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.