A significant body of research now demonstrates the efficacy of Cognitive-Behavioral Therapy for patients with personality disorders. To successfully engage and treat these patients, clinicians must understand the highly negative way in which these patients view themselves, other people and interpersonal relationships.

As a result of the interaction among their genetic inheritance, their biology and the meanings they ascribe to adverse childhood experiences, patients with personality disorders have developed highly negative, rigid, inaccurate and dysfunctional beliefs about themselves, other people and their worlds. They bring these rigid, overgeneralized understandings to the therapy session. They may believe, for example, that they are extremely helpless, unlovable or worthless.

These patients also hold extreme beliefs about other people. They may believe that others are untrustworthy, critical and likely to disregard, dismiss, criticize or hurt them — emotionally or physically.

These beliefs are quite painful, and patients develop certain assumptions about how they can get along in the world. Avoidant patients, for example, believe, “If I put on a false front and avoid intimacy, I’ll be OK, but if I show my true self, others will reject me because they’ll find out how unlovable I am.” It makes sense, therefore, that they display behavioral patterns (“coping strategies”) of avoiding intimacy.

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Dependent patients believe, “If I rely on others, I’ll be OK, but if I try to be independent, I’ll fail because I’m so incompetent.” They subjugate themselves so others will take care of them. Patients with narcissistic personality disorder believe, “If I impress others and act in a superior way, I’ll be OK, but if I don’t gain admiration and subservience from others, it will mean I’m inferior.” It is little surprise that they self-aggrandize, put others down and demand entitlements.

These same behavioral strategies are characteristic of individuals in general. However, most people are able to size up a situation, decide what their goal is and modulate their behavior in a flexible manner. Patients with personality disorders use a relatively small set of behaviors inflexibly — in a more extreme manner — in situations where such behavior is clearly dysfunctional.

The challenge for clinicians arises when patients with personality disorders bring their dysfunctional beliefs and coping strategies to treatment. They may assume, for example, that their therapist is untrustworthy and likely to hurt them, even in the presence of significant evidence to the contrary. They may be hypervigilant about harm and therefore appraise the therapist’s attitudes and behaviors in quite an inaccurate way. Negative beliefs about themselves are also easily activated, leading them to engage in therapy-interfering behaviors, in session or between sessions.

Understanding that these patients act reflexively to protect themselves or to cope with overwhelmingly painful emotions can increase clinicians’ empathy, an essential ingredient of therapy if the patient is to make progress.

In order for patients with personality disorders to see themselves and others more realistically and to achieve their goals, it is essential for clinicians to learn how to manage patients’ negative reactions and dysfunctional behavior, as well as how to repair ruptures.

Judith S. Beck, PhD, is clinical associate professor of psychology at the University of Pennsylvania and president of the Beck Institute for Cognitive Behavior Therapy, a non-profit organization based in Philadelphia that provides clinical services and has trained many thousands of health and mental health professionals worldwide.

References

Beck JS. Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work. New York, NY: Guilford Press; 2005.