggressive competition can be adaptive in childhood environments, but could contribute to the development of antisocial personality disorder symptoms.

Therapeutic techniques that identify, challenge, and modify dysfunctional beliefs form the basis of cognitive therapy. The goal of cognitive therapy for personality disorders is to reduce the intensity and availability of maladaptive schemas and strengthen more adaptive schemas (Beck, 1991). Consistent with SFT, the process of cognitive therapy for personality disorders includes assessment and change phases. Stemming from the initial assessment phase, the cognitive therapist develops a case conceptualization collaboratively with the patient. The developmental narrative, current life problems, and therapeutic relationship are three important sources of data for understanding, predicting, and effectively responding to the patient’s dysfunctional beliefs. For example, maladaptive schemas may be evident during therapy as early as the initial evaluation session via patient thoughts that occur in the moment (e.g., “automatic thoughts”) and are communicated to the therapist. These automatic thoughts (e.g., “this is going to sound stupid …”) reflect or can give rise to verbalized conditional assumptions (e.g., “if someone criticizes me, it means they know I’m inferior”) or to core beliefs within a schema about the patient’s sense of self, others, or future (e.g., “I am always inferior”). During the assessment phase of treatment, therapists listen carefully for imperative words such as “should” or “must” that span multiple contexts in a patient’s life, as they are common indicators of dysfunctional schemas. The therapist and patient collaboratively develop a case conceptualization by carefully discussing current life problems, the developmental history of such problems, as well as thoughts that arise during session.

The change phase of cognitive therapy involves helping patients become more facile at identifying and challenging maladaptive automatic thoughts, assumptions, and schema with ways of thinking that lead to more adaptive behaviors (Beck et al., 1990). A central therapeutic approach in cognitive therapy is questioning the patient about thoughts that occurred during problematic situations and tracing them back to underlying schemas. The therapist can draw upon many different techniques in this process, including but not limited to the use of Socratic questioning, a thought record or other homework to practice challenging automatic thoughts between clinic visits, problem-solving, or experiential exercises. Beck et al. (1990) recommended experiential exercises for personality disorders to elicit schemas and associated behavioral responses. As with SFT, experiential exercises in cognitive therapy include role-play between the therapist and the patient, reliving old childhood experiences, and imagery. For example, the therapist can prompt the patient to close her or his eyes, visualize a recent difficult situation, and reflect on the thoughts present at that time. The therapist would assist the patient in identifying and challenging any problematic ways of thinking that are elicited during such exercises.

As an example, when a patient becomes aware of relevant maladaptive schemas, the therapist can guide the patient through reality testing, evaluating the evidence for and against the schema. Testing the “truth” of the maladaptive schemas functions to weaken their ability to trigger other maladaptive patterns, such as dysfunctional coping behaviors. Eventually, the therapist can help the patient by modifying maladaptive beliefs with thoughts that are better grounded in evidence and reason and trigger more positive affect and adaptive behaviors. For example, patients can learn to modify their negative, generalized assumptions (e.g., “they criticized me, which means I’m inferior”) to more benign interpretations that are specific to the situation (e.g., “they commented on a small mistake I made, which means that they are paying attention to my work and may be identifying areas of improvement”). More generally, as in SFT, the cognitive therapist treating personality disorders can flexibly and creatively use different techniques both to (a) increase insight into how core schemas are activated and contribute to current life problems and (b) develop more flexible cognitive and behavioral response patterns when dysfunctional ways of thinking occur.

Empirical research has provided some evidence for the efficacy of cognitive therapy for personality disorders. Similar to SFT and DBT, cognitive therapy adapted for personality disorders was found to be efficacious for BPD (Brown, Newman, Charlesworth, Crits-Christoph, & Beck, 2004; Cottraux et al., 2009; Davidson et al., 2006; Davidson, Tyrer, Norrie, Palmer & Tyrer, 2010). For example, one randomized controlled trial with 106 patients with BPD compared the effects of TAU combined with cognitive therapy to TAU alone (Davidson et al., 2006). This study found that two years after treatment, the cognitive therapy plus TAU condition led to a significant reduction in anxiety, dysfunctional beliefs, and number of suicidal acts compared to TAU alone.

