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Psychotherapy © 2017 American Psychological Association

2017, Vol. 54, No. 3, 252–259 0033-3204/17/$12.00 http://dx.doi.org/10.1037/pst0000120

Behavioral Activation in the Treatment of Metacognitive Dysfunctions in


Inhibited-Type Personality Disorders

Keely Gordon-King and Robert D. Schweitzer Giancarlo Dimaggio


Queensland University of Technology Center for Metacognitive Interpersonal Therapy, Rome, Italy

Behavioral interventions are proposed as a critical treatment component in psychotherapy for personality
disorders. The current study explores behavioral interventions as a mechanism of change in Metacog-
nitive Interpersonal Therapy, an integrative psychotherapy for personality disorders. The goals and
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

implementation of behavioral principles are illustrated through the single case study of Roger, a
This document is copyrighted by the American Psychological Association or one of its allied publishers.

57-year-old man diagnosed with avoidant personality disorder and depressive personality disorder.
Transcripts of interviews and therapy sessions illustrate the role of behavioral interventions, including
behavioral activation, in Roger’s treatment. Roger demonstrated a reliable change from baseline to
posttreatment across all measures. He also showed gains with regard to his occupational functioning,
interpersonal relationships, and sense of fulfilment. Implications with regard to treatment planning for
personality disorders are discussed.

Keywords: behavioral activation, personality disorder, treatment, metacognitive interpersonal therapy,


psychotherapy

Personality disorders (PDs) represent a significant social health Considering the prominence of behavioral issues in PDs, the
burden and are associated with considerable suffering (Soeteman, potential benefits of behavioral interventions are multifold. Most
Verheul, & Bussehbach, 2008; Vaughn et al., 2010). Core features importantly, behavioral interventions, including behavioral activa-
include a disturbed sense of self and others, maladaptive relation- tion, provide patients with the opportunity to build more adaptive
ship patterns, and difficulties with emotional regulation. Emerging internal working models at an experiential level. Behavioral inter-
research also increasingly supports the key role of meta-cognitive ventions focus on interrupting maladaptive learned behavioral
impairments as a feature and maintaining factor of PDs (Dimaggio patterns, and promote the adoption of healthy behaviors. This may
& Lysaker, 2015; Semerari et al., 2014). Metacognition can be include exposure techniques, which aim to habituate patients to
broadly defined as one’s capacity to identify, understand, and feared stimuli to reduce avoidance. Behavioral techniques also
regulate internal mental states in the self and others (Dimaggio & include individualized behavioral activation, which aims to in-
Lysaker, 2015; Semerari et al., 2003). crease engagement in pleasurable and meaningful activities to
Behavioral issues are a key component of PDs. Problematic promote positive behavioral patterns, and improve motivation,
schemas are enacted and maintained through maladaptive behav- self-concept, and mood. Through engaging in meaningful or pleas-
iors. These can include dysregulated self-destructive behaviors ant activities, a patient may develop a more cohesive self-concept
(e.g., self-harm, substance use), and overregulated, controlling and greater personal agency, in addition to the alleviation of
behaviors (see Dimaggio, Salvatore, Lysaker, Ottavi, & Popolo, comorbid depressive symptoms. Behavioral interventions may
2015). Behavioral avoidance is also a core feature of many PDs also provide an opportunity to foster access to and awareness of
(see Dimaggio, Montano, Popolo, & Salvatore, 2015). In addition, mental states. Patients who tend to cope with feelings through
behavioral avoidance and low mood can be exacerbated by per- emotional avoidance may struggle to identify the triggers and
fectionism and self-criticism, as patients focus on events with a mental processes which contribute to this maladaptive coping
critical lens, contributing to a perception of failure and perceived pattern. Through behavioral exposure to feared situations, patients
need to engage in future avoidance (Shahar, Blatt, Zuroff, & can work with their therapist to understand the cognitive and
Pilkonis, 2003). affective antecedents to avoidance, helping to increase insight and
build metacognitive skill.

