A Cognitive Behavioral Perspective for

Understanding and Treating Patients with

Personality Disorders
PROF. DR. ARTHUR FREEMAN
PROFESSOR AND CHAIR
DEPARTMENT OF BEHAVIORAL SCIENCE
TOURO COLLEGE
NEW YORK, NY
MEXICO CITY, DF
DECEMBER 4, 2016

Quick Diagnosis of
Personality Disorder

Personality Style vs. Personality

Disorder
Personality

style is the schematicallybased manner in which the individual

responds to the broad array of life
stimuli, both internal and external.

Personality

disorder is when the style is

maladaptive or dysfunctional

Both style and disorder have elements that may be:

Genotypic (the contribution of genetics)

Phenotypic (the behavioral manifestation)

Sociotypic (the influence of culture and the

individuals system)

Schematypic (the influence of the individuals

schema or life templates)

The personality style is how we are known by others

and how we self-define.

Overall Impact on the Individual

Mild-may

or may nor seek therapy. Behavior may not be

noticeable or be seen as disordered or maladaptive (May be
as seen as different or strange, or annoying)

Moderate-may

seek or be referred for therapy. Behavior

seen as problematic or disordered but may be acceptable
within the group, subgroup, or community (dyssocial)

Severe-dysfunctional

within both the local and the larger

community.
Chronic-dysfunctional

and of long-standing

Becks Continuity Hypothesis

Behavior

needs to be viewed on
a continuum (i.e., dimensionally)

Understanding Schema

Schemas are the rules and templates we use for processing and understanding our
world.

They serve as an internal filing system.

Used for processing expressive and receptive data.

Are formed by middle childhood, and are modified after that point.

Schema may be active or dormant. Active schema govern day-to-day behavior.

Dormant (or inactive schema) arise under stress. When the stressor is removed, the
schema may return to their inactive state.

Schema may be compelling (cannot be ignored) or non-compelling (can be more easily

ignored or modified).

Will pervade and motivate all aspects of behavior (love, work, politics, place of
residence).

Some schema are easily identified, others must be inferred from cognitions or behavior.

Most often are taught or modeled by credible and significant others in family of origin.

The

earlier a schema is internalized,

the harder it will be to alter the
schema.
The more powerful and credible the
source of the schema, the harder it
will be to alter the schema.

 Identify

the schema

Explore

the source(s) of the schema

Have

patient estimate their willingness to

alter the schema.

Have

patient estimate their ability to alter

the schema.

Help

patient to build a model of their ego

ideal

Schematic Change Possibilities

Schematic
Schematic
Schematic
Schematic
Schematic

Reconstruction
Construction
Modification
Reinterpretation
Camouflage

Schematic Change Potential

Schematic

Schematic

Paralysis

Rigidity

Ossified

Dogmatic

Nothing will
bring about
change

Change may

Schematic
Stability

Schematic

Schematic

Flexibility

Instability

Steady

Creative

Chaotic

Internal rules

Rules can be

Rules shift without

come, but with are clear and

bent or
warning
difficulty
predictable
changed, as

needed

Setting Treatment Goals

Reasonable
Sequential
Proximal
Well-delineated
Potentially within the individuals repertoire
Agreed to by the patient
Seen by the individual as valuable*****
Contributory towards making the individual feel better.
*******Helpful for the individual to get more of what they
want

Elements of Treatment

M + S + S/S = Readiness
M= Motivation
S= Skills and/or abilities
S/S= Systemic support for change

Psychoeducational (Skill-Building)
Throughout

life, skills are acquired. These skills include

language, mobility, hobbies, academic, role,
social/interactional skills.

Taught

and modeled by significant others.

Some

skills are more useful or necessary at certain points

in life or in specific situations.

In

the past, individuals may have had sufficient skills for

success. Those skills no longer apply.

In

the past there may have been a prompter, enabler, and

coach available for assistance.

The

patient may have limited skill-building capacity or skillbuilding interest.

There

has been no one to teach skills.

Motivation for Change

(Freeman-Dolan Model)

Noncontemplation- (What? Who me?)

Anticontemplation- (Like hell I will.)
Precontemplation- (At some point I may consider it
maybe)
Contemplation- (I need to think about what I am doing)
Action planning- (Let me make a plan)
Action- (How can I implement my plan?)
Prelapse- (Thinking) (Need for redirection)
Lapse (Acting) (Need for redirection)
Relapse (Thinking and acting) (Need for review and
redirection)
Maintenance- (Let me stick with my gains)

Systemic Influence
Individuals

may have discovered that their

behavior continues to gain them success in the
world (at least their personal world and within the
myriad systems in which they live and operate, or
within their understanding and construction of the
broader world) despite the apparent price. The
price is, most often, a lesser or future consideration

Treating Personality Disorders

Use of Cognitive/Affective and

Behavioral/Environmental Interventions
Behavioral/environmental Techniques

Internalizing

Externalizing

Cognitive/Affective Techniques

Degree of Severity

100

Typical Pattern
Stimulus

Response

Revised Response Pattern

Stimulus
Awareness (Mindfulness)
Recognition
Problem Solving
Decision Making
Response

Vague Goals

Vague Therapy

Vague Results

Summary and Treatment Perspective

This difficult group is made even more difficult by the reactions that they engender in others
(including their therapist).

A focused structured CBT approach can have a powerful positive impact on both style and
disorder.

We are going to use schematic change strategies including: schematic reconstruction, schematic
construction, schematic modification, schematic reinterpretation, and schematic camouflage.

Use the pathology in the service of the therapy i.e. what is in their enlightened self interest?

Keep countertransference under control.

There is a need for focused treatment studies to identify the best possible treatment
alternatives.

The questions are:

Can we assemble a cohort for treatment?

Can we get funding to study personality disorders?

Does anyone care?