Cognitive Behaviour Therapy (CBT) for Personality Disorder

Core Components

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT and are used in the treatment of a variety of mental health disorders, including personality disorders. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one domain can impact other domains. CBT therefore identifies, challenges, and modifies unhelpful cognitive structures, facilitating emotional and behavioural changes.

Core CBT components for personality disorder can include;

1. Formulation: developing a narrative case formulation to understand the factors involved in the development from childhood and maintenance of the personality disorder and inform treatment.
2. Psychoeducation: To provide information on the cognitive behavioural model, the patient’s illness and symptoms, as well as the rationale behind application of CBT.
3. Cognitive restructuring: To address distorted thoughts and beliefs. This can be done through challenging automatic thoughts in a thought record, through testing a belief in a behavioural experiment and through methods to change core beliefs and schema. In CBTpd there is more emphasis on working on more helpful alternative beliefs about self and others.
4. Behavioural techniques: To alter negative behavioural patterns. It can consist of; 1) graded task assignments to establish daily routine, increase pleasurable experiences, and enhance problem solving skills; and 2) Behavioural experiments to gather evidence against the use of ineffective behaviours (e.g. safety behaviours) and 3) goal setting. In CBTpd there is more emphasis on behavioural experiments that reinforce more helpful alternative beliefs about self and others as well as work on developing underdeveloped behavioural strategies to promote improved levels of social and emotional functioning.
5. Somatic management techniques: Techniques such as breathing, relaxation, visualisation, mindfulness are developed to manage emotional distress.
6. Exposure: Although more commonly applied in anxiety presentations, exposure techniques can be employed, where required, to alter the pathological fear structure by helping people face their fears or triggers and helping them incorporate corrective associations in the fear memory. This in turn can reduce distorted associations and fear responses (e.g. escape, avoidance, and psychophysiological responses). Exposure based techniques can be imaginal, in vivo and interoceptive.
7. Interpersonal focus: in CBTpd there is increased focus on improving understanding and behaviours within interpersonal relationships.

In CBTpd, the historical understanding of the development of unhelpful beliefs and behaviours informs the therapeutic focus, which is then applied in the present circumstances. It involves setting of realistic goals that have been mutually agreed between the therapist and patient. It therefore benefits from a collaborative therapeutic relationship between therapist and patient, as this facilitates achievement of the goals of the intervention (e.g.  identification of problems, learning of relevant skills, and application of learned skills to manage identified problems). CBT is time-limited and, in CBTpd, is typically delivered over 30 sessions across a year. Each session lasting about 50-60 minutes. The structured sessions are delivered weekly or fortnightly and may decrease in frequency in mid-treatment to allow embedding of behavioural change skills. CBT has homework components as these provide opportunities for patients to challenge themselves between sessions, and to generalise the skills learnt to their everyday lives.

Fidelity

NICE recommends that CBT should be delivered by competent practitioner(s) with ongoing supervision. The intervention(s) should be delivered as per validated manual, and that stipulated content and structure are adhered to in order to ensure consistency in delivery of intervention. The use of competence frameworks developed from the treatment manual should also be considered. Treatment adherence and practitioner competence should be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions. Rating scales like the Cognitive Therapy Rating Scale- Revised (1) can be used to assess therapist fidelity to treatment. Raters should be trained in CBT and should consider the relevance of the formulation and change methods.  There is a fidelity tool that is specific to CBTpd and psychometric analysis indicates that the scoring correlates highly with CTS-R (2).

Modifiable Components

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, which can include Rational Emotive Behaviour Therapy (REBT), Dialectical Behaviour Therapy (DBT), metacognitive therapy, cognitive processing therapy, and mindfulness-based cognitive therapy. CBTpd has been applied in the treatment of borderline and antisocial personality disorder. CBTpd can be delivered in an individual format. Delivery is primarily in community mental health centres, outpatient clinic settings, hospitals and forensic settings. CBTpd can be modified to meet the unique needs of people at different stages of life, with different learning needs, and in different settings, as it can be tailored to consider the beliefs, expectations, associated behaviours, and challenges through development of an individualised formulation.

