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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.
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.
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.
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.
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
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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.
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.
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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