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Cognitive-behavioral therapy for personality disorders: A treatment manual

Technical Report · January 1992

DOI: 10.13140/RG.2.1.2635.6645

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 Cognitive-Behavioral Therapy for Personality Disorders
A Treatment Manual

Updated 2004

Arlinza E. Turner, Ph.D., J. Christopher Muran, Ph.D., & Elizabeth Ochoa, Ph.D.

Original reference: Turner, A.E., & Muran, J.C. (1992). Cognitive-behavioral therapy for
personality disorders: A treatment manual. San Diego, CA: Social & Behavioral Documents.
 2

Preface
This manual serves as a guide for conducting cognitive-behavioral therapy with patients
who have personality disorders, specifically those diagnosed with Cluster C or Personality
Disorders Not Otherwise Specified on Axis II in DSM-IV. These patients typically present as
anxious, fearful, introverted individuals, who are seeking treatment for resolution of symptoms
associated a concomitant Axis I disorder The standardized treatment consists of 30 face-to-face
sessions, each 45-minutes in duration, one per week. The paradigm is largely derived from the
Beck, Freeman, and Associates’ (1990) modification of cognitive therapy principles for the
treatment of personality disorders, and incorporates Persons’ (1988) case formulation approach.
Treatment of individuals with personality disorders often presents unique challenges for
the clinician that complicate the therapeutic process. As such, clinicians may need to adjust their
treatment approach when working with this patient population. With this in mind, the manual is
designed to be more flexible and less prescriptive than manuals exclusively designed for
treatment of Axis I conditions.
The manual is divided into three chapters. In Chapter 1 we present an overview of the
theoretical underpinnings of the model. The complexity of the topic often necessitated
us omitting items and presenting some complicated ideas in a simplistic manner. The therapist
should think of this chapter as a general introduction to cognitive theory and the influence of
theory on practice.
Assessment and treatment strategies are presented in Chapter 2. One hallmark of cognitive
behavioral therapy is that no a priori assumptions are made with respect to the individual patient
or to the specific treatment strategies this patient receives. We, for example, do not assume
understanding of the variables maintaining the patient's difficulties until a thorough assessment
has been completed. The results of such an assessment guide the therapist's behavior and choices
of treatment strategies. Risk assessment for suicidality, substance abuse, and symptom reduction
of comorbid Axis I disorders are routinely conducted.
Outlines proposing the structure of a typical first session, a middle session, and a
termination session are included. The goal is to present the therapist with a sample of the hows
and whys of this treatment. Whereas cognitive behavioral therapy is more than a set of
techniques, this chapter appears technique focused. It is critical that the therapist not become
entrenched in these techniques, thereby applying them in a rote mechanical manner, but rather
consider them tools to be chosen among during the course of therapy.
Described in Chapter 3 are common problems that beginning therapists often
face. Considerable attention is devoted to addressing the misconceptions that clinicians often
have regarding cognitive-behavioral theory approaches to treatment. How such orientation issues
might negatively impact on treatment provision is discussed.
It is important that this manual be understood as an adjunct to the clinicians’ training that
consists of weekly supervision of videotaped sessions and didactic instruction. This written
manual provides the therapists with a treatment framework that can be incorporated into their
supervisory experience, and it is recommended that each therapist read the entire manual prior to
initiating therapy.
 3
Table of Contents
Page
A. Theoretical Framework 4
1. Introduction 4
2. Cognitive theory
4
3. Self-schemas 6
4. Personality disorders 7
5. Cognitive manifestations of maladaptive self-schemas 9

B. Assessment, Case Formulation, & Treatment 10

1. Introduction 10
2. Assessment and case formulation 11
Establishing a case formulation 12
a) Problem list 12
b) Assessing the dimensions of each problem
13
c) Identifying self schemas 16
d) Treatment goals 17
3. Assessment strategies 17
a) Imagery 18
b) Think aloud 18
c) Within-session monitoring 18
d) Downward arrow
18
e) Self-monitoring 18
f) Scheduling activities 19
g) Format for first session 19
4. Treatment intervention 22
Phase 1: Symptom relief of Axis I Condition 22
Phase 2: Schema change 22
a) Cognitive change strategies
23
i. Three questions 23
ii. Cognitive errors 23
iii. Cognitive rehearsal 23
iv. Problem solving 24
v. Reattribution 24
vi. Imaginal Exposure 24
v. The use of metaphor 25
b) Behavioral change strategies 25
i. Breathing retraining 25
ii. Applied Relaxation 25
iii. Self reliance techniques 25
iv. Diversion strategies 25
v. Interpersonal strategies 25
vi. Homework 26
vii. Activity scheduling 26
viii. Role-playing 27
ix. Enactment exercises 27
x. Modeling 27
xi. Format for intervention session 28
5. Termination 28
Format of a termination session 29

C. General Treatment Issues 30

1. Treatment format 30
2. Initiation of treatment 30
a) Homework 32
b) Educating the patient 33
3. Supervision 35
4. Orientation issues 35

D. References 37
 4
CHAPTER 1
Theoretical Framework

Introduction
Cognitive behavioral therapy represents a short-term treatment that generally adheres to
four basic tenets: (a) "The human organism responds primarily to cognitive representations of its
environments rather than to those environments per se; (b) these cognitive representations are
functionally related to the processes and parameters of learning; (c) most human learning is
cognitively mediated; and (d) thoughts, feelings, and behaviors are causally interactive"
(Mahoney, 1977, pp.7-8). Its efficacy has been particularly supported in the area of depression
(e.g., Beck, Rush, Shaw, & Emery, 1979; Elkin, Shea, Watkins, & Collins, 1986; Rush, Beck,
Kovacs, & Hollon, 1977), although it has also been employed in the treatment of anxiety (Beck
& Emery, 1985; Clark, 1986), eating disorders (Edgette & Prout, 1989), and schizophrenia
(Perris, 1988). Most recently, it has begun to be addressed in the treatment of personality
disorders (Beck & Freeman, 1991; Cohen & Nezu, 1990; Young, 1990).

Cognitive theory
Cognition is a general concept embracing all forms of knowing, including perceiving,
imagining, reasoning, and judging. Its use in this manual refers to a particular type of self-
referent thinking, rather than to its more traditional use in the evaluation of intelligence, memory
functioning, abstract reasoning, etc.
Although there have been a number of reformulations over the years (see Muran, 1991,
for a review), early cognitive behavioral formulations, such as those by Ellis (1962) and Beck
(1976), have attributed causal primacy to cognition in the evocation of emotion. In other words,
the meaning of an event determines the emotional response to it. A significant factor that
contributed to the development of this mediational model was the information processing model
in cognitive psychology. Strongly influenced by the brain-as-computer metaphor, this theory did
much to render unobservable psychological phenomena amenable to scientific observation. A
central manifestation of the information-processing model is the schema concept, which proved
to be a useful construct in accounting for the way in which humans organize and process
information from the environment. This theory fails to take into account, however, that there is a
significant difference between the way in which computers process information and the way in
which humans acquire knowledge (Bartlett, 1932; Neisser, 1967). In reality, humans are not
disembodied computing machines that simply process static information. Instead, they actively
mine the world for information by maneuvering about, manipulating, and interacting with their
environment (Shaw & Bransford, 1977).
An alternative to the information processing model in cognitive psychology is the
ecological model to perception (Gibson, 1979). This theory focuses on human psychological
functioning in the context of the environment in which the functioning takes place. Accordingly,
humans are seen as biological organisms that live and operate in the context of specific
environments and are adapted through an evolutionary process to their environmental niche.
Thus, it is concerned with understanding the adaptive significance of various aspects of human
functioning in the context of the environment in which they evolved. The emphasis, therefore, is
on the acquisition of knowledge from the environment, rather than on the processing of
 5
information about the environment. Perception is considered the fundamental act through which
humans acquire information from the environment regarding their adaptation to the environment.
No distinction is made between perception and cognition, as meaning is considered inherent in
the act of perception. The individual is conceptualized as an organism in continuous interaction
with the environment, constantly acting upon the environment and acquiring information about
the environment through action. Thus, there is an integral link between cognition and action.
The brain is, therefore, a specialized organ of action, rather than a passive computing machine
(Weimer, 1977).
Neisser (1976) attempts to combine the best features of the ecological and information
processing models of cognition. He adopted the ecological emphasis on perceptual processing
and interaction with the environment but also retained the information processing concept of
schema. He proposed that the individual acts upon the world through perceptual activity and that
this activity revises schemas in an ongoing fashion. In other words, the individual acts upon the
environment and in turn is acted upon by the environment. This ongoing modification of
schemas in turn continues to direct perceptual activity in an ongoing fashion.
The integration of these two models lends itself quite well to understanding the nature of
emotion (Safran & Greenberg, 1986, 1988). Accordingly, emotion can be viewed in functional
terms as providing individuals with information about themselves as organisms interacting with
and adapting to the environment. Meaning is inherent in emotion. It emerges out of perceiving
the implications of environmental events for humans as biological organisms. The meaning is
essentially reflected in the action dispositions that help motivate potentially adaptive action in the
world. For example, if carried through to action, fear leads to flight, sadness to withdrawal, and
anger to aggression, all for the purpose of self-protection. There are specific expressive-motor
configurations that correspond to specific emotions.
Due to the adaptive significance of emotion, the basic structure for emotional experience
is considered neurologically hardwired in the human organism (Plutchik, 1980; Tomkins, 1980).
As Piaget (1954) recognized, infants are biologically programmed to make primitive perceptual-
motor responses prior to any learning, which are adaptive in nature. These responses
subsequently become more elaborated through the process of learning. Thus, the infant develops
memory structures consisting of specific expressive-motor responses, relevant eliciting stimuli,
associated images, and associated autonomic arousal. These memory structures, which can be
called emotional schemas, become progressively elaborated and refined over time and are central
to emotional experience.
The concept of emotional schemas represents an integration of both the information-
processing and ecological models. It is a concept also described by Leventhal (1984). He
hypothesized that emotional experience is coded in memory in schematic structures that
incorporate the following subsidiary components: episodic memory for specific events and
expressive-motor (instrumental and autonomic) reactions, all of which are associated with
specific emotional experiences. According to Leventhal, when one component of an emotional
schema is activated, it increases the potential for activating the entire schematic structure,
resulting in the subjective experience of emotion associated with that schematic structure.
This schematic conceptualization of emotion has been similarly articulated by Lang (1985)
and is consistent with the body of research regarding the intrinsic relation between affect and
memory (e.g., Bower, 1981; Teasdale, 1983). Simply put, its implications for cognitive
 6
behavioral theory is that cognition is a manifestation of emotion concomitant with affective and
motoric expressions. In other words, the experience of emotion is a wholistic integration of
cognitive, affective, and motoric components that are schematically structured (Guidano & Lotti,
l983; Mahoney, l991; Muran, l991; Safran & Greenberg, l986).
Having a basic understanding of emotion in human functioning is useful in understanding
the way in which change can occur on a schematic level. Since many important human
experiences are processed at an emotional level, it would seem to restructure meaning at this
level in order for therapeutic change to take place. Information that is processed at a conceptual
level often fails to capture adequately important aspects of human experience. Therefore,
problematic emotional schemas need to be assessed during therapy in order to make them
amenable to change. The more the stimulus configuration matches a schema, the more likely it is
that the schema will be evoked. The therapeutic setting becomes a powerful laboratory for
evoking schemas and for restructuring them. Restructuring can occur on the basis of decentering
and experiential disconfirmation. These concepts are discussed further in Chapter 2. Briefly,
decentering involves helping patients self-observe and develop awareness of their emotional
schema. Experiential disconfirmation involves providing the patient with a differential learning
experience that includes the generation of schema-inconsistent information, thereby altering the
organization of the schema (Greenberg & Safran, 1989; Safran & Segal, 1990).