Implementation Support

Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology workstreams, including webinars, CPD events and supervisor training. Regular CPD events can be accessed through the Turas Learn site: https://learn.nes.nhs.scot/46686/cognitive-behavioural-therapy/cpd-for-cbt-therapists. Implementation support is also available through professional organisations such as the British Association of Behavioural and Cognitive Psychotherapies (BABCP).  

Start-up Costs

There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations. 

Building Staff Competency

Qualifications Required

Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).

Training Requirements

Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT for is available through professional organisations such as the British Association of Behavioural and Cognitive Psychotherapies (BABCP) and specialist University courses. 

Supervision Requirements

Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:

• NES Generic supervision competences training (GSC) (or equivalent)
• NES Specialist Supervision Training: CBT (adult or child focus)

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills. 

Theory of Change

Cognitive Behavioural Therapy is based on theories that include:

1. Cognitive theory: This theory recognises the interrelationship between thoughts, feelings, and behaviours, and contributory role of maladaptive cognition patterns in the aetiology of maladaptive affect and behaviours. Cognitive theory therefore proposes identifying, challenging and altering distorted cognitions, which can facilitate alterations to problematic emotions and behaviours.
2. Emotional processing theory: This theory posits that cognitive fear structures retain information about fear stimulus, fear responses, and their meaning. Fear structures can become pathological when the stimulus or responses do not correlate with their meaning in reality, resulting in the activation of fear structures even on encounter with safe stimulus that are similar to the feared one. This theory proposes the alteration of the pathological fear structure by helping patients face their fears or triggers, and helping them incorporate corrective associations in the fear memory, in turn reducing distorted associations and fear responses.

Research Design & Number of Studies

A number of studies reported the effectiveness of CBTpd in the treatment of borderline and antisocial personality disorder. Some of the best available evidence has been summarised in meta-analyses that evaluated the effectiveness of CBTpd.  

Values

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT and are used for the treatment of a variety of mental health disorders including personality disorder. It identifies, challenges, and modifies unhelpful cognitive structures, facilitating emotional and behavioural changes. CBT is based on theories that can include cognitive theory and emotional processing theory.

• Do the underpinning theory and the underlying mental health condition addressed by the intervention align with the requirements of your organisation?

Priorities

CBTpd can include the delivery of sessions that focus on individualised formulation, psychoeducation, cognitive restructuring, behavioural techniques, exposure therapy, and emotion management. CBT can be adapted for different life stages or learning needs. CBT can be applied in the context of co-occurring problems.

• Will your service deliver this intervention to adults?
• Are there likely to be co-occurring mental health conditions (e.g. anxiety disorders including OCD, GAD, PTSD)?

Existing Initiatives

• Does your service currently deliver interventions to treat personality disorder?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

Cognitive Behavioural Therapy for personality disorder can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. CBTpd can be delivered to patients weekly or fortnightly, typically over 30 sessions.

• Does your service have qualified practitioners who are available and interested in learning and delivering CBTpd?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?
• If delivered face-to-face, is there capacity to support its delivery in person?

Technology Support

Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful, as is access to methods of recording sessions for supervision.

• Can your practitioners access technology to deliver therapy video videocall or record sessions for supervision?

Administrative Support

Cognitive Behavioural Therapy for personality disorders is typically delivered weekly or fortnightly, typically over 30 sessions, with each session lasting about 50-60 minutes. Face-to-face therapy sessions can be held in several settings including community mental health centres, outpatient clinic settings and hospitals. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what setting will CBT be delivered?
• Does your service have a venue to deliver CBT sessions?
• Can administrative supports needed to deliver this intervention be provided?

Financial Support

Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.

• Can your service financially support practitioner training costs if accessed outside NES?

Comparable Population

CBT has been shown to be effective in the treatment of personality disorders and with comorbidities.

• Is this comparable to the population your service would like to serve?

Desired Outcome

CBT has been shown to effectively reduce symptoms of depression, anxiety, distress and suicidal acts at post-treatment and follow-up.  It has also been shown to promote remission.

• Is delivering CBT for the treatment of personality disorders a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?