Metacognitive Interpersonal Therapy and


Keely Gordon-King and Robert D. Schweitzer, Faculty of Health, Behavioral Activation
School of Psychology and Counselling, Queensland University of Tech-
Metacognitive Interpersonal Therapy (MIT) is an integrative
nology; Giancarlo Dimaggio, Center for Metacognitive Interpersonal Ther-
apy, Rome, Italy.
psychotherapy for PDs. The approach marries behavioral home-
Correspondence concerning this article should be addressed to Robert D. work exercises with in-session interventions intended to enhance
Schweitzer, Faculty of Health, School of Psychology and Counselling, metacognition, while managing potential process issues. Therapy
Queensland University of Technology, Victoria Park Road, Kelvin Grove, is semistructured, with interventions focused on the promotion of
Qld 4059, Australia. E-mail: r.schweitzer@qut.edu.au metacognition, enriching the patient’s self-concept, and increasing

252
BEHAVIORAL ACTIVATION FOR PERSONALITY DISORDERS 253

meaningful and fulfilling behaviors (Dimaggio, Montano, et al., perience. Even if the events do not go the way
2015). Within session, interventions focus on exploring interper- you’d hoped, it would still be valuable, as it
sonal episodes and developing an understanding of the schemas, can help us to understand more about how
which drive relationship patterns. The therapist aims to help the patterns of feelings play out. What do you
patient to develop a greater awareness of their internal life, includ- think?
ing thoughts, emotions, and the influence of ingrained schemas on
current experience. Over time, the therapist helps the patient to Patient: That sounds okay, but I do not know where to
develop a higher level of differentiation—an awareness that inter- start.
nal experiences are subjective, influenced by past experience, and Therapist: What sort of things do you imagine doing;
separate from the underlying self. This within-session focus is what sort of things might you like, that could
complemented by between-session behavioral exercises (Dimag- meet this wish to feel connected?
gio, Montano, et al., 2015). Preliminary evidence for MIT effec-
tiveness for PDs comes from a single case series, with all three Patient: Well, I do not know, there are, you know . . .
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

patients enrolled completing therapy and achieving reliable change sometimes I get invited at work, that sort of
This document is copyrighted by the American Psychological Association or one of its allied publishers.

(Dimaggio et al., 2017). thing.


MIT employs behavioral activation with several objectives. In
the case of marked depressive symptoms, interventions may aim to Therapist: . . . Would it maybe be easier to accept an
improve mood. However, behavioral activation is not used for the invitation, rather than trying to create an
sole purpose of alleviating depression (Dimaggio, Salvatore, et al., event yourself or sign up for something?
2015a). More importantly, the exercises are primarily used to
Patient: Well, yes, I suppose so . . . I have thought
generate narrative episodes. The patient is aware that episodes that
about it, done it sometimes before. I maybe
arise between sessions will be discussed in the therapy; this ex-
could do that.
ploration is the rationale for engaging in behavioral exercises.
Episodes that arise from behavioral activation or exposure are Therapist: Maybe that could that be something to think
subjected to a detailed examination within session, with the aim of about for the next few weeks, maybe just
helping the patient to develop metacognitive skills, that is to have getting more involved at lunch, getting a cof-
a clearer picture of what he or she thought, felt, and experienced fee with your colleagues or something like
during the exercise and how this led to successful action or was on that?
obstacle to the target behavior (Dimaggio, Montano, et al., 2015,
Dimaggio, Salvatore, et al. 2015). The patient is provided with As shown in the above example, the goal of behavioral activa-
opportunities to experience avoided mental states, and to develop tion is framed as exploratory. Rather than aiming to produce a
a greater understanding of the relationship between external and positive mood state, the goal is to generate episodes so that feeling
internal events. The episodes are unpacked, to help the patient states can then be explored in session.
develop an awareness of the causal links between external triggers,
thoughts, feelings, and behaviors. Behavioral activation also serves The Current Paper
to connect patients with meaningful activities, which may help to
improve their sense of agency (Dimaggio & Lysaker, 2015). The current paper provides a case study analysis of the use of
In session, the goal of behavioral activation is thus framed as behavioral techniques in the MIT model. We present the case of
purely exploratory. Regardless of the outcome, a new experience is Roger, a man suffering from avoidant PD and depressive PD. All
always valuable, as it provides an opportunity to develop greater names and identifying details have been anonymized. Behavioral
self-awareness. Similarly to cognitive– behavioral therapy (CBT), intervention as a potential mechanism of change is examined with
the therapist works collaboratively with the patient to set progres- reference to qualitative observations, patient interviews, tran-
sive behavioral goals (Dimaggio, Salvatore, et al., 2015). Tasks are scripts, and quantitative outcome data.
planned based on perceived difficulty and achievability. Behav-
ioral activation is implemented using a “plan-execute-reflect” cy- Case Summary
cle (Kolb, 1984), where tasks are planned in session, attempted
between sessions, and then reflected on with the aim of increasing Roger is a 57-year-old Caucasian man, working in law enforce-
metacognitive function (Dimaggio, Salvatore, et al., 2015). A ment. At the time of commencing therapy, he lived alone, and had
hypothetical example of this process might proceed in session is one adult child. Roger presented to therapy seeking support with
provided below. chronic and severe low mood, feelings of worthlessness, suicidal
ideation, and pervasive anxiety in social situations. Roger de-
Therapist: So we’ve been talking a bit around your wish scribed a severe sense of emptiness and loneliness. These symp-
to feel connected to other people. Yet it seems toms were longstanding, having onset during Roger’s adolescence
that although you have this wish for connec- and reportedly persisting throughout his adult life. An assessment
tion, it is a struggle to reach out and go to of personality functioning was conducted using the Structured
social events. I am wondering, maybe if we Clinical Interview for DSM–IV Personality Disorders (SCID-II).
planned some social activities, it could pro- Based on this assessment, Roger met 20 SCID-II criteria. He met
vide us with some examples to work through, diagnostic criteria for avoidant PD, depressive PD, and major
so that we could better understand your ex- depressive disorder.
254 GORDON-KING, SCHWEITZER, AND DIMAGGIO