Self-schemas
It is important to recognize that using the schema concept does not eliminate the necessity
of clarifying what type of knowledge is central in the context of emotion and emotional
disturbance. Considering this, researchers have begun to categorize knowledge structure
according to the type of information they seek to organize. While a number of hypothetical
typologies of schematic structures have been proposed, the schematic structure that has received
the most attention in this regard involves representations of the self identified as self-schemas
(e.g., Beck, 1967; Guidano, 1987; Williams, Watts, Macleod, Mathews, 1988). There is a great
deal of confirmatory data (see Segal, 1988, for a review) suggesting that there exists in memory a
relatively cohesive and extensive knowledge base about the self, which individuals draw upon to
process emotional information in specific situations.
From the social cognition tradition, Markus (1977) probably has contributed most to the
development of the definition of self-schemas, which she has defined as "cognitive
generalizations about the self, derived from past experience, that organize and guide the
processing of self-related information contained in an individual social experience" (p.63). She
(1990) revised this definition to include the idea of "possible selves," that is, what the individual
might become, would like to become, and is afraid of becoming. This revision is compatible
with the use of self-schema in the cognitive behavioral therapy tradition to account for
maintenance of the self, in terms of how to maintain one's self-worth and relatedness to others, as
well as how to protect and keep oneself happy and secure (Beck & Emery, & Greenberg, 1985;
Safran & Segal, 1990).
Most recently, Markus (1990) has described the self as a multidimensional set of
structures or a collection of self-schemas that play a critical role in organizing all aspects of
behavior. In her emerging view of the self, she conceptualizes each person as holding multiple
representations of the self
 7

--the good me, the bad me, the not me, the actual me, the ideal me, the ought me,
the possible me, the undesired me, the hoped-for me, the expected me, the feared
me, and the shared me (i.e., me-in-relation-to-my-mother; me-in-relation-my-
spouse, etc.). Of this universe of self-representations, only some will become
focal for the individual and receive a high degree of cognitive, affective, or
somatic elaboration. Those representations that, for whatever reasons, become the
target of such intensive elaboration are the self-schemas. And it is the self-
schemas that will dominate consciousness, and perhaps unconsciousness, and that
can be considered the "core" self (p.242).

With her idea of "shared me", she introduces the interpersonal nature of the self into the
self-system, which is consistent with Neisser's (1988) inclusion of the "interpersonal self" in his
most recent exposition on self-knowledge, among others (e.g., Guidano, 1987; Liotti, Mahoney,
1991). Accord-ingly, "self-schemas are in large measure interpersonal achievements" (Markus,
1990, p.249). Hartley (1990) underscores the significant role of the other in the development of
one's self-schemas by reporting that older children become increasingly sensitive to the views of
others and learn to use these views to verify and refine their own self-representations. Bowlby
(1969) also suggested that finely-tuned, contingent responding from those in one's social
environment, particularly early caretakers, may be a key to the development of viable self-
schemas. There is also a great deal of compelling developmental research that focuses on the
critical role of attachment figures in developing the sense of self, including the research on affect
attunement and misattunement between self and a significant other (Stern, 1985, Tronick, 1989)
and the research on the importance of "reading" the other's affective state to get a second
appraisal of how one should feel in an ambiguous situation (e.g., Campos & Sternberg, 1980;
Emde & Sorce, 1983; Klinnert, 1983). Therefore, the emerging picture regarding the etiology of
self-schemas becomes clearer when the role of the other is addressed. The role of the other
becomes even more important when understanding how self-schemas account for personality
disorders.

Personality disorders
The concept of "personality disorder" is a relatively new one to those whose theoretical
orientation is anchored in learning theory. Recently, however, it has received greater acceptance
given the increased support of enduring person variables and evidence of both longitudinal and
cross-situational consistency of behavior (e.g., Mischel & Peake, 1982; Wright & Mischel,
1987). By most accounts, an individual is considered to have a personality disorder when their
construal style and interpersonal behavior are particularly rigid and restricted and when their
characteristic style of construing and interacting fosters vicious cycles that perpetuate and
intensify their difficulties (e.g., DSM-III-R, 1987; Millon, 1986).
 8

These vicious cycles can be accounted for by self-schemas that had played an adaptive
role in a early developmental context, but have become maladaptive in a later context. For
example, the individual, whose parents valued intelligence and were want in providing love and
affection, may have learned that their approval was only contingent on his intellectual behavior.
As a result, when he seeks the approval of others, he may behave in an intellectualized and
pedantic manner, which may only serve to distance others. The distancing responses, which are
characteristically evoked in other people, further confirm the belief that he is unlovable. Thus, an
interactional cycle is reinforced, according to which such an individual is guided by rigid beliefs
about the self in relation to others, which fosters repetitive interpersonal transactions. The more
rigid an individual's beliefs about oneself and others, the more rigid their interpersonal behavior.
Further, the more rigid their interpersonal behavior, the more likely they will elicit a similar
response from a range of different people in a range of different circumstances. This
subsequently limits their interpersonal learning experiences, which invariably serves to reinforce
their beliefs about themselves in relation to others (Cohen & Nezu, 1990; Muran & Safran,
1993).
Table 1 represents the rigid patterns of construing and behaving that are characteristic of
the personality disorders in DSM-III-R (adapted from Beck & Freeman, 1990). The presentation
of Table 1 is intended to be used as a gross picture that provides an approximation of the patterns
one might expect in personality disorders. It is not considered definitive and should not used to
pigeonhole patients. In reality, the picture is much more complicated as patients present with
varying pathological patterns that more or less agree with a number of personality disorders
categorized in DSM-III-R

Table 1
Cognitive and behavioral patterns of personality disorders

Self View Other View Interpersonal Behavior

Cluster A
Paranoid Innocent Interfering Wary & accusatory
Schizoid Loner Intrusive Withdrawn
Schizotypal Nothing Rejecting Distant and eccentric

Cluster B
Antisocial Autonomous Exploitative Aggressive & manipulative
Borderline Empty Black&white Impulsive & erratic
Histrionic Impressive Receptive Dramatic
Narcissistic Superior Inferior Competitive & manipulative

Cluster C
Avoidant Vulnerable Demeaning Avoidant
Dependent Needy Nuturant Clinging
Obsessive-compulsive Fastidious Casual Controlling
Passive-aggressive Vulnerable Controlling Passive resistance
 9

Treatment of individuals who have personality disorders needs to include a thorough

assessment of possible emotional difficulties, such as depression and/or anxiety, as well as a risk
assessment for suicidality and substance abuse. The emotional distress of a patient with
personality disorder, Cluster C or PD NOS might be manifest as particular features of an Axis I
disorder without meeting full diagnostic criteria, or conversely, might meet full criteria
warranting an Axis I diagnosis. Regardless of the etiology of the anxiety and depressive
symptoms, treatment of Axis I conditions is a necessary consideration when developing the
treatment plans and case formulation for personality disordered patients. Symptoms associated
with anxiety and depression often are the precipitants of these individuals seeking treatment and
usually are readily reported by patients. Data in support of the efficacy of cognitive behavioral
treatment methods in treating personality disordered patients directly, with or without co-morbid
Axis I disorders, is emerging within the literature (Arnitz, 1999).

Cognitive manifestations of maladaptive self-schemas

There are a number of cognitive manifestations of maladaptive self-schemas that have
been described as correlates of emotional disturbance and representations of underlying
personality disorders. Since incoming information is interpreted or processed in a manner that is
consistent with an already existing schema, it is reasonable to expect that maladaptive schemas
will lead to inaccurate or distorted processing of information. In fact, Beck's (l976) "cognitive
errors" are examples of how distortions in information processing attribute to emotional
disturbance. Such distortions as "overgeneralization" in which one draws general rules from
little or no data, or "selective abstraction," in which only some aspects of a stimulus array are
attended to and more salient information is ignored, may reflect the course of emotional
disturbance. These cognitive processes represent systematic errors in thinking that frequently are
manifested in cognitive products, which operate at an automatic level, often out of awareness and
without any apparent antecedent reflection. These products, which are discussed further in
Chapter 2, have been referred to as automatic thoughts (Beck, 1976). They include
misinterpretations and exaggerated evaluations that can be accessed through the process of
attention. Automatic thinking that is evaluative in nature is what Ellis (1979) has identified as
irrational thinking, including demandingness ("This shouldn't happen!"), awfulizing ("It's awful
that this happened!"), I-can't-stand-it ("I can't stand that this happened!"), and self-damnation
("I'm no good because this happened"). It is important to note that automatic thoughts are
considered to be 'hot' cognitions (Abelson, 1963) in that they are affectively laden cognitive
products.
Implicit to the automatic thoughts are what have been called dysfunctional attitudes.
These include rigid belief systems or underlying assumptions that are reflective of the knowledge
about the self contained within the schematic structure. Because these attitudes operate on an
implicit level, they cannot be readily articulated and can only be accessed through a process of
inference. The content of these typically concern such issues as competence, acceptance, and
control/comfort. They are typically couched in the form of if-then rules or contingencies (e.g., "If
I do this, then I am that"), although any linguistic formulation of a contingency is consistent (e.g.,
"I must do this in order to be that"). These contingencies are rules for activating sequences of
action by which the initiation of an operation is contingent on the presence of some input, i.e., if
the appropriate input is detected, then a certain operation is performed (Abelson, 1981).
 10

Examples include self-worth contingencies (e.g., "I need to succeed in order to be worthwhile"),
self-other contingencies (e.g., "I need to be strong in order to be accepted by others"), and self-
protection contingencies (e.g., "I need to take every precaution in order to feel safe and secure").
These beliefs/assumptions have also been represented in unconditional or noncontingent terms
(e.g., "I am a failure) where the conditional part has been omitted. Young (l991) has theorized
that this omission reflects the chronicity of the belief. However, it may be safer to assume that
the conditional part of the attitude is simply implicit.
These cognitive manifestations represent the central focus of cognitive behavioral
therapists in their attempts to better understand maladaptive schemas. Since self-schemas are
posited to be emotional in structure, it is crucial that assessment be conducted in the context of
relevant emotion. In other words, the relevant cognitions associated with, say one's fear of
abandonment, are most likely to be accessed when this fear is evoked. Furthermore, since self-
schemas are interpersonally derived, they may be activated in the therapeutic situation, which is
by nature interpersonal. Therefore, a fear of abandonment may be evoked in the context of the
therapeutic relationship. In light of this, it is important to explore and challenge, when
appropriate, automatic thoughts surrounding this relationship and the patient’s implicit self-
schemas that are evoked.
The process of schematic change is challenging because patients often are reluctant to give
up their entrenched, yet dysfunctional rules for navigating the world. Strategies for schematic
change include restructuring (accommodation) and modification or reinterpretation
(assimilation). These strategies are described in the treatment goals section of the manual.
Schematic modification and reinterpretation are best suited to our time limited treatment model.