As with DBT and SFT, relatively fewer studies have tested the effects of cognitive therapy on personality disorders beyond BPD. The studies that have investigated cognitive therapy across personality disorders have variability in the range of specific interventions used, with some emphasizing traditional cognitive change interventions and others using behavior therapy interventions as part of a more general cognitive behavioral approach. That is, cognitive therapy as a specific approach can be differentiated from the broader category of cognitive behavioral therapies for personality disorders, with the latter including a wide range of empirically supported behavioral and cognitive change interventions targeting a host of psychological processes (e.g., emotion regulation, behavioral dyscontrol, interpersonal dysfunction). For example, studies have found that behavioral therapy including exposure-based procedures may be efficacious in treating avoidant personality disorder (APD; Alden, 1989; Alden & Capreol, 1993). Another study with 62 patients with APD found that at a six-month follow-up, only 9 percent of patients randomized to a CBT condition were still diagnosed with APD, compared to 36 percent of patients randomized to a brief dynamic therapy group (Emmelkamp et al., 2006). This body of research suggests that cognitive behavioral approaches may be efficacious for the treatment of APD. However, as noted earlier in regards to DBT and SFT, more research is needed to reach definitive conclusions about the effects of cognitive therapy or other treatment protocols within the family of CBTs for patients with APD or other personality disorders outside of BPD.

Although DBT, SFT, and cognitive therapy have the largest number of rigorously controlled studies for the treatment of BPD, a few additional cognitive behavioral approaches have been developed and applied in the treatment of BPD. These include an emotion regulation group intervention developed by Gratz and Gunderson (2006) and systems training for emotional predictability and problem solving (STEPPS) developed by Blum and colleagues in 2005 (Blum et al., 2008), both of which are delivered in group format and are notably shorter than DBT.

Emotion regulation group therapy (ERGT) is designed as an intervention to target emotion regulation difficulties in BPD, and draws heavily on behavior therapy, DBT (Linehan, 1993), ACT (Hayes et al., 1999, 2012), and emotion-focused therapy (Gratz & Gunderson, 2006; Greenberg, 2015). In this treatment, participants learn about the function of self-harm behaviors and learn skills to increase emotional awareness, clarity, and acceptance, and behavior change (e.g., non-avoidance, alternatives to impulsive behavior) to promote values-consistent behaviors. Of note, many of these skills overlap with those taught during the emotion regulation module in DBT skills training (Linehan, 2014). Gratz and colleagues (Gratz, Tull, & Levy, 2014) conducted a randomized controlled trial comparing ERGT to a waitlist control condition among women with BPD and self-harm behavior. Individuals receiving ERGT demonstrated significant reductions in deliberate self-harm behavior and other self-destructive behaviors, emotion dysregulation, BPD symptoms, quality of life, and stress and depression symptoms, with medium to large effect sizes (Gratz et al., 2014). This study not only supports the promise for using ERGT but also suggests that a brief group skills-based intervention for BPD is feasible, acceptable, and can be efficacious.

STEPPS is a group-delivered intervention that includes psychoeducation and skill training by integrating cognitive therapy, behavioral skills, and a systems-based approach to improving interpersonal relationships. Examples of skills include: “distancing, communicating, challenging, distracting, and problem management … goal setting, healthy eating behaviors, sleep hygiene, regular exercise, leisure activities, health monitoring (e.g., medication adherence), avoiding self-harm, and interpersonal effectiveness” (Blum et al., 2008, p. 469). Notably, many of these skills overlap with those in the skill training modules of distress tolerance, emotion regulation, and interpersonal effectiveness modules of DBT (Linehan, 2014).

Among studies examining STEPPS as a treatment approach, Blum and colleagues (2008) compared STEPPS plus TAU to TAU alone in the treatment of BPD. STEPPS yielded significantly greater improvements than TAU in BPD symptoms, as well as impulsivity, negative affect, and global functioning and mood. Additional randomized trials demonstrate similar results (Van Wel et al., 2009), as do less rigorous studies in samples with BPD (Black et al., 2008) and co-occurring ASPD and BPD (Black, Simsek‐Duran, Blum, McCormick, & Allen, 2016).