Research Method out too much.” He underwent plastic surgery, and subsequently
became so distressed by his appearance that he broke all mirrors in
his house. In one instance, he cut his face with a knife, leaving a
Design and Procedure
noticeable scar.
Roger participated in a larger case series trial of MIT, approved During his 20’s, Roger met a woman at a work event, and
by the Queensland University of Technology University Human commenced a relationship. The couple married and had one child.
Research Ethics Committee (approval number 1400000909). He Roger reported that tension developed in the relationship owing to
underwent a pretreatment clinical assessment, in addition to com- his refusal to attend social gatherings or engage in any leisure
pleting baseline measures at three time points before commencing activities. Five years before beginning therapy, Roger’s wife ended
therapy. Outcome measures were then taken 3 months, 6 months, the relationship.
9 months, and 12 months after commencing therapy. Outcome At the time of commencing therapy, Roger had been taking
variables assessed recovery, symptom severity, emotional regula- antidepressant medication for 20 years. He had previously partic-
tion problems, and alexithymia. ipated in multiple CBT interventions, and had received supportive
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

counseling through his workplace. None of these interventions had


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achieved lasting symptom alleviation.


Measures
Clinical diagnosis. Personality functioning was assessed us- Formulation
ing the SCID-II. The SCID-II is a semistructured, diagnostic,
clinical interview for PDs. The interviewer rates PD criteria on a Throughout his childhood, Roger felt neglected and unloved by
3-point scale (1 ⫽ symptom absent, 2 ⫽ subclinical symptom his parents. A core interpersonal need for a stable attachment
present, 3 ⫽ clinical symptom present). The SCID-II has been relationship thus went unmet. Roger developed a sense of himself
found to have good internal reliability, ranging from 0.71 to 0.94, as inferior and worthless. Roger’s poor self-concept and interper-
and good interrater reliability (Maffei et al., 1997). sonal difficulties were exacerbated through his experience of bul-
Outcome Questionnaire-45.2. The Outcome Questionnaire- lying during school. He was repeatedly confirmed in his sense of
45.2 (OQ-45.2) is a 45-item self-report measure, designed to being worthless and unlovable. A schema was developed, whereby
measure change over the course of therapy. Participants rate the Roger wished for acceptance, but feared that if he reached out and
frequency with which they experience various difficulties on a made himself vulnerable, the other person would recognize his
5-point Likert scale (0 ⫽ never, 4 ⫽ almost always). Internal inherent flaws and reject him. Roger reacted to this imagined
consistency and test–retest reliability for the OQ-45.2 have both response by experiencing shame, and subsequently withdrawing
been reported as good; a ⫽ .93, r ⫽ .84, respectively (Doerfler, from relationships and activities. When Roger’s wife ended their
Addis, & Moran, 2002). relationship, he felt that his core beliefs about himself and others
Toronto Alexithymia Scale. The Toronto Alexithymia Scale were confirmed.
(TAS-20) is a 20-item, self-report measure, which assesses diffi- At the beginning of treatment, Roger’s presenting difficulties
culty in identifying and describing internal feeling states. Partici- were maintained by avoidance and his social isolation. High levels
pants rate the extent to which they agree with different statements of self-criticism also served to maintain this cycle, as Roger would
about themselves, on a 5-point Likert scale (1 ⫽ strongly agree, dwell on any interaction he did have, focusing on perceived
5 ⫽ strongly disagree). The TAS-20 has demonstrated good in- mistakes and flaws in the interaction. Research supports the role of
ternal consistency (a ⫽ .81; Ciarrochi & Bilich, 2006). perfectionism and self-criticism in maintaining avoidance and de-
Depression and Anxiety Stress Scale 21. The Depression pressive symptoms (Shahar et al., 2003). His maladaptive schema
and Anxiety Stress Scale 21 (DASS 21) is a 21-item self-report was also maintained by metacognitive dysfunction. Roger typi-
questionnaire designed to measure depressive, anxiety, and stress cally discussed his internal experiences in a highly intellectualized
symptoms. Each item is scored from 0 (did not apply to me at all manner, and had difficulty identifying both negative and positive
over the last week) to 3 (applied to me very much or most of the emotions.
time over the past week). The raw score is then doubled to produce
the final score. The DASS 21 has demonstrated good factorial Treatment Plan
validity and reliability (Yusoff et al., 2013).
Roger agreed to participate in 12 months of MIT, with a par-
ticular focus on behavioral interventions. Behavioral strategies
Client History
were considered a key component of Roger’s treatment. Before
Roger was raised an only child. He described both of his parents treatment, Roger described a pervasive sense of emptiness. The
as anxious people who suffered regular episodes of depression. His only positive self-aspect endorsed by Roger was his work identity.
father was an alcoholic. Roger recalled that he would often be Treatment aimed to provide Roger with an opportunity to engage
locked in a car for hours at a time while his father drank. He was in different activities, helping him to develop a richer narrative
subjected to severe verbal and physical bullying throughout his around his identity.
high school years. Perhaps most importantly, behavioral activation provided Roger
After leaving school, Roger commenced training for a career in with an opportunity to develop his metacognitive skills. At the
law enforcement. He excelled in his work and quickly received commencement of treatment, Roger showed a limited capacity to
promotions to rise to a manager level. During his early adulthood, identify, understand, and regulate his emotions. The primary goal
Roger began to suffer from an intrusive thought that his ears “stuck of behavioral activation in Roger’s case was thus not only to elicit
BEHAVIORAL ACTIVATION FOR PERSONALITY DISORDERS 255