CHAPTER 2
Assessment, Case Formulation, & Treatment
of Cluster C Personality Disorders or Personality Disorder NOS

Introduction
Three core phases of treatment: the assessment phase, the intervention phase, and the
termination phase, define this 30 session protocol. The assessment phase includes the first five
treatment sessions, during which time the clinician clarifies the nature of the patient’s presenting
complaints through the process of functional analysis. Functional analysis refers to the
thorough, methodical examination of the patient’s symptoms and problems and the underlying
mechanisms that contribute to the patient’s view of self, others, and the world. The results of
the analyses leads to the attainment of the clinician’s primary assessment goal: to generate
hypotheses that synthesize the patient’s automatic thoughts as core schemas. The schemas that
emerge as maladaptive then are examined to determine their role in maintaining the person’s
symptoms, conflicts and personality difficulties. The assessment process culminates with the
unfolding of a thorough, albeit preliminary and malleable case conceptualization, which serves as
the backbone of treatment.
During the assessment phase, an in-depth risk assessment of suicidality and substance
abuse is conducted at the beginning of each session. The re-assessment of suicide potential and
 11

substance abuse is an ongoing process that occurs at the beginning of each session throughout the
treatment.
Sessions six through 25 comprise the intervention phase of treatment. Patients and
clinicians collaborate to test the veracity of the hypotheses generated during the assessment phase
and begin to effect change using cognitive and behavioral strategies. Patients learn to identify and
modify rigid, maladaptive schemas about himself or herself, significant others, and the world that
have contributed to distress. Education, experimentation with schematic change principles, such
as modification or reinterpretation, and confrontation of cognitive distortions exemplify
cognitive-behavioral strategies that increase patients’ flexibility and adaptability in challenging
their core beliefs.
The final phase of treatment is termination. The process of terminating therapy, while a
difficult task for most patients regardless of diagnosis, is a particular challenge for personality
disordered patients. These individuals often present with interpersonal conflicts and struggles
around autonomy and control, which are evoked during the termination process. Although
discussion of termination is encouraged throughout the time-limited treatment to prepare patients
for its eventuality, the final sessions of treatment are devoted to the termination process. The
goals of the termination phase are to review of treatment gains, to anticipate future concerns and
coping strategies, and to discuss the personal significance for the patient of ending treatment and
the therapeutic relationship.
This next section will consider key aspects of each phase of treatment (assessment,
intervention, termination) and describe salient points. The format of a typical session in each
phase will be outlined to guide the reader in structuring sessions, thus facilitating adherence to a
standardized treatment. It is important to note, again, that while these session outlines are meant
to illustrate prototypic sessions, they can be modified when necessary to allow for the flexibility
in approach that is often required for the successful treatment of individuals who have Axis II
personality disorders.

Assessment and Case Formulation

Cognitive behavioral therapy begins with a functional assessment of the patient’s
complaints and a formulation of each case. The primary goals of this phase are the identification
of target problems, the development of a problem list, and the specification of the maintaining
variables associated with each problem. The therapist examines each problem with the specific
goal of identifying patterns and common themes that might connect these target complaints, so
that a guide or a map that dictates the therapist's future clinical decision making is developed.
Consider, for example, the difference in clinical decisions when two patients who present as
relatively dependent and who frequently complain of difficulties in interpersonal relationships.
One person believes, "I can't do anything right, and most people are more competent than I am."
The second person operates under the assumption, "People will find a way to use you if you let
on that you know too much." Again, the same presenting problem exists but each person has
different maintaining beliefs. The goal of the case formulation is to identify self schemas that are
specific to the individual.
One male patient seen in our clinic presented at intake with three target complaints,
including difficulty making a career choice, inability to meet the right female companion, and
 12

family conflicts. Through sampling past attempts to leave his job, the therapist concluded that
the difficult career decision was due to fear of leaving a very comfortable, longstanding job as a
computer expert for two or more years of education with little or no income. The patient
accounted for his difficulty meeting women as due to not knowing where to meet them and his
poor conversational skills. His younger brother was described as not "serious-minded" and
"connected" to the family. One can imagine the treatment scenario that might develop when
these targets are viewed in isolation. A problem-solving approach, for example, might be
employed to address his difficulty making a career decision, while social skills training or
cognitive restructuring might be suitable for the relationship problems. However, when each
target problem was thoroughly evaluated with respect to his self view, his other view and his
interpersonal behavior, the patient's poor self-esteem ("If I were a professional, then people
would respect me.") and his need to be impressive to others, underscored all of his difficulties.
His dysfunctional self schemas became the target for treatment, rather than his career difficulties,
etc., per se.
A well formulated case should identify variables that connect the patient's complaints. In
the absence of this organization, the therapist is likely to view each of the patient's problems as a
"target" to be addressed independently of each other. It is important to clarify that this is a likely
scenario and not an absolute one. In other words, there may be times when it is quite appropriate
to target the specific difficulties of a patient as a focus of treatment. Again, this is a decision that
it determined by the case formulation.

Establishing a Case Formulation

A case should be formulated within the first five treatment sessions. Persons (l989) has
identified several factors that are important to consider in assessing and formulating each case:
identifying a problem focus, assessing the dimensions of each problem, and identifying self
schemas. While each of these are discussed separately in the following sections, it is important
to understand that in actual practice, they require a continuous process.
Problem list. During the elaborate screening process of this research project, most
patients will have identified at least three problematic areas that interfere with their optimal
functioning. Often these complaints are clear, such as "I am depressed. I can't make a
commitment to one person" or more vaguely, "I can't seem to get my life going. My life is a
mess." Given that patients in our project usually have both Axis 1 disorders and personality
disorders (Cluster C or PD NOS), it is highly unlikely for this list to be exhaustive of the
patient's difficulties. Therefore, one of the first goals of treatment is to establish a problem list of
the specific difficulties that will be addressed during treatment. Data about each problem
obtained through a functional analysis of the patient’s complaints facilitate the therapist’s linking
of the target complaints, thereby identifying possible maladaptive schemas. Both Axis I and
Axis II difficulties are included on the problem list.
There are a number of strategies that the therapist might find helpful in clarifying this
problem list. These, as suggested by Persons (l989), include:
a) Having the patient to elaborate on the problems that were presented at intake. This is
especially important when problems are presented in vague, general terms. For
example, a problem such as "I can't seem to get my life moving" might lead to one or
more discrete problems, such as lack of assertiveness, skills deficit, interpersonal
 13

difficulties --angry, hostile presentation, etc.

b) Providing a structure for talking about the patient's difficulties. The therapist might
simply say to the patient: "Let's come up with a list of problems that you would like to
work on in therapy."
c) Careful monitoring of patient's behavior during the initial sessions. Behavioral and
affective strategies employed by the patient during a session might provide useful
information on how the patient interacts with people in general. For example, does the
patient jump to conclusions with little data or does the patient tend to catastrophize
events or what are the patient's social skills like?
d) Examining the history. Educational, family, interpersonal history can often provide
useful information on the difficulties that patients are having.
The therapist will need to decide when and how to share each identified problem with the
patient. In most instances, this will be a simple task since the patient will have identified the
problem. Occasionally, a patient may be unwilling to see something as a problem (e.g., hostile
interactions, sabotaging relationships, manipulative style) even after some discussion. In this a
case, the therapist probably should not force the patient to view this as a problem, but instead
makes a mental note to add this to the problem list when evidence may be more convincing to the
patient. Also, it becomes critical to identify the problems as they occur during the sessions or in
homework as this becomes the source of data, such as "I notice that you become angry each time
I mention your daughter." While it is important to identify problems early on in the treatment,
some difficulties, for various reasons, do not emerge until much later. This is especially true for
problems that are interpersonal and socially unacceptable. As such, the therapist should consider
the process of identifying a problem list as ongoing.
Assessing the dimensions of each problem. Each problem on the problem list is
considered to have multiple dimensions, each of which the therapist is expected to assess through
a functional analysis. The goal of the functional analysis is to obtain a thorough detailed
depiction of the patient’s emotional and interpersonal conflicts. Symptoms of Axis I disorders as
well as the problems associated with the patient’s personality disorder are identified and
characterized along the following dimensions: verbal-cognitive information, overt behavior and
affective experience. Information from each of these areas is critical in understanding the
problem and thus to a case formulation. It is expected that the patient will be able to articulate
each problem along these three dimensions. Data gathered for each problem along these
dimensions facilitates the clinician’s understanding of the nature and extent of the Axis I
disorder, including suicide and substance abuse risk. These data also serve as the backbone for
hypotheses generated by the clinician about the underlying mechanisms of the patient’s
personality problems and his or her core schemas. The dialogue presented below of a patient
who complains of lack of assertiveness should illustrate this point.

Patient: I need to be more assertive.

Therapist: What does that mean?
Patient: I let people walk all over me. (behavior)
Therapist: Can you give me an example of this?
Patient: People are always doing it. At work. At home. I can't seem to get
my point across because people either talk louder or quicker than I
 14

or they think they know everything. I am never heard. I guess its

just as well since I don't usually have much to say (behavior) and I
don't usually like arguing at work. (behavior)
Therapist: I see. Can you give me an example of this?
Patient: Last week my boss said that he would appoint someone to do a
survey by the end of the week. Everyone is busy and no one wants
additional work so they all told him this. On Friday he asked me to
do the survey. I was so angry. (mood) How could he ask me to do
this when I am just a busy as everyone else? I should have
complained like everyone else.
Therapist: Any thoughts about why you did not complain?
Patient: I thought that it was no use. (thought)
Therapist: Did you consider telling your boss about how busy you are?
Patient: Yes. Everyday, but I couldn't bring myself to go into her office.
(behavior)
Therapist: Why is that?
Patient: I keep thinking, what if I am wrong, what if she doesn't agree with
me that I am too busy or maybe she will think that I am just trying
to get out of doing work. (thoughts)
Therapist: What was that like for you to be so angry?
Patient: I was nervous all Friday morning. I just knew she would ask me to
do the survey since I hadn't complained. She figured "what the
heck, he doesn't mind." But I do mind doing all the work. They
don't respect me. (thought and affect)
Therapist: Who is it that doesn't respect you?
(Note that the therapist is not interested in the reality of the
patient's statements during this early assessment. The goal is to
determine what is going on for the patient from the vantage points
of behavior, thought and affect.)
Patient: No one at work. In meetings they don't listen to me. I always get
the worst cases to work on.
Therapist: What is it like for you when people don't respect you?
Patient: They don't take me seriously. They dump things on me. They
don't consider my feelings. They look over me when its time for
raises and promotions.
Therapist: Earlier you said that people tend to walk all over you. Does this
happens often?
Patient: Yes, I guess it does. At work is where it really bugs me. (affect)
Therapist: Can you tell me about some of the other situations where this
happens?
(Note that the therapist is trying to determine how broad this
problem is. If another example is provided by the patient, the
therapist will again try to understand it from the vantage point of
three critical dimensions.)
 15

Patient: My wife sometimes expects too much of me.