STEPPS incorporates family members and partners in psychoeducation around BPD. However, this is not unique among empirically supported cognitive behavioral interventions for BPD. For example, DBT has been adapted for adolescents and young adults by incorporating family members in skills training and individual therapy as needed (Miller, Rathus, & Linehan, 2006). In these adaptations, multi-family skills training groups are used, which include both the patient and at least one family member learning DBT skills. In addition, within standard DBT for adults, family members are encouraged to periodically attend individual therapy sessions (no more than one per month) to enhance alignment in skills training between the patient and family members.

DBT, SFT, and cognitive therapy share similar theoretical models, but are distinct in their approach and emphasis. Because all three branded treatments are within the family of CBTs, they are all founded on the premise that individuals develop certain patterns of thoughts, behaviors, and emotions in early life environments, but that such learned patterns are not effective within their current environments. Because thoughts, behaviors, and emotions are interrelated and can influence each other, CBTs aim to modify one of these three phenomena to change problematic patterns of behavior. SFT is the most similar to the traditional cognitive therapy model, except it arguably places more emphasis on experiential exercises, the therapeutic relationship, and the role of childhood experiences. Perhaps more importantly, the SFT model includes specific types of schemas, modes, and coping styles that can manifest transdiagnostically across personality disorders and other more episodic disorders. Both cognitive therapy and SFT involve monitoring and challenging core schemas and their associated problematic behaviors. In both therapies, exercises that trigger strong emotional reactions are indicative that patients have accessed and may be able to use learned skills to modify core schemas. Additionally, the overarching goal of both treatments is to reduce how often dysfunctional schemas are triggered and to increase newer and more adaptive responses when such schemas are elicited.

DBT deviates most from the other two branded cognitive behavioral treatment protocols. Indeed, DBT was developed, in part, in response to gaps in traditional cognitive therapy, such as the prioritized emphasis on changing behavior and ways of thinking in the absence of guidelines for validation and acceptance of patients (Linehan, 1993). Because patients may respond aversively to the common cognitive therapy technique of challenging the truth of automatic thoughts, assumptions, or underlying schemas, DBT places more emphasis on the balance of acceptance and change. Change strategies in DBT include cognitive modification techniques directly adapted from Beck’s cognitive therapy, but are used alongside mindfulness and acceptance strategies to help patients learn a broad repertoire of skills to respond to unpleasant thoughts and emotions.

Notably, all three branded CBTs for personality disorders have the strongest empirical support for BPD. Of these treatments, DBT is the only one specifically developed for BPD. Importantly, there is a distinct lack of CBTs developed for other personality disorders, such as paranoid, antisocial, obsessive-compulsive, and narcissistic personality disorders (Trull et al., 2010). Considering this gap in the field, clinicians treating symptoms of other personality disorders can draw upon the principles of change within the family of CBTs to target cognitive, behavioral, or affective processes underlying these symptoms.

Without a Branded Empirically Supported Protocol: Principles of Change from CBTs

There are few evidence-based treatments with strong empirical support for personality disorders, even fewer that are cognitive behavioral, and, among the CBTs, fewer still that have not been evaluated only or primarily for patients with BPD. Without a branded and well-researched CBT intervention, clinicians who wish to use a cognitive behavioral approach need to flexibly tailor treatments using strategies, processes, and principles of change from empirically supported CBTs. This work includes an assessment of ways in which one’s learning history may have contributed to the development and maintenance of the presenting problems. It also includes functional analysis as a primary tool to understand and gain insight into the context and function of primary problem behaviors and ongoing life stressors. As with the CBTs previously reviewed, a general approach also would include the collaborative and iterative development of a case conceptualization that includes mutually agreed upon cognitive and behavioral targets for change. However, which interventions should be used, for whom, and in what sequence?

We suggest that interventions selected are extensions of the case conceptualization, tailored to the individual patient, and drawn from the literature on CBTs for other disorders and problem behaviors. Approaches used across behavior therapies and cognitive therapies, for example, should be considered. We have already reviewed cognitive modification and skills training approaches used in CBTs for personality disorders. Standard behavior therapy approaches used across treatments for a range of disorders, such as stimulus control procedures, shaping, and contingency management, also can be considered for use when appropriate in the management of personality disorders. Exposure-based procedures are another example of interventions that can be considered when treating patients with personality disorders.