positive feelings. Rather, the main objective was to expose Roger and join in on any general sort of talk and
to new experiences, which could then form the basis of metacog- stuff.
nitive skill building within sessions. Roger could then generalize
Therapist: And how has that been for you?
these skills to between-session exercises, resulting in compound
gains over time. Patient: Umm, at times there was no real feelings
come up, at other times they would come up.
Treatment Progression Therapist: Did you notice what was different about the
When Roger first began therapy, he was unable to view his times they did come up or didn’t come up?
thoughts as hypotheses, regarding them instead as incontrovertible
Patient: Umm, the only thing I can say was Times I
facts. In his initial interview, Roger repeatedly stated that he was
had to expose myself. There was multiple
“hopeless” and was “waiting to die.” Roger’s therapist framed
occasions where . . . there was the aspect of
these emotions as universal human experiences, rather than signs
being focused on . . . but in a certain sense a
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of personal weakness. The treatment goal at this early stage was to


bit of relief that you’re opening up.
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encourage Roger to differentiate from his belief that he was


fundamentally different from all other people. The therapist began Therapist: So can you give me an example, say in this
to encourage Roger to discuss detailed episodes from his daily life. past week, where this happened?
Over time, a formulation of Roger’s core schema was collabora-
Patient: I suppose directly this morning, so . . . we’ve
tively developed. This helped Roger to identify the impact of past
got someone filling in a position . . . and he’s
experiences on his interpretations and behaviors.
a good fellow . . . not totally aware of my
Roger responded well to these interventions, gradually showing
background. And I explained . . . I’m a part of
a greater level of differentiation from his thought processes and
a program . . . and that I’ve had depression in
feelings. Rather than seeing his thoughts and feelings as objective
the past . . . so I was quite happy to disclose
truths, he came to understand that his feelings and thoughts were
to him.
subjective, and influenced by his prior experiences and schemas.
At the commencement of treatment, Roger would often make Therapist: . . . how did you feel in that moment when you
statements such as “I am an anxious person—a worthless person.” disclosed to him?
As therapy progressed, the way he related to his internal experi-
ences changed (e.g., “I am feeling anxious, and I used to have Patient: I felt . . . at ease . . . I know that he’s a genuine
thoughts that I was pathetic”). He thus began to separate his sense sort of person . . . he appreciated that. He
of self from his temporary internal experiences and thoughts. In his said “thanks for being honest” . . . it benefits
seventh session, Roger expressed a wish to increase his social me talking in a social situation or more inti-
connectedness. This provided an opportunity for the therapist to mate situation, because I’m feeling that . . .
initiate the behavioral activation plan-execute-reflect cycle. In his you know like my marriage I was worried that
ninth session, Roger and the therapist agreed to experiment with I’d be found to be a fraud, that I’m not good
increasing his social connectedness. enough . . . and I realize things are different
now . . . over the last week there have been times
Therapist: Well we’ve been talking again about this wish when I’ve felt, well, not too bad. I’ve been
you have . . . to feel more connected. engaging, that sort of thing . . .
Patient: Yeah, yeah, I want to engage more . . . There Therapist: So tell me about this “I’m not too bad” feel-
are some options, some potentials I suppose ing, what did that feel like?
. . . going to dinners and that sort of thing.
Patient: Umm it, well it felt a little bit of a relief. It’s
Therapist: Mmm . . . does that sound do-able to you? more that there is some hope there, it’s not
completely bad, it’s not as bad as I had main-
Patient: Yes, well . . . umm . . . I suppose so. I do get
tained for so long, that there is an opportunity
invited to things.
for me to move forward . . .
The therapist and patient worked together to develop a plan to
At this point, the therapist noted that Roger was engaging in his
engage in a behavioral activation task, starting at a level achievable
usual defensive pattern, avoiding exploring feelings by discussing
for the patient. In the next session, Roger reported that he had
thoughts. The therapist, drawing on principles of behavioral acti-
successfully taken part in “several engagements.” The following
vation, as articulated within MIT, focused on detailed episodes that
extract demonstrates the exploration of the feelings that arose from
arose from an ecological model of behavioral activation. Such
these episodes within session. The therapist and client began by
tasks are explored in detail with the goal of promoting metacog-
discussing Roger’s experience of social activities over the past
nition. This approach is different to more traditional conceptions of
week. Roger identified that he had been pleasantly surprised by
behavioral activation, which focus more on mood symptom alle-
positive feelings toward himself.
viation rather than enhancing emotional awareness, differentiation,
Patient: Yeah since last session it’s been pretty good, and metacognition. Following these principles, the therapist de-
I’ve sort of . . . in a social context . . . engaged cided to engage in metacognitive skill building, helping Roger to
or tried to engaged in different occasions, identify underlying feelings.
256 GORDON-KING, SCHWEITZER, AND DIMAGGIO

Therapist: When you were sort of thinking about these Patient: Umm . . . there’s a BBQ I’m invited to on
things how did you feel? Saturday night . . .

Patient: Umm, I felt that . . . there is the opportunity The above excerpt demonstrates the movement from an essen-
and the hope that I can, you know, be able to tially ecological perspective to a more behavioral planning-
create a new life for myself . . . execution-reflection cycle in MIT. This is consistent with Dimag-
gio and Lysaker (2015) inclusion of thoughts, feelings, wishes, and
Therapist: You’re hopeful about the future, would you motives, being integrated with planning, adopting, and reflecting
say that’s one of the feelings coming up? on new behaviors in seeking to promote change. The therapist took
time to examine the impact of episodes from the previous week.
Patient: Yeah absolutely . . . there’s a bit of light Metacognitive skill building was conducted by inviting Roger to
starting to shine through . . . practice naming emotions. From this interaction, positive feelings
were identified, which formed the basis for planning new activi-
Therapist: So you’re sort of feeling that sense of hope
ties. The process can best be described as collaborative and flex-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

and peace . . . and it feels quite opposite to


ible, rather than directive.
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that anxious, tight sort of self-hatred. It feels


