17a
Christopher D. Hughes and Shireen L. Rizvi
Rosenthal, Wyatt, and McMahon (this volume) have written an impressive chapter that outlines well the difficulties faced by CBT clinicians treating clients with personality disorders, and the empirically supported, “branded” CBT interventions available for clinicians. In addition to providing an overview to CBT as applied to personality disorders, the authors paid specific attention to three treatments: dialectical behavior therapy (DBT), schema focused therapy (SFT), and cognitive therapy. We wholeheartedly agree with the authors’ recommendation that, when treating clients with personality disorders without specific established protocols, a collaboratively constructed, CBT principle-based case conceptualization and treatment plan is warranted. In fact, given the complex, heterogeneous, and pervasiveness of the dysfunctions related to personality disorders, it seems that flexible and individualized principle-based CBT approaches may even be preferable to protocol-based treatments. We recognize that developing and implementing such interventions can be a daunting task for clinicians. Therefore, the following commentary aims to briefly review and expand upon some relevant aspects of personality disorders that present challenges for clinicians, and to outline the steps we recommend clinicians follow in their treatment of personality-disordered clients.
In addition to the problems detailed by Rosenthal and colleagues, there are other factors that are likely to contribute to the difficulty faced by CBT clinicians treating clients with personality disorders. First, the screening and assessment of personality disorders is often not a part of routine clinical care, leaving them undiagnosed in many clinical settings (Bender et al., 2001; Tyrer, Reed, & Crawford, 2015). This is likely, at least in part, a symptom of the lack of evidence-based treatments for most personality disorders (i.e., clinicians may be less inclined to assess for a problem they feel ill equipped to address), as well as a reluctance to give a diagnosis due to the stigma related to personality disorders among mental health providers and in the general community (Sheehan, Nieweglowski, & Corrigan, 2016).
Second, the ten DSM-5 personality disorders are heterogeneous, with hundreds of distinct constellations of symptoms possible within any single personality disorder (APA, 2013). The interpersonal and intra-personal difficulties associated with personality disorders vary widely – not only across different personality disorders but also within each specific disorder. For example, the interpersonal problems of an individual with paranoid personality disorder would look quite different from those of someone with dependent personality disorder. Furthermore, one individual meeting criteria for BPD may experience interpersonal problems stemming from efforts to avoid abandonment, whereas another may not, instead experiencing greater interpersonal problems related to dysfunctional expressions of anger. Given their vast heterogeneity, it seems implausible that any one intervention could effectively address all the possible needs of clients with personality disorder diagnoses. Therefore, it seems that any effective personality disorder treatment would require a wide range of interventions that can be applied in a flexible and idiographic manner to address each individual’s unique set of problems. An approach to treatment requiring clinicians to select relevant, empirically supported methods of behavior change would also require a principle-based framework to ensure that it remains organized and structured, and to prevent therapist drift or theoretical eclecticism (see Tolin, 2016). In fact, the CBTs for personality disorders detailed by Rosenthal and colleagues (DBT, SFT, and cognitive therapy) are more akin to this approach than they are to protocol-based CBTs for other disorders.
A third important factor to consider, touched on by Rosenthal and colleagues, is comorbidity. As Rosenthal and colleagues pointed out, personality disorders are highly comorbid with anxiety, mood, and substance use disorders. Furthermore, co-occurrence among the different personality disorders is also common (Lenzenweger, Lane, Loranger, & Kessler, 2007). Therefore, treatments that are transdiagnostic and/or modular in nature may be more useful than disorder-specific interventions when treating personality disorders and their likely comorbidities (see Lungu & Linehan, 2016, for a description of DBT as a modular treatment).
Fourth, compounding the issues of comorbidity and lack of routine assessment is the fact that clients with personality disorders often do not present to treatment seeking help for personality disorder behaviors, but for other disorders, such as depression, anxiety, and/or substance use. By definition, the complex constellation of pathology in personality disorders is longstanding and consistent across various contexts. Therefore, individuals with personality disorders may view those symptoms as part of life (never having known anything different), and instead seek treatment for the later-onset and/or episodic problems related to their comorbid disorders (Tyrer, Mitchard, Methuen, & Ranger, 2003).
These issues of comorbidity and heterogeneity, although perhaps more pronounced in personality disorders, are not unique to these disorders. Whereas many non-personality disorders have manualized CBTs, the difficulties translating them from the randomized clinical trials in which they were developed to ‘real-world’ clinical practice have been discussed in numerous papers (e.g., Kendall & Beidas, 2007; Nock, Goldman, Wang, & Albano, 2004). Further, although many empirically supported CBT protocols have been developed and widely utilized, CBT is, at its core, a principle-driven treatment; CBT clinicians, guided by their case conceptualization, implement empirically derived techniques to modify the specific cognitions and behaviors hypothesized to be maintaining the client’s presenting problems (Beck, 2011; Tolin, 2016). Generally, the recommendation for clinicians delivering CBT in “uncharted clinical territories” is to make modifications to branded CBTs based on relevant research and broader CBT principles, while treating each case as a scientific experiment by collecting and analyzing data from the case to test the effectiveness of the modified treatment (Nock et al., 2004). We agree with Rosenthal and colleagues that a similar approach can be applied to the treatment of personality disorders in the absence of branded CBTs. The remainder of this chapter outlines the components we believe can be used to guide CBT clinicians treating personality disorders in a manner that is flexible enough to be tailored to each client’s unique set of problems while remaining grounded in research and adherent to the principles of CBT.