Therapist: How does she do that?
Patient: Like when there is an opportunity for a promotion at work, she gets
angry when I don't apply for it, even though its not the right
position for me.
Therapist: How does your wife know when there is a position available at
your job?
Patient: Various ways. Usually positions are announced in a weekly
newsletter or at a company's party. She will see someone new or
someone might mention it to her. And there were times when I
would tell her about it, which I don't do anymore. They are usually
positions for someone with my background and I could do a great
job, but they are often more pressure than I can tolerate right now.
Therapist: What kind of pressure are you talking about?
Patient: Work pressure. People put pressure on you. They expect you to
know everything, and then when you make one mistake, although
you've been a good worker for years, its all over. You're on the bad
list for life, never to recover. (thought) I know. I've being there.
Therapist: You seem angry as you're telling me this?
Patient: I'm not angry.
Therapist: Then what are you feeling right now?
Patient: Well, I guess I feel a little sad. I don't know which way to turn to
make things right. If I do it this way, these people will not like it
or if I do it another way, some other person is not going to like it.
Therapist: What happened when your boss asked you to do the survey and
you got angry?
Patient: I called my wife (behavior) who was busy and who did not want to
talk. Then I really got angry (mood) and I started yelling at her
over the phone. (behavior) She hung up on me and said we will
discuss it at home.
Therapist: Why did you get angry?
Patient: I was feeling overwhelmed. No one seems to care. It's always just
dump it on old Carl. He doesn't care. He's not going to give you
any trouble. And now my wife is getting more and more like this.
(thought)
Therapist: Any thoughts about why this is happening?
Patient: I think that if I question people they won't like me anymore.
(thought)
Therapist: And what would happen if you were not liked?
Patient: People would say disgusting things about me. It would be difficult
for me to get raises and promotions. It would be more difficult
functioning since I can't imagine being any other way.

To reiterate, each problem on the list is examined along behavioral, cognitive and
 16

affective dimensions, considering both Axis I and Cluster C or NOS personality disorder
features. Clarification at this level is critical as these components are often derivatives of the
patient's self schemas. The automatic thoughts gleaned from the case example might include
"People walk over me. They don't respect me. I'm never heard. I don't have much to say".
Automatic thoughts tend to be situation specific, emotionally laden, and again, reflective of
patient's self schemas. Sometimes these thoughts are merely maladaptive in that they are accurate
but have a negative impact on the patient. Others may be irrational in that they are either not data
based or based on distorted data.
Using the case example, we find that the automatic thoughts are either statements about
the patient (e.g., I don't have much to say) or statements about others view of the patient (e.g.,
"They have no respect for me") and patient's view of others (e.g., "People walk over me").
Automatic thoughts are derivatives of the patient's self schemas, which can be best understood
using the structure of self view, others view of self and interpersonal behavior.
Identifying self schemas. As mentioned self-schemas include self view, view of others and
the patient's interpersonal behavior. From the case illustration we might conclude the following
with respect to these three dimensions:

Self View Other View Interpersonal Behavior

Weak No one cares Quiet and aloof
Unsure about skills They put pressure on you Yelling
Never heard They have great expectations Withdrawn
They don't respect you

Once these views are clarified across the problem list, the therapist identifies common
themes that connect these problems. Typically we like to think of one clear perception as
maintaining the problem list, but it is probably best to talk about a series of self schemas rather
than a single way of evaluating the world, although within this series, there may be one view
more pronounced than others.
For the sake of demonstration, let us say that the case example represents just one of
several target problems explored by the therapist. Let us also assume that in assessing the other
problems, similar responses were given by the patient. The following schema may be relevant:
"If I ask for what I want, then people will not like me. And if people don't like me, then I will not
get very far," or "I am incapable of asking for what I want. I am weak." Note here that self
schemas are couched in contingencies, "If" I do this, "then" this is going to happen. Such
contingencies might not always be apparent and it is likely that the therapist will need to take the
responsibility for clarifying the schema(s). Also self schemas may not be contingency based. A
patient, for example, may think that he or she is "a bad person" or "not capable of doing anything
right."
Self schemas become critical targets for treatment. For example, when a young female
executive presented to therapy citing job difficulties and being depressed about her intimate
relationships as her target complaints, the treatment emphasis was not on her automatic thoughts:
"I hate my job, people at work are incompetent and lazy", or concerning her intimate
relationship, "He is uncaring, he doesn't know what he wants, I don't know what I want".
Instead, treatment goals were aimed at self schemas: "If I let people get to know me, then once
 17

they know me, they will see that I am not as great as I present myself." Interpersonally, this led
her to sabotage relationships when they became too close and to respond flippantly and critically,
thereby demeaning the entire work setting when given any type of feedback at work.
In summary, clinical decision-making is a function of the case formulation. The process of
formulating a case involves the therapist helping the patient to establish a list of problems and
conducting an examination of these difficulties along several dimensions (e.g., cognitive, overt
interpersonal behavior and affective experiencing) during a functional analysis. Both Axis I and
Axis II disorders are evaluated. The therapist uses this information to characterize the patient’s
mood and emotional difficulties, as well as to elucidate the patient's self view, view of others and
interpersonal behavior. This data in turn leads to the case formulation and the inference of
hypotheses about the underlying mechanisms associated with the patient’s difficulties.
Treatment goals. A patient diagnosed as having a personality disorder in addition to an
Axis I disorder typically requires more work within the session and more energy from the
therapist than a patient with an Axis I diagnosis alone. Furthermore, the difficulties in managing
patients with personality disorders may be magnified in the current project since there is a 30
session time limit to the treatment. As such, treatment goals need to be clarified. While
treatment goals should be discussed with each patient, the beginning of therapy may be too early
to do so. At the initiation of treatment patients are more likely to be anchored in Axis I
complaints (e.g., depression, anxiety and interpersonal problems) than in goals seemingly
unrelated to their reported difficulties.
Several treatment goals can be articulated with respect to this project. It is expected that, at
the end of treatment, patients will have a reduction in Axis I symptoms and will come to
understand better their maladaptive, patterns and how these may relate to dysfunctional self
schemas. Secondly, the therapist should be able to provide the patient with differential learning
experiences so that dysfunctional beliefs can be tested and challenged. Schematic change can be
promoted through techniques such as schematic modification or reinterpretation (assimilation),
which can be implemented in a time limited model. Finally, there should be some evidence at
the end of treatment that the patient is beginning to make changes in his or her maladaptive
interpersonal style and lifestyle. This should be reflected in both intra and extra-session
activities.

Assessment strategies
The patient will need to articulate automatic thoughts in a number of affectively laden
situations. This process, referred to as decentering, is a necessary component of schematic
change. Decentering is the process by which one steps outside of one's immediate experience
and observes oneself in the process of interpreting a situation negatively.
Patients may need to be taught the process of decentering. In doing so, several problems
may arise. Many patients may have difficulty monitoring thoughts because of their own
dysfunctional beliefs (e.g., "If I fail, then the therapist will reject me"). Some patients find it
difficult to report their thoughts because of little or no experience monitoring cognitive
processes. Others may simply feel that they should not have negative thoughts. Some may have
the experience of monitoring and acknowledging negative thoughts, but not monitoring them in
an on-going manner. As described by Safran and Segal (l990), patients frequently say that they
 18

are aware of their negative, self-critical thinking and, therefore, question the value of monitoring
thoughts. This problem may not be unique to patients, as beginning therapists often question the
value of encouraging their patients to monitor their thinking when they have already become
aware of them. However, "knowing that one engages in negative self-critical thinking is very
different from having the tangible experience of observing oneself in the process of interpreting a
situation negatively. It is the stance of the dispassionate observer of one's own construction
process that is the essential ingredient" (Safran and Segal, l990; p.118).
Several cognitive and behavioral strategies for decentering are provided below. Only
their assessment function is provided here as some have treatment properties that are discussed
later in this chapter. It might be useful for the therapist to think of this array of decentering
strategies as falling into one of two categories: those performed within the session (i.e., imagery,
think aloud, within-session monitoring, downward arrowing), and those that might be assigned as
homework (i.e., self-monitoring, activity scheduling).
Imagery. Some patients may have difficulty expressing their thoughts directly into words.
The use of imagery: (e.g., "What pictures or thoughts come to mind?") might be particularly
suitable for these patients. The use of images may help to clarify the automatic thoughts that
occur in a similar naturalistic situation.
Think aloud. This technique might be particularly useful when a patient does not
understand the task, which is to observe oneself thinking. One patient who had difficulty
understanding how to monitor her automatic thoughts when in a specific feared situation (i.e., on
the subway) was told by the therapist at the beginning of a session, "We are going to ride the
subway today. Tell me what's going through your mind right now." The patient became quite
anxious and verbalized many thoughts relative to her fear of the subway. These thoughts were
audio-taped and then later played to the patient as a demonstration of her automatic thoughts and
what cognitions the therapist is asking her to monitor.
Within-session monitoring. The patient's in-session behavior and affect, both of which
are good yardsticks of the events and experiences that are subjectively meaningful for the patient,
should be employed to assess patients' automatic thinking. A change in behavior or affect, for
example, might lead the therapist to ask "What is going on for you right now? What are you
thinking about?" The therapist might express his or her concerns, "I am confused by what you
are saying. What would it mean if I rejected you?" Automatic thoughts tend to be situation
specific. Therefore, it is necessary to sample them in as many situations as possible. Also,
because patients often label their feelings and thoughts in unusual ways, the therapist will want to
search for idiosyncratic meaning. As discussed below, one strategy that is useful in this search is
called downward arrowing (Beck et al, l979).
Downward arrow. Some thoughts reported by the patient may initially seem meaningless
or easy to challenge with respect to validity. For instance, in response to being overlooked by the
boss in a meeting, a patient may think, "She doesn't think I have anything to offer." This thought
is likely to be upsetting to the patient. The initial reaction of the therapist might be to ask
questions about how reasonable the inference is (e.g., "Has she given you any other indications of
her interest or disinterest in what you have to say?" or "Could there be other reasons why she
acted that way?"). The therapist could lose valuable information at this level of assessment since
there may be meanings the patient extracted from this inference that are particularly important to
her. A better line of questioning might be of the form, "and what would it mean (regarding you
 19

or your future) if it were true that she sees you as not providing useful information?" Downward
arrow refers to a series of questions that can be asked of almost any inference, where each answer
begs another question. They are of the form, "What if it is true that...?" or "What about that
bothers you?" The aim of each question is to probe for the personal meaning of the inference. In
the example provided above, the downward arrow might yield, "I am basically not valued here."
Self-monitoring. This is the process by which one observes his or her own behavior,
usually in the natural setting. Patients may be asked to monitor their automatic thoughts as they
occur in relation to some specific event. Patients are typically asked to allow negative affect
(e.g., anxiety or depression) to serve as a "cue to monitor" self-talk. The goal is twofold: to
assess situational variables, dysfunctional and irrational cognitions and, more importantly, to
teach the patient to attend to his or her thoughts and images as they occur. As described above,
while this information might be obtained retrospectively, self-monitoring of cognitions as they
are produced is likely to yield a more valuable sample as they are likely to be observed in the
context of emotionally laden situations. Since patients often avoid situations that give rise to
negative emotions, there may be decreased opportunities for the patient to self-monitor automatic
thoughts. Therefore, the therapist may need to schedule some activities to ensure occurrence.
Scheduling activities. The therapist might schedule an activity that is known to be
affectively laden for the patient with the goal of doing nothing except listening and recording
self-talk. It is important that the patient understands the purpose of a scheduled activity.
Scheduling an activity that the patient has a history of avoiding may seem ludicrous, but may be
employed not so much to get the patient to engage in the activity, but as a vehicle for
understanding what happens when the patient makes an attempt to carry out the task. Successive
approximation may be necessary as some tasks may be too overwhelming in their entirety for the
patient to perform.
To summarize, any one or a combination of techniques can be useful in helping a patient
to decenter. Decentering, the process of stepping back and observing one's automatic thinking,
has been approached here as purely an assessment goal and something that occurs very early in
treatment. It is important for the therapist to recognize, however, that decentering is a task to be
taught and is on-going. Furthermore, by increasing awareness, decentering may facilitate the
change process.
Format of a first session (adapted from J. Beck, 1995, and Persons, 1989). The structure
of an initial cognitive-behavioral session in this protocol does not differ strikingly from that of
the remaining assessment sessions, and therefore, can be considered prototypic.