Exposure-Based Procedures

Exposure is a well-established therapeutic strategy used to promote new learning in response to emotionally evocative stimuli, including long-term reductions in emotional arousal and avoidance behaviors (e.g., Bouton, 1988; Craske et al., 2008). Traditional exposure models, long-established for treating anxiety and associated disorders (e.g., Malleson, 1959; Watson & Marks, 1971), involve repeated and/or prolonged presentation of feared or aversive stimuli and representations of those stimuli that evoke emotional reactivity and expression, while blocking fear-based behavioral urges of avoidance and escape. These strategies are used with the goal of reducing anxiety intensity and avoidance behaviors over time in contexts with the evocative stimuli, and have been implemented using a variety of modalities to contact the feared stimuli, including imaginal, in vivo (real-life), narrative, interoceptive, and virtual reality (e.g., Craske, Rowe, Lewin, & Noriega‐Dimitri, 1997; Foa, Steketee, Turner, & Fischer, 1980; Reger et al., 2016). Evidence for these approaches in the treatment of anxiety and posttraumatic stress disorder is robust for exposure-focused treatments, as well as multi-component cognitive behavioral treatments that emphasize exposure (e.g., Abramowitz, 1996; Barlow, Craske, Cerny & Klosko, 1989; Choy, Fyer, & Lipsitz, 2007).

Evidence examining application of traditional exposure approaches in personality disorder specific samples is limited, with some studies examining outcomes for obsessive compulsive personality disorder (OCPD), APD, and BPD. For example, Sadri and colleagues (2017) examined the application of exposure and response prevention in a sample with co-occurring OCPD and obsessive compulsive disorder (OCD), finding noted improvements in OCD symptoms post-treatment (Sadri et al., 2017). Although this result is promising, other studies have found that OCPD severity and presence can impede efficacy of exposure for OCD symptoms, with perfectionism significantly contributing to less improvement (Pinto, Liebowitz, Foa, & Simpson, 2011). These findings may suggest that perfectionism as a class of behaviors may be particularly important to target in this population with exposure or other interventions, with some studies suggesting that exposure-based treatment effectively reduces perfectionism in socially anxious individuals (Ashbaugh et al., 2007). For example, non-reinforced exposure to imperfection in a patient with OCPD related to impression management could include crafting an email that is imperfect (e.g., misspelled words, communication of objectives without much clarity, leaving off an important recipient). The CBT therapist would help the patient by blocking urges to fix the errors or imperfections, encouraging the patient to allow the imperfect email to be sent without correcting the imperfections. Similarly, in this example, the therapist could encourage the patient to communicate via email or in other ways with spontaneity, and without effortful and distressing scrutiny. Having been exposed to such imperfect communication multiple times without adverse outcomes, the distress associated with such impression management would be expected to decrease and give rise to an increasingly diverse and flexible behavioral repertoire.

For APD, several researchers have observed the overlap in symptomology and presentation between social anxiety disorder (social phobia) and APD (e.g., Carter & Wu, 2010; Lampe & Sunderland, 2015; Tillfors, Furmark, Ekselius, & Fredrikson, 2004; Turner, Beidel, & Townsley, 1992). There has been debate about the utility of the distinction between these disorders (e.g., Lampe & Sunderland, 2015), considering the high rates of generalized social anxiety disorder reported amongst individuals with APD (36–100 percent; Cox, Pagura, Stein, & Sareen, 2009; Herbert, Hope & Bellack, 1992) and other studies reporting non-significant differences in amounts of APD in generalized social phobia as compared to non-generalized social phobia (Dyck et al., 2001). Despite data pointing to differences between social phobia and APD, including greater functional impairment (Huppert, Strunk, Ledley, Davidson, & Foa, 2008; Marques et al. 2012), depression symptoms (Huppert et al., 2008), social fear, and avoidance (Kose et al., 2009) for individuals with generalized social phobia with (vs. without) APD, and greater similarities between generalized social phobia and APD than specific social phobia (Carter & Wu, 2010), many researchers have contended that there is no significant difference (e.g., Hope, Herbert, & White, 1995; Widiger, 1992).