Assessment
Clinicians need a comprehensive understanding of each of their client’s problems and how they relate to one another. Assessment often begins with diagnostic clinical interviews and self-report measures. However, because personality disorders are so heterogeneous and (other than BPD) lack evidence-based CBTs, knowing the specific personality disorder(s) for which a client meets criteria provides little guidance for intervention selection. Therefore, an assessment of the client’s presenting problems (difficulties with emotion regulation, interpersonal dysfunction, experiential avoidance, etc.) and overall levels of functioning within specific domains (e.g., work, interpersonal, recreation, etc.) is likely to prove useful to clinicians. During the initial assessment, the clinician should also take a comprehensive history of the client’s treatment experiences, assessing their helpfulness, as well as what the client did and did not like about each. Finally, clinicians should assess what the client wants to get out of treatment, setting the stage for identifying treatment goals/targets.
Case Conceptualization
Following the initial assessment, clinicians should work with clients to organize their problems into one coherent clinical picture, forming the basis of the case conceptualization. This goes beyond simply listing their diagnoses, or even all of their problems, to identifying how their problems relate to and interact with one another. This process can help identify clients’ core problems – the ones that are contributing to the greatest amount of impairment and/or distress in their lives.
Translating Goals/Problems into Treatment Targets
Next, clinicians should help clients translate their problems/goals for treatment (e.g., improve depression) into behaviorally specific, operationalized targets for treatment (e.g., increase daily positive affect, decrease time spent ruminating, etc.). This will facilitate both the selection of interventions aimed to address the problems and the assessment of their utility in terms of reduction in problems and progress towards goals. During this process, clinicians should be careful to set targets collaboratively and avoid imposing their own goals on the client.
Creating a Target Hierarchy
Clinicians should then work with clients to prioritize treatment targets, creating a hierarchy by determining the specific goals the client is interested in working towards first (with an emphasis on prioritizing those targets that will have the biggest impact on improving the client’s life). This structure will help clinicians and clients organize and prioritize the multiple, complex, and interrelated problems they wish to address, keeping treatment structured from week to week in the absence of a session-by-session protocol. It is important to note that the target hierarchy is not grouped by disorder, but based on transdiagnostic, behaviorally specific targets. For example, rather than “(1) decrease specific phobia of insects, (2) decrease social anxiety, (3) improve academic performance, (4) increase positive affect, etc.” a more effective target hierarchy could condense those targets into “(1) decrease avoidance of anxiety provoking situations, including environments with insects, social interactions, and studying for school, and (2) increase daily positive affect and pleasant events.”
Intervention Selection and Implementation
Once the highest order target has been identified, clinicians must work with clients to conduct a functional analysis of the behavior to develop a comprehensive understanding of the problem. Understanding the problem behavior in relation to its antecedents and consequences, often using recent experiences as illustrative examples, facilitates the identification of the problem’s maintaining factors (Rizvi & Ritschel, 2014). Clinicians can then use this understanding to select appropriate CBT interventions that are most likely to lead to the desired changes, based on research and broader CBT principles. Once the intervention is selected and implemented, its utility must be evaluated through continual tracking and assessment of problems and check-ins with clients to monitor changes in target behaviors over time. Based on these assessments, clinicians can determine what adjustments should be made to the treatment plan to more effectively address treatment targets, or repeat the previous steps to determine which target to address next and how to do so.
In the absence of a protocol to follow over the course of treatment, it is paramount to treat each case as an experiment – generating and testing hypotheses (assessment and treatment planning), gathering and analyzing data (self-monitoring, symptom tracking, check-ins), and adjusting theory based on data (modify/update treatment plan based on relative utility of interventions used). This process allows clinicians to flexibly create an idiographic treatment package tailored to each client’s specific needs that is based on existent empirically supported CBT interventions and guided by broader CBT principles, thereby preventing treatment from drifting into intuition-driven, theoretical eclecticism.
The Therapeutic Relationship
A significant component to any therapy is establishing and maintaining a positive therapeutic alliance. This may be particularly critical when working with clients with personality disorders, given the interpersonal difficulties at the core of many of these disorders. As interpersonal conflict is likely to arise within treatment, clinicians should work to address ruptures head on, using them as an opportunity to model effective skills use in resolving interpersonal problems. This approach may be facilitated by setting the foundation for doing so at the outset of treatment by acknowledging that conflicts are likely to arise, asking the client about past experiences and problems with therapy and therapists, and planning for how both parties can bring up and address problems when they arise.
Conclusion
In the absence of evidence-based treatments for the broad range of personality disorders, we believe that the above outlined methodology represents a CBT-grounded approach to personality disorder treatment. Ideally, researchers will develop and assess the efficacy of CBT interventions for individuals with personality disorders that future clinicians can integrate into their work. For example, Radically Open DBT (RO-DBT; Lynch, 2018), although requiring further research, has shown promise in addressing various disorders of overcontrol (e.g., obsessive compulsive personality disorder). Although it would be virtually impossible to create specific protocols for every combination of personality and comorbid disorders, transdiagnostic and/or modular CBT packages that can be idiographically tailored and applied to the wide variety of clients with personality disorders may be the most promising. The treatments outlined by Rosenthal and colleagues, as well as the principles described here, could serve as the foundation upon which future researchers and clinicians can create new empirically driven CBTs for clients with personality disorders.
References
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