Cognitive-Behavioral Therapy Continued

In addition to changing the core beliefs that cause a faulty interpretation of external, environmental events, CBT can be useful for modifying habitual, maladaptive patterns of thinking that may not necessarily result from a core belief. One such pattern is called black-or-white thinking, also known as all-or-nothing thinking. We previously used the example of a woman with a Borderline Personality Disorder LINK whose partner had forgotten their anniversary. The same CBT steps can be used to make corrections to this pattern of thinking. The therapist and client begin to identify this pattern and the client records her internal thoughts about this event such as "How could he possibly forget our anniversary? He must not love me anymore, otherwise he would have remembered. Oh my gosh, he must be having an affair! How could this be happening to me? I can't believe it - my husband hates me!"

Next the therapist guides the client to consider alternative reasons someone might forget an anniversary and to examine the evidence for the conclusion, "He must hate me." In particular, the client will be asked to consider evidence that refutes this statement. She would be reminded that her husband just took her on a romantic trip to Bermuda for Valentines Day. She would learn to reframe these thoughts into a more realistic appraisal of those events: "Well, that was pretty thoughtless to forget our anniversary but it doesn't mean he hates me. He's been under so much stress at work lately, and when we took our trip to Bermuda he was so loving and romantic." Over time, the client learns to consider shades of grey and to think in a more accurate and less extreme manner. This change in thinking leads to more positive feelings and less reactant behaviors and therefore, the client's functioning and quality of life are significantly improved. For instance, rather than angrily accusing her husband of having an affair, she might calmly express her disappointment that their anniversary passed by unacknowledged. This would certainly result in a different outcome than making wild accusations of an affair.

Thus far, we have been focusing on the cognitive portion of cognitive-behavioral therapy as these interventions have the most direct application to personality disorder. However, a second set of interventions are more behavioral in nature and are very effective in the treatment of anxiety disorders. But you may recall that Cluster C personality disorders are characterized by anxiety. Therefore these behavioral interventions are readily applicable to the anxious/fearful Cluster C personality disorders (Avoidant, Dependent, and Obsessive-Compulsive Disorders). One such behavioral intervention is called exposure therapy. In order to explain the application of exposure therapy to personality disorder it is useful to briefly describe this process. However, the interested reader may wish to have a more detailed explanation of these techniques and the principles which underlie their effectiveness. This information is available in our article entitled, Understanding Anxiety and Anxiety Disorders. 

As the name implies, exposure therapy involves exposing the person to a fearful situation so that the fear eventually subsides through a process called habituation. Habituation refers to the process by which a person's behavioral and sensory responses diminish after continued exposure to the stimulus that activated those responses. We all have experienced habituation. For example, think of jumping into an ice cold swimming pool; after you remain in the pool awhile, it no longer feels ice cold.

Now let's review how exposure therapy functions to eliminate irrational fears, providing an opportunity for a corrective experience to take place. Consider the person with an Avoidant Personality Disorder. They avoid social situations because they fear that people will ridicule, reject, and/or criticize them. Because they avoid social situations, there is no opportunity to correct this faulty assumption. Using the techniques of exposure therapy, the recovering person would be encouraged to participate in social situations despite the fact that their fear will initially make them highly uncomfortable. With prolonged exposure, habituation causes this high degree of discomfort to subside. From this exposure to social situations, the person learns their fear and anxiety were unfounded; i.e., that nothing terrible has happened to them. This realization enhances their relaxation and calm.

In addition to these techniques, the person may be directed to focus their attention outwardly on other people, rather than inwardly, which only serves to heighten their experience of anxiety. They may also be asked to attend social skills training group to help them navigate these social interactions more skillfully and comfortably. These skills can include conversational techniques, and learning to attend to social cues by correctly interpreting other people's responses and facial expressions. The acquisition of these skills can be quite important because someone who has avoided all social situations is likely to be missing these important skills. Research has shown that exposure techniques can be quite effective for people with Avoidant Personality Disorders (Herbert, 2007).