In some instances, Roger had unpleasant experiences while
more relaxed in the chest, you said . . .
carrying out behavioral tasks. Through exploring these episodes in
The above excerpt demonstrates the process of using episodes to therapy, Roger was able to come to an understanding that these
promote metacognitive skill building. The therapist, in linking the difficult experiences still held value, as they enabled him to learn
patient’s experience with the encouragement to engage in social about himself. The following extract is taken from a session where
activities, as described previously, encouraged Roger to consider Roger had aimed to look at a community noticeboard and follow
the impact of his activities on his emotions, helping him to rec- through with at least one of the offered community activities. He
ognize that it was possible for him to experience positive feelings. did not complete the task, triggering a sense of inadequacy, strong
This is consistent with Dimaggio’s more ecological conception of memories of receiving divorce papers from his wife earlier in the
behavioral activation, where the process is more deeply embedded year, and suicidal ideation. Regardless of the fact that the episode
in the therapeutic relationship (Dimaggio, Salvatore, et al., 2015). triggered difficult feelings, the therapist used Roger’s response as
As the session progressed, the focus shifted, linking the experience an opportunity to both engage empathically, and to build meta-
of hope to new possibilities for further behavioral activation ac- cognitive awareness.
tivities.
Therapist: So after our last session, how were you feel-
Therapist: . . . The possibility of maybe having new ing? . . .
friendships, and engaging with clubs, and
Patient: I think there was . . . no real issues . . .
that that feels like . . . peace in your body. And
it feels like hope, there’s some hope, begin- Therapist: Because we talked about you doing a social
nings of hope. activity or trying to do a social activity . . .
how did you feel when you left here? In that
Patient: Yeah . . . it opens up possibilities . . . to do
moment when you let here and you were sort
different things. I’m looking at different so-
of, given this task to do?
cial groups . . . doing bushwalking . . . a
range of different activities . . . meeting peo- Patient: I was okay, I was feeling okay . . . I did go in
ple . . . and I looked at stuff . . . I didn’t go any further
with it.
Roger and his therapist proceeded to discuss imagined dinner
party experiences, and how these narratives related to Roger’s Therapist: . . . So when you looked at it how were you
interpersonal schema. Eventually, the session began to focus on feeling?
planning an activity.
Patient: I was feeling okay . . .
Therapist: So I’m sort of wondering: does Roger really
like dining out? And does he really like you Therapist: . . . did you find anything that might interest
know getting out and getting among nature? you?

Patient: . . . To a certain degree yes . . . I’ve just gotta Patient: . . . There was a . . . like a picnic type event
try all these things . . . from a logical point of . . . but I didn’t take the next step . . .
view, is that with the restaurant and with
Therapist: . . . so when you tell me that you didn’t take
meetings and dinners . . . I’m using that as a
the next step, how are you feeling?
platform to develop social skills . . .
Patient: . . . I didn’t follow through on something that
Therapist: So now we’ve kind of built a pathway I guess you wanted me to do.
to engaging in things which I guess are quite
terrifying to you . . . so have you got anything Therapist: . . . How do you feel that you didn’t do that?
planned coming up? . . . There’s no right or wrong answer.
BEHAVIORAL ACTIVATION FOR PERSONALITY DISORDERS 257

Patient: . . . the feeling I was saying before (feeling depressive disorder. At posttreatment, Roger no longer met diag-
suicidal in the context of remembering being nostic criteria for any PD, and no longer met criteria for major
served divorce papers) just overrode every- depressive disorder. He met 2 SCID-II criteria.
thing.
Therapist: . . . I guess what I’m trying to get an under- Reliable Change Outcomes
standing of . . . is how you got there, because Reliable change is generally measured by a metric, referred to as
when you left last week I didn’t get a sense the RCI. RCI is a metric to calculate whether a change in an
that you were suicidal. individual’s score (e.g., before and after an intervention) is statis-
Roger and his therapist began to discuss the triggered memory tically significant. Statistically, the RCI is defined as the change in
of receiving divorce paperwork. The therapist decided to revisit the the client’s score divided by the standard error of the difference for
episode in which Roger had received the papers, exploring the the measure used. The RCI is not the same as clinical significance,
feelings of loss and shame as understandable human experiences. which is also a metric used to represent clinical change, but in the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

case of clinical significance, the metric refers to the movement


Therapist: . . . I want you take a moment and go back to
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from a clinical range to a nonclinical range, or from a severe to a