Among the studies of exposure-based treatment for social anxiety disorder, only a few have explicitly included APD. Among these studies, Hope and colleagues (1995) and Brown, Heimberg, and Juster (1995) included APD in their sample of social phobia and examined cognitive behavioral group therapy (a multi-component treatment with emphasis on exposure) for social phobia (Heimberg, 1991). Both studies concluded that APD was not a predictor of treatment outcome. Brown et al. (1995) observed that the number of individuals meeting criteria for APD significantly decreased from pre- to post-treatment. Hope et al. (1995) found that individuals with APD did not benefit differently than individuals without APD on self-report measures of social anxiety and improvement ratings, though socially phobic APD individuals reported higher distress during a behavioral approach task than subjects with social phobia without APD. Huppert et al. (2008) found that APD influenced the rate of change, wherein individuals with APD (randomly assigned to a multi-component group CBT using exposure-based procedures, medication alone, combined treatment, or placebo) responded more quickly early in treatment than socially anxious subjects without APD. Using a more exposure-focused group treatment, Feske, Perry, Chambless, Renneberg, and Goldstein (1996) found that individuals with APD improved significantly over treatment, though demonstrated less improvement than non-APD subjects at post-treatment and follow-up time points.

Taken together, the evidence across these studies suggests that exposure-based procedures are reasonable candidate interventions to consider when using a non-manualized CBT-based protocol for the treatment of APD. For example, non-reinforced exposure to contexts and stimuli associated with imperfection may be considered for individuals with OCPD. Exposure to cues associated with social anxiety and avoidance of interpersonal contexts may be helpful for patients with APD. Such approaches can be informed by the previously identified evidence-based treatment protocols for social anxiety disorder. For patients with dependent personality disorder, exposure-based procedures can be considered as one way to help patients learn to tolerate the anxiety associated with behaving with more autonomy and less dependency. In such a case, a hierarchy of fearful situations associated with increasing anxiety and dependency can be collaboratively generated, with the patient being exposed imaginally and in vivo to gradually more anxiety-evocative contexts and cues. Indeed, across Cluster C personality disorder diagnoses, exposure-based approaches may help reduce anxious distress and avoidance, creating opportunities for new learning to occur, and, over time, for more flexible and context sensitive responses to life stressors.

Beyond applications of exposure to anxiety, treatment developers in the 1990s began applying exposure-based procedures to other emotions. Some researchers emphasized three components of exposure therapies: cue exposure, response prevention, and acting opposite to emotion-based urges (e.g., Barlow, Allen & Choate, 2016; Linehan, 1993, 2014; McMain, Korman, & Dimeff, 2001), whereas others have emphasized decreasing experiential avoidance across emotions (e.g., Hayes et al., 1999, 2012) or behavioral inhibition of problematic emotion-based urges (response prevention) and activation of alternative skillful behaviors (acting opposite; approach behavior) with somewhat less emphasis on subjectively experiencing the distressing affective state (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011).

With the exception of DBT, these approaches have not been directly examined in personality disorders. However, exposure-based interventions have been applied to the emotions of shame, anger, disgust, and depression in a number of research studies. Directly germane to personality disorders, Rizvi and Linehan (2005) used an opposite action intervention (Linehan, 2014) over the course of eight to ten sessions, alongside DBT skills group, to target the reduction of shame in a sample of individuals with BPD. In this study, opposite action included cue exposure (i.e., presenting the trait or behavior about which the individual feels ashamed), blocking shame-based action tendencies (e.g., sustained eye contact, representing or maintaining exposure to shame cues despite urges to avoid or escape from them), and engaging in behaviors (including changing body posture, facial expression) opposite to the shame-based action tendencies. Importantly, these procedures were only used when shame was not justified, as defined by behavior that did not violate the participant’s values and would not result in rejection by others if known. Rizvi and Linehan observed significant decreases in self-reported shame from pre- to post-treatment, with reductions specifically in event-specific shame. Given that shame has been found to predict self-injurious behaviors in BPD (Brown, Linehan, Comtois, Murray, & Chapman, 2009), application of exposure in this manner may be especially important in the treatment of BPD.