Session 1.
Set an agenda (5 mins.): Collaborate on goals of the session and topics to be
covered.

Rapport building (ongoing)

Education (10 mins.): Introduce key cognitive behavioral principles and

process, the rationale for change, Define the nature of the patient’s disorder;
Clarify expectations about treatment goals and outcome.
 20

Mood/Mental Status Query (5 mins.): Assess patient‘s mood to determine nature

and extent of emotional distress. Assess for presence of Axis 1 symptoms.
Assess use or dosage of psychiatric medication. Risk assessment for suicidality
and substance abuse. Yields baseline data to be monitored throughout treatment.

Identification of Target Complaints (5 mins). Patient’s report of difficulties

he/she is experiencing that are the impetus for treatment at this time. Patient
indicates which of three target complaints he/she wants to examine first.

Begin to assess dimension of first target complaint (15 mins.) by functional

analysis: Contributes to clinicians understanding of problem through
identification of automatic thoughts. Provides initial data upon which to build
case conceptualization.

Wrap-Up and Feedback (10 mins.): Assign first homework task, stressing
rationale, utility and import. Summarize key aspects of session. Answer
questions/concerns patient might have.

The first session is a very important one because it introduces cognitive-behavioral therapy
principles, clarifies the roles of the clinician and patient, and elucidates expectations regarding
the interactions between the participants. When working with personality disordered patients,
particularly those who present with Axis I symptoms or co-morbid disorders and interpersonal
difficulties, it is crucial that the clinician attend to the development of a positive therapeutic
alliance and to the building of trust. Patients often experience considerable anxiety when
beginning treatment and have preconceived notions of the therapy process. It is the job of the
clinician, during the first session, to orient the patient to the treatment in a supportive,
collaborative manner, so as to foster rapport. While a systematic examination of the patient‘s
presenting or target complaints is necessary during the first session, in depth scrutiny of specific
treatment goals at this time is better postponed for subsequent sessions.
During the first session and subsequent assessment sessions, the case formulation is
developed. As shown in Table 2, key ingredients of the case formulation include: basic
demographic information, identification of the chief complaint, specification of the problem list
and the summary of data from the functional analysis of each problem. Hypotheses about the
underlying mechanisms of the self schemas, that reflect self beliefs, other beliefs, and cognitive
processes or behavioral patterns, are generated. Also included in the case formulation is the
clinician’s understanding of the links between the underlying mechanisms and the presenting
problems. The origins of the problems and the patient’s history, are explored as well. Lastly, a
treatment plan is developed with goals identified and the interventions to be implemented
specified. Predicted obstacles to treatment are noted.
 21

Table 2
Case formulation worksheet

Identifying information:

Chief complaint:

Automatic Thoughts/
Problem List: Stimulus Situations: Affective States: Behaviors: Consequences:
1.
2.
3.
4.
5.
6.
7.
8.

Hypothesized Mechanisms
Underlying Cognitive Processes or Underlying
Self-Beliefs: Behavioral Patterns: Other-Beliefs:

Relation of Mechanisms to Problems:

Origins of Problems:

Treatment Plan
Goals: Interventions:
1.
2.
3.
4.

Predicted Obstacles to Treatment:

 22

Treatment intervention
A well formulated case should define the clinical course. Specifically, it tells the
therapist which Axis I conditions and which self schemas will be targets of change in this
treatment. This is particularly important as there may be self schemas that will not be the focus
of attention in this therapy. The targets for treatment are the dysfunctional schemas that are
inferred from an assessment of the patient's self-view, others’ view of self, and his or her
corresponding interpersonal behavior patterns.
Treatment intervention in this paradigm involves a two stage process:1) Symptom relief or
reduction, which targets the Axis I symptoms or disorder, and 2) Schema change, which focuses
on ameliorating the Axis II personality disorder difficulties Many patients initiate treatment
because of distress associated with symptoms of an Axis I disorder, with their chief complaints
generally reflecting symptoms of anxiety or depression or both, rather than of symptoms
associated with a personality disorder. As such, the initial phase of treatment focuses on patients
first learning the skills necessary to achieve reduction of Axis I symptoms (pp.430), with the
subsequent application of these skills to the interpersonal and behavior problems associated with
their personality difficulties (Freeman & Leaf, 1989). Although the treatment design suggests a
two prong process initially, with the focus of treatment first being on symptom relief of the Axis
I condition, over the course of treatment, the two phases operate in tandem rather than follow a
sequential path.

Phase 1: Symptom Relief of Axis I Conditions

Individuals who have personality disorders frequently present with symptoms associated
with Axis I disorders, usually anxiety or depression or a combination of the two, as chief
complaints. These complaints are incorporated into the problem list that is developed by the
clinician and patient during assessment. Based upon the case formulation, a decision tree is
implemented, to guide the direction of treatment as focusing either on the reduction of anxiety or
of depression symptoms. In cases where both anxiety and depression exist, both pathways are
employed. Each pathway consists of specific interventions and techniques aimed at the reduction
or relief of either anxiety or depression symptoms. The anxiety pathway incorporates techniques
that include: breathing retraining, applied relaxation, imaginal exposure based exercises, and
cognitive restructuring. The depression pathway employs cognitive techniques such as eliciting
and challenging automatic thoughts, cognitive rehearsal, and behavioral techniques such as
scheduling activities, self-reliance training, role playing, and diversion strategies. Extra session
tasks, particularly homework, are integral components of each track.

Phase 2: Schema Change

Phase 2 involves the continuation of utilizing these techniques as applied to Axis I
conditions, but now incorporates techniques aimed at facilitating changes in core schemas that
maintain the personality disorder.
Cognitive distortions and biases serve as the markers of maladaptive schemas. A number
of strategies can be employed to challenge these distortions so that modifications to the
dysfunctional scheme occur. One strategy, schematic restructuring or accommodation, involves
the replacement of dysfunctional schemas with adaptive schemas. In other words, schemas that
 23

support dysfunctional adaptation are attenuated or eliminated, and new beliefs that are adaptive
replace them. However, because of the time-limited nature of this treatment, the change
strategies of modification and reinterpretation are better suited to our model than schematic
restructuring. (Beck et al., 1990).
Schematic modification is less ambitious a process than restructuring in that it operates by
changing just certain aspects of the dysfunctional schema under particular circumstances. In this
way, a patient can evaluate the value or feasibility of change as part of a gradual process (Beck et
al., 1990).
Another option for promoting schematic change is that of schematic reinterpretation.
Reinterpretation involves a patient understanding his or her dysfunctional schemas or rules and
reconceptualizing them in functional ways (Beck et al., 1990).
Schematic change may evoke anxiety in some patients when asked to give up old
comfortable, albeit dysfunctional, lifestyles and behavior patterns and to “try on” new ways of
responding to others and the world. Patients should be prepared by clinicians for this eventuality.
Symptoms of anxiety should be monitored consistently so that the patient does not become
overwhelmed and resort to maladaptive patterns (Beck et al., 1990).
Several strategies for change are provided below. For the sake of clarity, these strategies
for change are divided into two lists; those that are that more cognitive in nature and those that
are more behavioral. There is much overlap between the two groups. These strategies can be
applied to the reduction of either anxiety or depression symptoms and have relevance for
schematic changes as well. It is expected that the therapist will use this as a guide rather than as
an exhaustive list of treatment strategies.

Cognitive change strategies

The following strategies form the basis for cognitive restructuring. The strategies
described below are adapted from various sources, including Barlow, 2001; Beck et al., 1979;
Beck et al., 1985; Beck et al., 1991; and Freeman et al., 1989.
Three questions. Though there are any number of ways to classify the questions that can
be asked of inferences, one classification serves a heuristic function for patients while they learn
the methods of this therapy (Beck et al, l979). The three kinds of questions patients are taught to
ask are: (1) "What is the evidence for and against the belief?" (2) "What are alternative
interpretations of the event or situation?" and (3) "What are the real implications, if the belief is
correct?" Each question is stated here in a general form and it is expected that the therapist will
be able to modify them given the needs of the patient.
Cognitive errors. The therapist teaching the patient to recognize when his or her thinking
falls into one of several categories of cognitive errors. These cognitive distortions, as described
by Beck et al (l979) are presented below:
a) Arbitrary Inference. Drawing a particular conclusion in the absence of substantiating
evidence or even in the face of contradictory evidence. An example of this is the
working mother who concludes after a busy workday, "I am a terrible mother."
b) Selective Abstraction. Conceptualizing a situation as the basis of a detail taken out of
context, ignoring other relevant information. An honoree at a banquet was not asked
to speak before her admirers. She concluded, "They don't really think I'm that great
because they didn't ask for a speech."
 24

c) Overgeneralization. Formulating a general rule based on one or a few isolated

incidents and applying the rule broadly to other situations. An example of this is the
man who concludes after a brief affair, "I'll never get close to anyone because I can't."
d) Magnification and Minimization. Viewing something as far more or far less
significant than it actually is. Upon putting a minor dent in her car, a young woman
concluded that she was a terrible driver who had a major collision.
e) Personalization. Attributing external events to oneself in the absence of any causal
connection. After being treated brusquely by a supervisor, a man concluded, "I must
have written a bad quarterly report."
f) Dichotomous Thinking. Categorizing experiences in one of two extremes; for
example, a complete success or a total failure. A doctoral candidate said, " I must be
the best student in the department, or I've failed."
These labels are used to remind the patient that he or she is prone to various forms of
exaggerations and other biased thinking. At these times, the patient can discount the improbable
or illogical inference, reframe it in a less extreme form, or analyze the inference using the three
questions. For example, a student finding it difficult to study for finals may conclude that she
will not graduate, not get into law school and be a disgrace to her family. The student may then
notice that she is catastrophizing or magnifying the situation, particularly if another outcome is
likely (e.g., The student has done reasonably well in school and this course up to this point).
Cognitive rehearsal. This technique involves the therapist asking the patient to imagine
the successive steps needed to implement a particular task to completion. Breaking down a task
into its component parts in this way allows the therapist and patient to determine what type of
obstacles interfere with the patient’s ability to perform the task.
Problem-solving. Patients with personality disorders are likely to be limited in their
problem-solving and alternative generating skills. As such, one task is to help the patient learn
how to generate alternatives and to make available as many solutions to the problem as possible
and to maximize the likelihood that the best and the more effective solution is among them. Two
goals in problem solving include: (a) helping the patient learn to brainstorm, that is, generate as
many solutions or ideas relevant to the problem as possible, and (b) helping the patient learn the
process of considering the value or effectiveness of each alternative. These two goals are not
mutually exclusive, but may be difficult for a patient whose focus is very narrow to learn
simultaneously.
Reattribution. One strategy for inducing positive cognitions involves helping the patient
alter his or her beliefs regarding certain causes and effects, that is, modifying attributions. For
example, when one patient who presented with a history of insomnia had difficulty sleeping, she
thought, "My problem is returning. I won't be able to sleep and it's going to get more
problematic." During the course of the therapy session, the therapist discovered that the patient
had moved into a new apartment and that there had been some minor problems with the move.
The therapist suggested that this recent change in lifestyle is probably enough to disrupt most
people's sleeping pattern. Attributing her recent sleeping difficulties to a change in stimulus
situation was more reassuring than "My longstanding sleep problem is returning."
Imaginal Exposure. There are various ways in which imagery may be employed to
produce change. One method, decatastrophizing, might involve the therapist pushing the patient
to state the most extreme aspects of a situation (e.g., What is the worst thing that could happen?),
 25

