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Principles of Cognitive Therapy with Personality Disorders

Because of the rigidity and primacy of dysfunctional schemas in individuals with personality disorders, cognitive therapy goes beyond the cognitive and behavioral interventions used in the treatment of Axis I disorders and includes strategies to increase collaboration and confront schemas. Specifically, cognitive therapy for personality disorders integrates cognitive, behavioral, interpersonal, and experiential techniques. Compared to the treatment of uncomplicated Axis I disorders, cognitive therapy for personality disorders places a greater emphasis on the therapy relationship, pays greater attention to childhood experiences and memories, and uses experiential techniques to gain access to painful emotions linked to schemas.

Cognitive therapy for personality disorders begins with a cognitive conceptualization that outlines the patient’s core beliefs and relevant life history from which they are derived, conditional beliefs, compensatory strategies and current situations in which they are triggered, and the thoughts, feelings, and behaviors that accompany the activation of core beliefs ( Beck, 1995). By identifying core beliefs and relating them to current distress, a patient’s reactions to stressful life events are more understandable and predictable. The cognitive conceptualization is developed collaboratively with the patient and is elaborated over the course of therapy as new information is learned. Similarly, treatment goals are determined collaboratively. Collaboration is often diffi cult with patients who have personality disorders, for their same sensitivities and vulnerabilities in other relationships impinge on the therapy relationship.

The therapist must consider to the patient’s interpersonal schemas, adjust to them, and introduce them to therapy as appropriate. A number of strategies are used to unravel the meaning of experiences for the patient. Because cognitive and emotional avoidance are common in personality disorders, imagery of past events and present states can reduce avoidance and gain access to core beliefs. Specific treatment strategies for working with various personality disorders (Beck et al., 1990, 2004) andEMS(Young et al., 2003) are explained at length elsewhere. The following discussion offers a very brief description of techniques to confront schemas. Confronting schemas is the keystone of cognitive therapy for personality disorders.

This is done in several steps. First of all, labeling a schema or core belief as such is less stigmatizing than a diagnostic label. It allows the patient to gain some distance from the distress that feels so much a part of his or her identity and conceptualizes it as something that is learned. Education about how schemas operate and working together on a cognitive conceptualization further build an alliance between therapist and patient and against the schemas. Experiential techniques of reliving painful childhood experiences through imagery or roleplay can motivate schema change and are often necessary before cognitive and behavioral techniques can be implemented. Beck et al. (2004) identify three approaches to challenging dysfunctional schemas: schematic restructuring, schematic modification, and schematic reinterpretation.

Schematic restructuring entails decreasing the power of dysfunctional schemas and developing more adaptive ones. To decrease the authority of a negative schema, a historical test or review of how the schema has directed a person’s life is conducted (Padesky, 1994; Young, 1990). Evidence supporting the schema and evidence contradicting the schema is listed for each age period of the patient’s life. Evidence that supports the schema can be challenged by looking for biases in interpretations or alternative explanations of events. For example, a woman who believed, “I am unlovable” used her mother’s lack of attention during childhood as evidence. In reviewing the patient’s history, it was clear that the mother had been very young, uninterested in parenting, and out of the house frequently. In addition, the patient was able to identify other family members and caregivers who had been very attentive. This examination of evidence helped to decrease the intensity of her belief. Unlike people with normal personalities, many people with personality disorders have never formed adequate schemas to incorporate positive beliefs, so they are typically unable to recognize and remember positive information that would contradict their negative beliefs. To build new schemas, an alternative, positive belief is first identified. The patient then keeps a diary or “positive data log” of any evidence, however small, that supports the new belief. Sometimes skills training can increase the power of the new belief by improving the behavior congruent with it.

 For patients who have begun to change, keeping a diary of events along with their old and new perspectives is helpful. For example, a patient might write about a performance, “In the past I would have seen this as a failure, but my new view is that I tried something diffi cult and achieved a partial success.” The Schema Diary (Young, 1993) and Schema Flashcard (Young, Wattenmaker, & Wattenmaker, 1996) are forms used to identify old beliefs and new ways of responding. Schematic modifi cation has the patient gradually test small increments of change. Padesky (1994) describes a number of ways to develop continua for breaking rigid thinking and for making gradual behavioral changes, such as taking small steps to increase trust.

Schematic reinterpretation helps the patient to use their schemas in more functional ways; for example, someone who wants admiration might contribute to the community rather than striving for status. These are just a few specific cognitive interventions. A complete course of cognitive therapy requires the integration of behavioral, interpersonal and experiential techniques as well. As mentioned, there are protocols based on a cognitive conceptualization for each of the personality disorders andEMS. Despite the unique features of the various personality disorders, however, the general principles of schema identification and change prevail.

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