that moment . . . how did you feel? less severe range, that is, it refers to the observable impact on the
Patient: I felt I felt, umm, that the situation was now client’s quality of life. An RCI of ⬎1.96 indicates that an observed
real. change is statistically significant (as an RCI of 1.96 is equivalent
to a 95% confidence interval for variation between participant
Therapist: Okay, that was how you were thinking. How
scores). For the DASS-21 (SDDepression ⫽ 6.97, ␣Depression ⫽ .91;
did you feel?
SDAnxiety ⫽ 4.91, ␣Anxiety ⫽ .84; SDStress ⫽ 7.91, ␣Stress ⫽ .9, and
Patient: I felt, I felt, ummm heartache . . . pain . . . a the OQ-45.2 (SD ⫽ 22.23, ␣ ⫽ .93) the RCI was calculated using
sense of loss. normative psychometric properties reported in the manuals for
these measures (see Lovibond & Lovibond, 1995; Lambert et al.,
Therapist: Loss. So you were grieving, you were grieving
2004). For the TAS-20 (SD ⫽ 11.35, ␣ ⫽ .86) and DERS (SD ⫽
for the loss of your marriage . . .
22.37, ␣ ⫽ .94), psychometric properties were taken from large-
As shown in the extract above, Roger was able to use an scale community-based studies (see Parker, Taylor, & Bagby,
unpleasant experience to develop skills in coping with difficult 2003; Ritschel, Tone, Schoemann, & Lim, 2015).
emotions, and to continue learning about himself and developing Roger’s progress from baseline to the conclusion of intervention
an integrated self-narrative. In his new self-narrative, he incorpo- was assessed using the RCI. Roger demonstrated marked improve-
rated a sense of faith that he could cope with emotional suffering ment across all measures over the course of therapy. For all
without becoming overwhelmed. Although he continued to expe- measures, a reliable change was achieved. Results are summarized
rience some thoughts about being “worthless,” these thoughts did below in Table 1.
not dominate his sense of identity. He was able to develop a sense
of worth, including a belief that although he had difficult experi- Clinical Change Outcomes
ences in his past, he was capable of bringing value to a relationship
and was worthy of being cared for. As shown in Table 1, at baseline Roger was in the clinical range
As Roger continued to progress over the course of therapy, he for symptom severity across all measures with available normative
began developing his own initiative with behavioral tasks. The data. On the DASS-subscales, at baseline Roger was in the ex-
therapist’s role evolved into to a less active, supportive role. In his tremely severe range (⬎28; Lovibond & Lovibond, 1995) for
posttherapy interview, Roger indicated that he believed behavioral
activation to be a key driver of change within the therapy: Table 1
On the second 6 months things started to get traction . . . Going and Reliable Change Index Outcomes Across all Measures
doing things, you know, like going out in a social situation somewhere
Reliable
and just allowing it to occur and see what happens . . . I would just Measure B1 B2 B3 Bmean M3 M6 M9 M12 RCI change
engage with anyone, so I just started making those small connections,