and then guide him or her to see that even the worst scenario is not as catastrophic as the patient
had imagined. Similarly, the therapist might have the patient exaggerate an image. For example,
Beck, Emery and Greenberg (l985) describe a patient who was fearful that others would find out
that he had failed a licensing exam and was told to imagine his story appearing on the front page
of the newspaper and the headlines for the six o'clock news. The goal is to get the patient to
move beyond the limits of the fear so that it may be placed in a different perspective. One patient
seen in our clinic feared that he might act on his homosexual thoughts. During the therapy
session the patient was pushed "to the limit" with these thoughts as a means of demonstrating
that these thoughts do not immediately lead to action. Again, the goal is to help the patient to
place these thoughts and images into perspective.
The use of metaphor. One of the better ways of reinterpreting what people think is
through the use of metaphor. Specifically, behavior that may not be identified easily by the
patient, might be clarified in the context of someone or something else. For example, one patient
who believed that she "should know everything" was told, in addition to this being impossible,
that she would have to be a set of encyclopedia books to know everything. That then became a
cueing device each time the patient began to operate under that belief system. "You're being that
book again. What volume are you today?" It is reasonable to expect that the patient will begin to
apply this in her routine daily experiences. The decision to employ metaphors must be
individualized as some patients may have difficulties with this strategy.

Behavioral change strategies

Breathing retraining. Patients who have anxiety symptoms may experience irregularities
in their breathing, such as hyperventilation syndrome. Regulation of breath may reduce a
patient’s tension level. When anxious or under stress, a person’s breathing can become shallow
and rapid. When relaxed, breathing is usually slow and deep. Teaching a patient to control their
breathing through abdominal breathing exercises can produce a state of calm relatively quickly.
Applied relaxation. Applied relaxation is a technique shown to be effective in the
treatment of anxiety disorders. Therapists teach patient’s a sequence of relaxation exercises that
target specific muscle groups and involve a tensing and releasing of these muscles. Attention is
maintained throughout the exercise on the muscle group that is being tensed and relaxed and on
the feelings of relaxation that ensue. This technique is often used in combination with imaginal
or meditation techniques.
Self reliance techniques. Patients who experience crippling anxiety or depressive
symptoms might fail to take care of their basic needs or activities of daily living, such as
grooming, showering, cleaning, without aide from significant others. Self reliance techniques
foster a patient’s greater independence and responsibility for their self care, by having them take
action. This strategy also involves the patient learning greater control over their emotions.
Diversion strategies. Sometimes patients are overwhelmed by their negative feelings and
are overreact to painful emotions. Techniques to distract oneself from negative or overwhelming
thoughts include: physical activity or exercise, socialization, mental activity involved with work
or play.
Interpersonal strategies. Behavior and affect generated by maladaptive schemas may be
apparent in the therapist-patient relationship. The patient's behavior may elicit similar responses
in the therapy setting as those that are problematic in other relationships. As such, it is important
 26

that the therapist be aware of this possibility. The therapy session might be viewed as a form of
in-vivo exposure whereby the patient is confronted with his or her difficulties and where the
interpersonal difficulties of the outside world remain intact. Sometimes within-session
difficulties will be explicit: The patient argues about well defined treatment parameters (e.g., the
time-limited 30 session treatment, changing the appointment times, etc), while on other
occasions, these difficulties may be more implicit and require the therapist to be cognizant of his
or her feelings towards the patient and the patient's internal experience (e.g., "I am confused. I
keep doing things for this patient. I am terribly bored by this.") Again, given the adaptive
inflexibility of the patient's response style, others may respond in an identical manner to this
patient. Being able to examine one's feelings towards the patient has important treatment
implications as the therapist may need to use this information to determine how he or she will
respond to the patient.
Homework. Patients diagnosed with personality disorder with or without Axis I disorders
typically have adopted behavior patterns that are relatively inflexible across a variety of
situations. Rigid schemas often make it very difficult for these patients to "test" new waters. As
such, automatic thinking and dysfunctional attitudes are rarely put to test. For instance, a male
who believes that women will reject him is likely to avoid women or engage in behavior that is
likely to lead to his rejection, thus confirming his dysfunctional thinking. In addition to various
other functions (see Chapter 3) homework has proven to be a useful means of providing patients
with new learning opportunities. For many it is viewed as a safe way of testing hypotheses as it
is often framed as an experiment designed to see if it will work rather than as something that is
sure to work. For instance, a patient who feels ignored by his superiors might be encouraged
initially to identify someone that the superior does listen to and then to assess what that person is
doing differently. Later, the patient might be asked to engage in similar behavior with his
superiors as a way of practicing these skills, rather than as a way of getting the boss to listen. If
successful, the patient has new and immediate data that are inconsistent with his previous way of
thinking. If there are difficulties, then it becomes a unique assessment opportunity that focuses
more on the impact of the patient's skills rather than on some external variables.
Activity scheduling. One form of homework that may be particularly relevant in altering
rigid patterns is to help the patient schedule activities outside of the therapy session. The purpose
of scheduling activities is to remove decision-making as an obstacle in the initiation of an
activity. Since the decision was made during the session, the probability of it being initiated is
increased. An activity might be scheduled to allow the patient to "test out" a hypothesis. For
example, one patient seen in the project believed that her boyfriend of several years would get
uncontrollably angry if she asked him to consider having a baby. The therapist assigned the
activity to help the patient see that such a reaction would be quite inconsistent with the behavior
patterns so often exhibited by the boyfriend. Sometimes an activity in its entirety may be too
overwhelming or counter-productive. For example, getting a patient who has difficulty
establishing social contact to date, may be an assignment doomed to failure and further reinforce
the patient's belief that "I am socially inept." The therapist might establish a graded series of
tasks that will ultimately culminate in a dating situation. Activities are arranged over time so that
they progress from least to most affectively laden. In the above example, the first step to dating
might be to get the patient to attend a social gathering with no specific agenda. This might be
followed by having the patient talk to someone that he or she knows at a social gathering,
 27

followed by having the patient meet someone new at a social gathering, and so on until the
patient has been able to establish a date.
Role playing. Sometimes, within-session activities, such as role-playing may be
necessary in preparing the patient for out-of-session activities. Frequently it is too difficult for a
patient to engage in exposure based work outside of the therapy session. Role playing provides
an opportunity for the patient to step out of a "safe" world to test his or her skills without the
added component of failure. Often times patients plays themselves, with the therapist assuming
the role of a significant person in the patient's life, such as a spouse or a boss. Sometimes these
roles are shifted so that the therapist plays the patient and the patient plays the significant other.
Enactment exercises. Several enactment strategies may be useful in helping patients
understand the dysfunctional nature of their thinking. One technique, similar to role-playing, is
for the therapist to play out the patient's dysfunctional thinking with the goal of getting the
patient to convince the therapist that he or she is thinking irrationally. An alternative is to have
the patient play out his or her irrational side. Specifically, after establishing that a particular
position that the patient takes is irrational, the therapist might have the patient give voice to that
side. The patient who states "I am very self-critical" might be asked "Let me hear you being
critical." This strategy might help the patient step outside of him or herself and observe the
irrational self.
Modeling. Modeling may also be necessary in preparing the patient for out-of-session
activities. Since rigidity is often a characteristic of this patient population, it is expected that
most will limit their learning experiences to those that do not confront or challenge dysfunctional
schemas. Modeling has proven to be a useful means of helping patients to learn new appropriate
behaviors, to demonstrate already learned behavior patterns in more appropriate ways or towards
more appropriate people, and to approach difficult feared situations. Sometimes the therapist
may serve as a model. Other times a patient may be able to identify persons in their environment
who may be engaging in a particular behavior that the patient has found difficult to perform. The
patient is instructed to observe the other performing this behavior. One patient, for example,
found that her colleagues had no difficulty getting projects approved by her boss, whereas she
frequently failed at this. The therapist had her observe and later practice the behavior of her
colleagues.
In summary, a number of techniques were described that have been shown to be effective
cognitive behavioral strategies for symptom reduction of Axis I anxiety and depression disorders.
These strategies are applicable to facilitating schema change as well. Again, this list is not
exhaustive. The combination of techniques employed is individualized for each patient, and is
directly related to the case formulation.
Format of an intervention session. The structure of an intervention session does not vary
considerably from session to session. Once the assessment phase has been completed, the task of
treatment is to effect change as directed by the case formulation. Treatment goals have been
reviewed previously, so that patient and therapist ideally share the same expectations about the
process of therapy.
During a typical intervention session, identification of Axis I symptoms and core schemas
is made explicit to the patient. Links between the patient’s view of self, others, and the world,
and his/her presenting complaints are underscored. Strategies for change are explained and
implemented. Monitoring of the patient’s progress and the reduction or resolution of the
 28

patient’s presenting complaints is ongoing.

 29

Session 15.
Set an agenda (5 mins.): Collaboratively agree on goals of the session and
topics to be covered. Introduce new items/updates.

Rapport building (ongoing)

Check-In (5 mins.): Mood Assessment. Assess for change in Axis I symptoms

compared to initial session. Risk assessment for suicidality and substance abuse.
Monitor use or dosage of psychiatric medication.

Review Previous Session (5 mins.): Brief synopsis of work to date. Solicit

patient’s additional thoughts on material from prior session.

Homework (10 mins.): Review patient’s written or verbal homework task.

Discuss obstacles if not completed.

Continued Discussion of Target Complaints as Related to Axis I symptoms or

Core Schemas and Maintenance of Problems (20 mins.): Strategies to decrease
emotional distress or to create differential learning experiences reviewed and
applicability to target problem considered (problem solving techniques,
reattribution, etc.). Identify patterns of maladaptive responding to self and others.
Address problems within the therapeutic relationship when present.

Wrap-Up and Feedback (5 mins.): Assign homework task. Summarize key

aspects of session. Address questions/concerns patient might have.