Studies also have investigated the effects of exposure on disgust in psychiatric samples characterized by difficulties with disgust. In one study, individuals with body dysmorphic disorder who engaged in mirror exposures viewing themselves demonstrated significant reductions in disgust (Nezirolgu, Hickey, & McKay, 2010). In another study examining disgust in contamination-based OCD, researchers found significant decreases in disgust after exposure to disgust-inducing stimuli (Broderick, Grisham, & Weidemann, 2013). Similarly, another study observed marked reductions in disgust during intensive exposure-based treatment for OCD (Athey et al., 2015). These findings may be particularly applicable to OCPD, given the overlap in symptoms between OCD and OCPD (Garyfallos et al., 2010), and in BPD, in light of findings indicating that high pathogen disgust has been associated with more BPD features (Standish, Benfield, Bernstein, & Tragesser, 2014).

Exposure-based procedures as applied to problems related to anger also have begun to be investigated. Because high levels of trait anger in BPD and ASPD predict physical aggression (Kolla, Meyer, Bagby, & Brijmohan, 2017), cognitive behavioral therapies for these personality disorders may benefit by using exposure-based interventions to reduce anger. Some studies have used exposure techniques as part of other more primary interventions (e.g., self-statements; Tafrate & Kassinove, 1998) or as a brief mood induction (Lobbestael, Arntz, Cima, & Chakhssi, 2009). The use of exposure-based procedures for problems with the regulation of anger may be germane to the treatment of anger in BPD and antisocial personality disorder, both of which are associated with similar anger problems (e.g., Bateman, O’Connell, Lorenzini, Gardner, & Fonagy, 2016). Others, such as Grodnitzky and Tafrate (2000), applied a group-based imaginal exposure intervention in a sample of individuals with anger problems and observed significant reductions on several anger measures. It is important to note that there is no rationale for using exposure-based interventions as a single method for the treatment of anger across personality disorders. Nonetheless, exposure procedures can be considered when using a cognitive behavioral case conceptualization-based approach to treat a patient with personality disorder symptoms that include anger regulation problems.

The impact of exposure-based interventions on a range of affective states beyond anger has also been examined in the context of the treatment of posttraumatic stress disorder (PTSD). For example, in a sample of individuals with BPD and PTSD, researchers found that over the course of prolonged exposure treatment, participants reported significant reductions in emotions beyond fear/anxiety, including general distress, guilt, shame, and disgust (Harned, Ruork, Liu, & Tkachuck, 2015). Further, in a sample of individuals with PTSD, Langkaas and colleagues observed decreases in internalized anger, hostility, guilt, and trauma-related shame following exposure-based trauma treatment (Langkaas et al., 2017). These findings lend further support to the hypothesis that exposure-based procedures may have beneficial impacts across emotions, and thus may be helpful in treating problem behaviors occurring in response to emotional distress across personality disorders.

Lastly, indirect support for the use of exposure-based procedures can be derived from studies that have explored attempts to control unwanted private experiences in personality disorders. Many studies have investigated avoidance, emotional suppression, and emotional inhibition in personality disorders (Bijttebier & Vertommen, 1999; Cheavens et al., 2005; Kruedelbach, McCormick, Schulz, & Grueneich, 1993; Lynch, Robins, Morse, & Krause, 2001; Rosenthal, Cheavens, Lejuez, & Lynch, 2005). Bijttebier and Vertommen (1999) observed use of avoidant coping strategies among psychiatric inpatients with diagnoses of paranoid, schizoid, schizotypal, borderline, and avoidant personality disorders. Further, experiential avoidance specifically has been associated with a range of personality disorders, including borderline (Chapman, Specht, & Cellucci, 2005), avoidant, dependent (Spinhoven, Bamelis, Molendijk, Haringsma, & Arntz, 2009), and obsessive-compulsive (Spinhoven et al., 2009; Wheaton & Pinto, 2017) personality disorders. Although we are not aware of any studies that have examined experiential avoidance in paranoid, schizoid, or schizotypal personality disorders, a greater tendency to avoid unwanted and unpleasant private experiences has been associated with higher frequency of paranoid ideation amongst individuals with psychotic disorders (Castilho et al., 2017). Given that one of the primary aims of exposure is to reduce avoidance behaviors, findings related to the role of experiential avoidance in personality disorders underscore the importance of considering exposure-based approaches when treating these patients.

Third Wave Behavior Therapies for Personality Disorders: Beyond DBT

Although not developed and tested for personality disorders specifically, acceptance and commitment therapy (ACT; Hayes et al., 1999, 2012), mindfulness based cognitive therapy (MBCT; Segal, Williams & Teasdale, 2013), and functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991) are third wave cognitive behavioral therapies that may be considered when treating patients with personality disorders.