so it just became natural. OQ 45.2 106 97 94 99 79 71 43 41 6.97 Yes
DASS-D 36 42 40 39.33 18 14 12 0 13.3 Yes
Treatment Outcome DASS-A 12 16 14 14 8 10 4 0 5.04 Yes
DASS-S 26 20 26 24 14 14 14 2 6.22 Yes
Primary treatment outcome was assessed in terms of diagnostic TAS-20 62 67 66 65 51 44 37 31 5.66 Yes
DERS 101 108 121 110 103 77 61 54 7.23 Yes
status posttreatment. Other outcome variables were assessed using
the reliable change index (RCI). Roger’s mean baseline score was Note. B1 ⫽ baseline one, B2 ⫽ baseline two, B3 ⫽ baseline three, BM ⫽
compared with his final score, 12 months after commencing ther- mean of all baseline data, M3 ⫽ 3 month data, M6 ⫽ 6 month data, M9 ⫽
9 month data, M12 ⫽ 12 month data, RCI ⫽ reliable change index
apy.
comparing Bmean to M12. Normative clinical cut-off scores are as follows:
OQ 45.2 clinical range cut-off ⱖ63 (Lambert et al., 2004); DASS-D
Recovery normal/non-clinical range cut-off ⬎9; DASS-A normal/non-clinical range
cut-off ⬎7; DASS-S normal/non-clinical range cut-off ⬎14 (Lovibond &
Before commencing therapy, Roger met 20 SCID-II criteria and Lovibond, 1995); and TAS-20 alexithymia cut-off ⱖ61 (Parker et al.,
met diagnostic criteria for avoidant and depressive PD, and major 2003). Clinical cut-off scores are not available for the DERS.
258 GORDON-KING, SCHWEITZER, AND DIMAGGIO

depressive symptoms, the moderate range (10 –14; Lovibond & lenge maladaptive schemas and develop metacognitive skill
Lovibond, 1995) for anxiety symptoms, and the moderate range through lived experience, rather than attempting to change these
(19 –25; Lovibond & Lovibond, 1995) for stress. On the OQ-45.2, ingrained patterns through cognitive work alone (Dimaggio, Sal-
Roger was in the clinical range (ⱖ63; Lambert et al., 2004) for vatore, et al., 2015). Clinicians should aim to incorporate stepped
symptom severity, and he met the cutoff of 61 (Parker et al., 2003) behavioral interventions from the beginning of therapy.
on the TAS-20, indicating that he suffered from alexithymia. At Although the current study indicates that MIT behavioral inter-
the conclusion of therapy, Roger was in the nonclinical or normal ventions are implicated for use with PD populations, such inter-
symptom range across all measures. Clinical cutoff scores were not ventions should be approached with care. Roger’s experience
available for the DERS. demonstrates that behavioral interventions can easily trigger feel-
ings of personal inadequacy if the patient feels that they have
“failed” in a particular task. To avoid triggering negative self-
Functional Gains
representations, emphasis should be placed on the framing and
As the therapy progressed, Roger developed hobbies, formed rationale of interventions. The aim of behavioral exercises should
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

meaningful relationships with other people, and began to socialize be exploratory rather than achievement driven. MIT emphasizes
This document is copyrighted by the American Psychological Association or one of its allied publishers.