Termination
Cognitive behavioral therapy is time-limited, and as a result, many of the problems often
associated with termination are usually not as complex as those associated with some of the
longer forms of therapy. However, just as any therapy, much of the benefit can be lost through
inappropriate or inept closure. For this reason it is important that the process of completion of
therapy be handled as effectively and smoothly as possible.
One primary mistake that therapists often make is that they frequently wait until the end
of therapy to talk about termination. The issue of termination is one that should be touched on
periodically throughout the therapy. From the beginning the therapist stresses to the patient that
he will not stay in treatment indefinitely and that he or she will spend the time working on the
difficulties presented at intake. One of the main goals of cognitive behavioral therapy is to teach
the patient to become his or her own therapist. A very good example of this is the "three
questions exercise." This is further supported in the sense that therapy takes on a collaborative
style in which the patient actively takes part in the therapy rather than seeing it as something
which is done to him or her. The therapist attempts to present himself realistically in the process
of therapy. This has the effect of countering the patient's dependency on the therapist and any
belief in the "magic" of therapy. Throughout therapy, the patient is encouraged to become more
independent and self-reliant. As therapy progresses, the patient plays an increasingly active role
 30

in identifying target problems and choosing strategies. This sets the stage for the patient to
become his or her own therapist.
The doubts and concerns that patients express regarding termination should be treated as
any phenomena that comes up in cognitive behavioral therapy, that is, as a vehicle for examining
cognitive distortions. For example, a common concern expressed by patients is not being
"completely cured." This may be an example of dichotomous thinking, the patient seeing mental
health as either "sick" or "cured" (see the section of cognitive errors.) In this case the therapist
can point out that mental health is not dichotomous but rather continuous with many points along
the continuum. This might be further reinforced by pointing out how the patient has moved
along this continuum during treatment. Also, it is important to review and reinforce the initial
treatment goal: to teach the patient ways to more effectively handle his problems and not to cure
him or restructure his personality.
For many patients the arrival of termination activates issues and concerns about the
interpersonal meaning of separation. "Because therapy is an interpersonal relationship of
potential significance for the patient, it is likely that complex feelings and characteristics (often
maladaptive) ways of handling separation will emerge" (Safran & Segal, l990, p.214). In a
cognitive behavioral framework, the therapist uses this approach to termination as an opportunity
to explore the patient's maladaptive way of responding to and managing separations.
One consistent finding among therapists in our group is an increase in anxiety as the close
of therapy approaches. Such questions as, "We only have six more session. What can we do?"
The patient's anxiety about the end of therapy often exacerbates this, "I feel like we are just
getting started. I don't feel very different than when I first came." Often this gets translated into
the therapist feeling incompetent. It is important that the therapist recognizes that the
termination of therapeutic contact does not signal the end of therapy or the change process.
Some would argue that in some cases the more dramatic changes will take place after
termination. This is important to keep in mind as it may reduce the pressure to produce change.
The termination of therapy should not be treated any differently than any other
component of treatment. Specifically, whatever happens during termination should be
approached and understood in a systematic manner with the goal of exploring as fully as possible
its significance for the patient and the relationship between the therapist and the patient.

Format of a termination session

The structure of the last sessions in this protocol follows that of the intervention sessions.
However, there is a shift in content of the last sessions. The primary emphasis becomes
addressing the significance and meaning of the end of treatment to the patient. Exploration of
any competency concerns ensues.
During the process of terminating treatment, the following material should be
communicated: summarizing the course of treatment, reviewing treatment gains by assessing the
extent of resolution of the target complaints; specifying change strategies that were effective in
helping the patient confront and modify maladaptive patterns of behavior and thought; and,
anticipating future problems or concerns the patient might face post-treatment. It is of particular
import, given the interpersonal difficulties of most individuals who have personality disorders,
that a frank discussion about the patient’s feelings about the ending of the therapeutic
relationship occur.
 31

Session 30.
Set an agenda (5 mins.): Collaboratively agree on the goals of the session and topics to be
covered. Limit the introduction of new items/updates. Explicitly acknowledge the
session as final.

Rapport building (ongoing)

Check-In (5 mins.): Mood Assessment. Compare to mood report at initiation of treatment.

Assess for suicide and substance abuse potential. Review use of or need for psychiatric
medication.

Review Previous Session (5 mins.): Solicit patient’s additional thoughts on termination

material from prior session.

Summarize Course of Treatment (25 mins.): Final review of status of target complaints.
Summarize treatment gains, including symptom reduction or relief of Axis I disorders,
while identifying the relationships between maladaptive views of self, others, and the
world that had initially defined core schemas and dysfunctional problems/behaviors.
Briefly review key change strategies that were effective for the patient in attaining desired
changes. Reconsider import of therapeutic relationship during treatment.

Wrap-Up and Feedback (10 mins.): Anticipate future difficulties the patient might
encounter. Summarize key aspects of session. Answer questions and concerns patient
might have about future treatments and therapist’s post-treatment availability.

CHAPTER 3
General Treatment Issues

Chapter 3 provides a practical guide for considering and resolving the general treatment
issues that can emerge during the course of a time-limited, standardized cognitive-behavioral
treatment. It serves as a reference tool for clinicians when negotiating the unique challenges
inherent in treating the personality disordered patient and augments material presented earlier in
the manual. General information about the treatment protocol is included as well.

Treatment format
Patients will be seen on a weekly basis for approximately 45 minutes face to face for a
total of 30 sessions. All sessions are videotaped. Each patient and therapist will complete a
questionnaire following each therapy session. Patients entering treatment will be knowledgeable
of these parameters and will have agreed to them.
 32

Initiation of treatment
Given the nature of the screening process, it is likely that each patient will have seen a
number of people prior to their first contact with the therapist. Patients frequently have
formulated expectations about the therapy process, the type of therapy, and the therapist by the
initial contact. These are likely to emerge during the first few sessions. The therapist is to treat
these expectations in the same manner as any other phenomena in cognitive behavioral therapy.
One patient, for example, questioned the time-limited nature of the therapy during the first
session, asking what happens at the end of 30 sessions. One approach might have been to answer
the question directly, "This is a time-limited research project, and as such, there is a need to stick
to the protocol. However, if after 30 sessions you feel that additional therapy is necessary, we
ask that you wait a while and then return for therapy." Another alternative was to use this
question as an assessment opportunity, the goal being to examine the patient's thinking
(automatic thoughts) regarding what has happened thus far. For example:
Patient: What happens after 30 sessions? I mean what if the patient is not
better.
Therapist: Are you concerned that you will not be better after 30 sessions?
Patient: I don't know. Its just very hard to start with someone and then just
when you think it is getting somewhere it's over.
Therapist: Has this happened before?
Patient: Well, I have been in therapy before and I can't seem to get on with
my life because of some of my difficulties.
As can be seen, the difficulty has less to do with the current time-limited therapy, than the
concern of the patient that he or she is "a hopeless case." The therapist might also continue this
line of questioning to assess issues of attachment and loss which are also implied by the patient's
question. Patients often depend on the therapist to initiate sessions. One question that is
particularly useful in that it lends itself to assessing schemas is "How did you feel about coming
here today." The patient might use this as an opportunity to discuss concerns about therapy,
feeling about the evaluation process, and the type of treatment group that he or she has been
assigned. Alternatively, the patient might use this as an opportunity to express feelings about
therapy in general. Specifically, patients diagnosed as having personality disorders tend to have a
long treatment history and are often frustrated and discouraged about the process. The therapist
might use this as an opportunity to elicit some of the automatic thoughts associated with coming
to therapy. This might contribute to the therapist's understanding of the patient's self view and
view of others. For example:
Therapist: How did you feel about coming here today?
Patient: I was nervous.
Therapist: What thoughts (as opposed to Did you have thoughts?) did you
have about coming here today?
Patient: I was nervous. I didn't know exactly what to expect. I filled out so
many papers. I thought that I might be rejected because there were
so many different questions on the test.
Therapist: Are you feeling nervous now?
Patient: A little, but now that I am here and we are talking, most of my
nervousness is gone. I have been a little nervous since I made the
 33

first phone call. I knew that you had to meet certain criteria in order
to get in.
Therapist: What would it mean for you to be rejected (as opposed to what
would have happened).
Patient: I don't know. Maybe filling out all the papers was a waste of time.
I don't know.
Therapist: But it sounds like you felt this way long before you knew that there
were so many papers to complete?
Patient: Yes, I guess you are right. I worried a lot about getting in, and the
longer it took you guys to call, the more worried I became.
Therapist: What else (as opposed to Is there) would it mean to be rejected?
Patient: Oh, I don't know (Pause). Maybe I think that there is no help for
me. Maybe my problems are so bad that no one can really help me
get better. Maybe I didn't fill out the papers correctly. If I had
been deemed unsuitable for the therapy, then not taking me would
have confirmed this for me, I suppose. I feel much better now that I
am here, though.
Note that the therapist is expressing concern about the patient's feelings with regard to
what the patient has experienced thus far. This might be considered a rapport building technique.
However, in doing so, the therapist has not lost sight of the mission, that is, the assessment of
cognitions (automatic thinking) and understanding the patient's self schemas. Furthermore, even
in this brief initial contact several hypotheses can be generated (e.g., patients is a worrier, there is
fear of rejection, fear of going crazy, fear of negative evaluation). As the assessment and
treatment continues, the goal is to support (as oppose to confirm) or discard these hypotheses.
Homework. The power of homework has been documented as an effective
psychotherapeutic component. In assigning homework we generally tell patients: An important
component of your treatment will be what you do between the sessions. Frequently, you will be
given homework assignments. These assignments will vary depending on a number of factors.
These factors are not important right now, but it is important for you to understand that these
assignments are important to the treatment process." The patient is encouraged to view
homework as an integral component of the treatment and not just an elective, adjunct procedure.
The therapist spends time presenting the rationale for each assignment. The importance of
carrying out each assignment is stressed frequently throughout treatment. Research (see Bellack
& Hersen, l977) has demonstrated that patients are more likely to complete an assignment if they
understand the rationale for it and if allowed to express any concerns. Instructions for homework
be clear. Vagueness is a major reason for noncompliance with homework assignments. Written
instructions seem best for increasing compliance. Homework should be presented as an
experiment (e.g., "Let's see how this works?") rather than delivering it as something that will
work or that one must do.
Homework has both assessment and treatment value. The differences should be clear
prior to giving the assignment. The therapist needs to be clear on how the information gathered
from homework is going to be meaningful. Listed below are examples of homework
assignments that are often given to depressed patients. Note that there is a clear rationale for each
assignment.
 34