ACT is designed to increase patients’ psychological flexibility and present-moment focus to facilitate adaptive behaviors in line with patients’ long-term values. This treatment uses several principles of change in service of these goals, including exposure and mindfulness to target experiential avoidance (Hayes et al., 1999, 2012). A few recent studies have explored the use of group ACT interventions with personality disorders (Clarke, Kingston, James, Bolderston, & Remington, 2014; Morton, Snowdon, Gopold, & Guymer, 2012). One study found that the addition of an ACT intervention to TAU led to significant improvements in BPD symptoms compared to treatment as usual (Morton et al., 2012). Although no published studies have demonstrated its efficacy with other personality disorders, providers may draw upon ACT interventions to treat problems with experiential avoidance and cognitive rigidity in patients with personality disorders.

Similar to ACT, MBCT targets experiential avoidance through present-moment awareness and acceptance. As MBCT was originally developed as a group treatment for major depression, it combines traditional cognitive therapy techniques with mindfulness skills to help patients bring awareness to negative thought patterns and develop adaptive coping strategies in response to them. The benefits of mindfulness include changes in attentional control (Bishop et al., 2004) and reduced experiential avoidance (Hayes et al., 1999, 2012), which may effectively treat problematic cognition and behavior in personality disorders. One quasi-experimental study found an eight-week MBCT program adapted for BPD led to increases in attentional control and mindfulness (Sachse, Keville, & Feigenbaum, 2011). Another study found that a mindfulness intervention reduced anxiety and negative affect among participants with high trait interpersonal dependency (McClintock & Anderson, 2013), pointing to the hypothesis that such techniques may be beneficial in patients with dependent personality disorder. As previously detailed, DBT is a well-established mindfulness-based psychotherapy for BPD. However, clinicians wishing to use a contemporary CBT approach in the absence of a specific branded treatment protocol for personality disorders can consider using mindfulness exercises from ACT or MBCT as part of the treatment plan.

FAP may also be useful for treating personality disorders, as it was originally developed as a behavioral treatment for patients with interpersonal difficulties. FAP aims to target and change problematic interpersonal behaviors within the therapeutic relationship by reinforcing adaptive in-session behaviors (Tsai, Yard, & Kohlenberg, 2014; Tsai et al. 2009). Only one single-case study has evaluated the efficacy of FAP for personality disorders, finding that narcissistic and histrionic behaviors decreased over a brief course of FAP (Callaghan, Summers & Weidman, 2003). The findings from this study suggest that these decreases could be attributed to the therapist responding contingently to patient problem behaviors and improvements. Therefore, narcissistic and histrionic behaviors may be able to be targeted and changed using contingency management and other basic principles of behavior change. Although considerably more empirical research is needed to determine the efficacy of FAP for the treatment of personality disorders, we suggest that a case conceptualization-based intervention for personality disorders include the use of therapist contingency management of relevant interpersonal behaviors. This includes, for example, explicit orientation to and implementation of contingency management and behavior change strategies in response to real-time clinically relevant behaviors during therapy sessions.

Summary

In this chapter, we have focused on the use of branded CBT protocols and interventions drawn from the family of contemporary CBTs that can be used in the treatment of patients with personality disorders. Most empirical research investigating CBTs for personality disorders have been evaluated for use with BPD. These include DBT, SFT, and cognitive therapy. Only DBT was developed specifically for BPD, and, to date (based on the available treatment outcome research), DBT remains the gold standard approach for the outpatient treatment of BPD. Because far less treatment research has been done outside of BPD, clinicians using cognitive behavioral approaches in the treatment of personality disorders are encouraged to collaboratively build a CBT-based case conceptualization and treatment plan with patients. This would include the use of similar strategies, techniques, and procedures used in other CBTs, tailored to the individual and to the specific psychological processes being targeted. In this way, and in the absence of manualized and well-established protocols for all personality disorders, patients can receive treatment from CBT therapists that is coherently organized (i.e., not eclectic), grounded in empirically supported methods of behavior change (e.g., functional analysis, contingency management, stimulus control, shaping, skill training, cognitive modification, exposure-based procedures, mindfulness and acceptance-based procedures), and flexibly tailored to the individual needs of each patient.

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