regularly on weekends. Toward the end of his therapy, Roger that all experiences—whether easy or difficult—are valuable, as
commenced a romantic relationship. At the end of therapy, Roger they provide opportunities to develop greater self-awareness (Dim-
had ceased taking any psychotropic medication. This represented aggio, Salvatore, et al., 2015). Clinicians should carefully explore
the first time he had been medication-free in ⬎20 years. patient reactions to behavioral exercises, and be mindful of any
schema-driven interpretations that the patient may make. Any such
reactions can be unpacked and explored to help that patient de-
Therapy Termination
velop an awareness of how their schema impacts interpretation of
Therapy ended after a 12-month intervention period. The ther- events within the therapy. Finally, clinicians should seek feedback
apist began discussing termination several months before the end from the patient for any behavioral intervention, to ensure that the
of therapy, aware that Roger could interpret the end of therapy as patient does not feel overwhelmed or pressured, and that behav-
a personal rejection. Roger reported that he found the lead up to the ioral hierarches are developed and adjusted in a collaborative
end of therapy anxiety provoking. Despite this anxiety, Roger process.
stated that he felt ready to finish therapy. He felt hopeful and Several limitations impact the conclusions that can be drawn
planned to continue with his hobbies and relationships. from the study. The single case design allows for a detailed
analysis of the MIT process and change over time, however,
clinical trials are needed to confirm the broader applicability of
Discussion
MIT behavioral interventions for PD populations. The behavioral
The current case demonstrates that PDs are maintained not only interventions described were part of an integrative treatment pack-
by maladaptive schemas, but by behaviors that reinforce internal age which included psychodynamic, Gestalt, and cognitive ele-
working models. Roger’s difficulties were maintained by avoid- ments (Dimaggio, Salvatore, et al., 2015). Therapy transcripts and
ance and withdrawal behaviors, which prevented him from devel- Roger’s posttreatment interview indicate that behavioral interven-
oping meaningful relationships, confirming his preconception that tions were a driver of his progress; however, it is not possible to
he was unlovable. The cyclical repetition of schema-consistent isolate behavioral activation as a definitive mechanism of change.
behaviors was thus a central aspect of the schema itself (Dimaggio, In addition, Roger presented with avoidant and depressive PD
Montano, et al., 2015). Although Roger presented with avoidant symptoms. Avoidant PD has been shown to be highly responsive
and depressive PDs, other PDs also feature strong behavioral to behavioral interventions, possibly due to a strong overlap with
components, suggesting that behavioral interventions, as concep- social anxiety disorder (Alden, 1989; Feske, Perry, Chambless,
tualized by MIT, are likely to be useful for all PDs where more Renneberg, & Goldstein, 1996; Zimmermann et al., 2013). Patients
traditional forms of behavioral activation may well be resisted with other forms of PD may be less responsive to behavioral
(Dimaggio et al., 2015). In more traditional forms of behavioral strategies.
activation, there is less focus on the details of episodes, whereas in Future studies should focus on conducting broader clinical trials,
MIT, there is a greater emphasis on grounding behavioral activa- and examining the impact of behavioral interventions for other
tion in the context of metacognition, which can assist in general- PDs. Overall, the current study suggests that behavioral interven-
izing therapeutic gains from the activity. For example, individuals tions can play a key role in improving patients’ quality of life. As
with obsessive– compulsive PD may display controlling and per- Roger stated during his exit interview:
fectionistic behaviors, which ultimately maintain anxiety around
failing to meet strict internal standards. Persons with narcissistic The program has saved my life, you know . . . when I first started, I’d
get up in the morning and I’d just think about killing myself. I hated
PD may oscillate between lashing out with dysregulated and
life . . . once you remove that baggage . . . you can just accept . . . It’s
aggressive behaviors when criticized, and withdrawal behaviors like a dance; it’s like a dance with life.
when they are unable to maintain their sense of grandiosity (Dim-
aggio, Montano, et al., 2015). Considering the central role of
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