a) Self-monitoring of mood state. Patients are asked to monitor the degree of depression
at various times of the day over some specified period of time (e.g., usually for one to
two weeks). The goal is to determine fluctuations in mood that the patient may find
difficult to remember or is insensitive to in retrospect. Furthermore, if fluctuations do
occur, this assignment might also be helpful in determining what factors, if any, covary
with this fluctuation.
b) Self-monitoring of activity level. Typically, this is done over a one to two week period
to assess how active the patient is. This may be done in the form of a diary or list.
Activity level and type of activity have been demonstrated to correlate with depression.
c) Self-monitoring of cognitions. We have found it helpful for patients to record their
thoughts when symptoms are pronounced (e.g., sad, depressed, anxious). This
assessment might generate useful information regarding the patient's view of the
world, and also as a method of helping the patient decenter.
d) Activity scheduling. This assignment usually has behavior change as its goals. (see
Chapter 2)
Some patients resent the use of the word homework. It is good practice to assess the
meaning patients place on this term or type of task. Again, treat the patient's negative reactions
to homework as you would any other phenomena that occurs in cognitive behavioral therapy, that
is, as an opportunity to assess meaning, automatic thoughts and self schemas.
Failure to complete a homework assignment often has assessment implications. It is important to
get specific details when a patient is unable to complete an assignment. The therapist will need
to be cognizant of the possibility that the patient may have been set up to fail by an assignment
that was too difficult (e.g., anxiety provoking). Also, the therapist will want to examine the
failure so as not to be blaming. This is especially important for patients who believe that "others
are critical of them."
Educating the patient. It is important to keep in mind that the patient's treatment history
is likely to impact on the patient's expectations about therapy and behavior during the sessions.
For example, a patient with a prior history of more traditional dynamic therapy may bring in
dreams and early childhood experiences and may generate doubts when these are not reinforced.
Our experience is that patients, except for those having a rudimentary conceptualization, will be
unfamiliar with cognitive behavioral therapy. Thus, one of the earlier tasks will be to educate the
patient about this therapy. Typically, patients will ask for this explanation. But even if a patient
does not, an explanation is important in that it helps specify the role the patient is expected to
play during therapy. The following explanation might be offered:
"During cognitive behavioral therapy people explore and become aware of how attitudes,
beliefs, expectations and thoughts, taking place at an automatic level, are very much
related to aversive/negative emotional states, such as anxiety, depression and
interpersonal difficulties. Let's look at an example:"
The therapist should be prepared to use several examples. At this point in therapy it is probably
best to use examples that are unrelated to the personal issues that brought the patient into
treatment. These are likely to be too emotionally laden for the patient to follow the points being
made. Also, it is very likely that the patient holds a different view of the etiology and
maintaining variables of his problems. Again, it is too early to challenge this view.
The first step is to establish a relationship between feelings and thoughts. One example
 35

that we have found particularly easy for patients to comprehend is the story of the two
businessmen traveling by plane from New York to Los Angeles.
Therapist: I want to tell you the story of two executives that work in New
York for two different organizations and just by coincide they end
up flying from New York to Los Angeles on the same day and time
and in the same plane. The first man gets into his cab at Times
Square and ask the driver to take him to Kennedy Airport. The
driver takes off and immediately Man 1 starts to read the
newspaper. Later he begins to focus on his upcoming presentation
in LA, and thinks about whether he needs to contact anyone at the
office while waiting for his flight to take off. He gets to airport.
The plane takes off. He works on his presentation. He watches the
movie and then he takes a nap and six hours later he arrives in LA.
Are you clear of the sequence of events that took place for Man 1?
Patient: Yes.
Most patients are able to follow the example to this point. Occasionally, a patient will request
that the sequence be repeated.
Therapist: The second man gets into his cab at Time Square and asks the
driver to take him to Kennedy Airport. The driver takes off. Man
2 thinks about the flight. What if something goes wrong. Suppose
I get too nervous. What will I do? There might be bad weather.
What if I get sick in the airplane? Maybe I should not go? By the
time he gets to the airport, he is quite anxious. He gets onto the
plane, which takes off. He spends the entire flight with hands
clenched to the seat and focuses on every movement of the plane.
He arrives in LA exhausted and with thoughts of his return trip to
New York. Are you clear with what happened to Man 2?
Patient: Yes.
Therapist: Do you see any similarities or differences between the two cases?
Patient: One man was nervous, the other one was not.
At this time the patient is asked to identify the differences between
the two situations. The first reaction will probably be towards Man
2 who was anxious. The therapist will need to focus on the
differences in thinking patterns (automatic thoughts) that existed
between the two men and how thoughts might contribute to the
differences in mood state.
Therapist: Yes, this is true. Why do you think that this was the case? How
did one come to be nervous and the other not so?
Patient: One is just a nervous guy and the other was not.
Therapist: Yes, this is one difference. One is nervous and the other is not.
Can you think of any other ways in which the two differ?
If the patient does not highlight the difference in thinking pattern at this point, it is probably
useful to compare the cases along each dimension as you talk the patient through the sequence.
 36

For example, Man 1 got into a cab and so did Man 2. They both request that the cab take them to
Kennedy Airport, etc. Note that the emphasis is on demonstrating automatic thoughts.
Once the patient has come to recognize some existence of a relationship between
cognition, affect and behavior, the therapist should then talk more in terms of thinking patterns
and automatic thoughts. Again, be prepared to provide examples. In explaining the cognitive
behavioral model to patients, it is often helpful to employ visual cues (e.g., paper and pencil, a
chart board) for demonstration, which might later be given to the patient to take home to study.

Supervision
Supervision of project clinicians is considered a vital part of the CBT process.
Supervision takes place in a small group format and meets weekly for 90 minutes. Senior
clinicians from multiple disciplines (MDs, PhDs, and CSWs) with considerable experience in
cognitive behavioral interventions provide the supervision. Didactics are considered an
important adjunct to direct clinical supervision and are included in each supervision session.
Lectures and readings that are reviewed and discussed provide a theoretical and practical
framework from which informed clinical interventions emerge. Use of videotapes of treatment
sessions by skilled cognitive behavioral clinicians, and consistent review of supervisees’ own
videotaped sessions, allow for “in vivo” examination of treatment adherence and technique.
Role playing exercises also are regularly used to allow supervisees to gain facility in providing
basic techniques, such as setting agendas, eliciting automatic thoughts, or employing behavioral
techniques, such as challenging cognitive distortions.
A typical supervisory session often mirrors a treatment session. The tasks of supervision
vary according to which phase of treatment is being offered to a particular patient. Supervision
involves the teaching of cognitive-behavioral conceptualization of anxiety, depression, and
personality. Establishing a case formulation, identifying core schemas, and implementing the
two phases of treatment intervention (Symptom Reduction/Relief and Schema Change) are
underscored. While early supervision sessions might place a greater focus on case formulation,
middle sessions focus on videotape review and implementation of intervention techniques. Later
supervision sessions tend to highlight the termination process and prepare the patient to function
without the structure of the therapy. Issues in the therapeutic relationship are discussed
throughout supervision as well.
Generally, each supervision session begins with setting an agenda. A brief review of each
supervisee’s case is done, in order to assess any urgent situations, such as suicidality or active
substance use. Supervisees are asked to present segments of their videotapes from the previous
session, for evaluation of adherence to treatment techniques (i.e., following up on homework) as
well as monitoring of the patient’s progress. Each supervisee’s tape is reviewed during each
supervision session. Supervisees are able to share each other’s work in this way and learn from
each other. Discussion of the reviewed segment is facilitated by the supervisor and appropriate
next steps identified. Feedback to the supervisee about treatment adherence and skillfulness is
provided on an ongoing basis.

Orientation issues
Because cognitive behavioral therapy involves a number of specific treatment techniques
 37

many of which are applied in a planned and logical manner, the novice therapist is likely to
become enamored of techniques, applying them often in a rote, mechanical fashion. For
example, it is not uncommon for the beginning therapist to challenge every dysfunctional or
negative thought or belief with one of Beck's three questions, most likely "Where's the evidence
for that?" Whereas there are certainly times when this is an appropriate question, most often it is
done at the expense of losing critical information regarding the patient's self schemas. To
intervene with a treatment technique or an assessment one is not always an easy decision, but one
made easier by the structured of a well formulated case.
It is important that the therapist be able to identify and manage any orientation problems
that he or she may have with respect to cognitive behavioral therapy as this might impact
significantly on treatment outcome. Without doing so, the therapist is not likely to succeed as a
cognitive behavioral therapist. An example from our own clinic should clarify. A trainee had
spent many years as a therapist but was new to cognitive behavioral therapy. Subsequent to
describing the cognitive model to the patient, the patient acknowledged that she understood the
model and agreed to work in this capacity. She also shared with the therapist what he considered
to be the etiology of his problem as having "deeper rooted causes." The therapist who has a
history of looking for deeper, underlying causes of behavior informed the patient that "We don't
do that here. This is not that kind of therapy. If you are looking for that type of therapy, you will
need to go some place else."
The therapist assumed that (a) there are deeper underlying causes of emotional difficulties
that cognitive behavioral therapy do not address, (b) the patient had understood the cognitive
model as he had delivered it, and (c) the patient's belief system of a "deeper rooted cause" is
independent of the self schemas which impact on the presenting target complaints. The first
assumption is a theoretical one and is open for debate. Such a debate is beyond the scope of this
manual. The other two assumptions, however, are not. Cognitive behavioral therapy is often
didactic and frequently requires that the patient understands one concept prior to moving to the
next. As such, it is important that the therapist do not take it at face value when patient's says
that he or she understands a concept. Assess (e.g., "Tell me how you understand it. Provide an
example") might be employed to explore how the patient understands this. Failure to do so is
likely to have negative consequences. Following a description of the cognitive model, many
patients will clearly say they understand, but on further questioning have a different
understanding of it than that which was intended. It is not uncommon for patients to say
something to the effect, "So all I have to do is think positive and all my problems will disappear"
or " You're right, this is what my friends say. I need to not think this way." The patient who
perceives his difficulties as characterized by deeper rooted causes may simply be saying that
"thinking positive" is not enough to change his difficult lifestyle problems. One can imagine the
difficulty in therapy if the patient headlines the model and if misconceptions are not addressed.
There are cognitions that tend to be situational specific (automatic thoughts) and there are
others that tend to permeate the bulk of one's life (self schemas). Stated differently, a patient's
perception of how treatment should proceed may relate to being in treatment, but may also be a
function of the patient's world view, a view which may also be the source of the difficulties that
brought the patient into therapy. On further exploration, the patient who believed his problems
were related to "deeper rooted causes" was in fact functioning under the belief, "I do not have
 38

very much control over anything in my life." It seems reasonable that he viewed his problems as
also caused by sources outside of his control.
Another orientation issue that warrants discussion has to do with the therapist's activity
level. Typically, learning theory approaches to treatment are viewed as highly active and
directive on the part of the therapist. While this is often the case, there is danger in following
this nomothetic rule. The activity level of the therapist is viewed differently by each patient. For
example, a patient who believes that people tend to get involved and then reject you, might be
particularly anxious as the therapist's activity level increases. One can imagine the reaction of a
dependent patient who believes that he or she is completely helpless in the presence of a therapist
who continually makes suggestions and plans. The rule then is to choose your activity level in
accordance with the case formulation.
The activity level of the therapist might also serve to decrease the patient's learning
opportunities. In the session the patient may seek similar behavior/interaction from the therapist
as that typically shown by others in the patient's presence. For example, one patient recently seen
by one of our therapists believed that he was brighter than most people and that there was little
anyone could tell him. Consequently, he had few friends and could not maintain any intimate
relationships. In the session he constantly belittled the therapy and challenged the therapist. As
such, the therapist was constantly on edge and frequently going through great lengths to prepare
herself for each session. It is essential that the therapist's activity level meets the clinical needs of
the patient. How active or directive one should be is constantly being assessed and changed.
More importantly, the activity level of the therapist is intimately related to the case formulation.
Any successful use of cognitive behavior therapy requires (a) a sound understanding of its
theoretical and conceptual underpinnings, (b) knowledge of strategies and techniques, and (c) a
mastery of a variety of relationship skills, some of which are nonspecific and others very specific.
A therapist anchored in either technique or relationship is not likely to do well as a cognitive
behavioral therapist. Likewise, a therapist who knows technique and has mastered relationship
variables but has not mastered cognitive behavioral theory is not likely to do well as a cognitive
behavioral therapist. It is the understanding of theory that allows the clinician to adapt
techniques to particular patients based upon accurate conceptualizations of their problems and
the subsequent development of personalized treatment strategies.

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