Personality and Mental Health

4: 86–95 (2010)
Published online 20 November 2009 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/pmh.94

CBT for violent men with antisocial

personality disorder. Reflections on the
experience of carrying out therapy in
MASCOT, a pilot randomized controlled trial

KATE DAVIDSON1, JUDITH HALFORD2, LINDSAY KIRKWOOD3, GILES NEWTON-HOWES4,

MELANIE SHARP5 AND PHILIP TATA6, 1University of Glasgow, Faculty of Medicine, Gartnavel
Royal Hospital, Glasgow, UK; 2Liaison Psychiatry Teambase, NHS Ayrshire and Arran, UK;
3
Consulting and Clinical Psychology, NHS Ayrshire and Arran, UK; 4Imperial College (UK), Hawkes
Bay District Health Board, New Zealand; 5NHS Greater Glasgow and Clyde, Glasgow, UK; 6Central
and Northwest London NHS Foundation Trust, London, UK

ABSTRACT
Cognitive therapy for personality disorders (CBTpd) has been developed and assessed in borderline and anti-
social personality disorders (ASPD) using a variety of research methodologies from single cases to randomized
controlled trials. An exploratory randomized controlled trial of CBTpd compared with the usual treatment for
men with ASPD in the community allowed insights into how to carry out therapy with this group of patients
who are traditionally thought of as being difficult to manage. CBTpd for ASPD is time-limited, is problem-
focused and aims to develop new ways of thinking and behaving that would reduce anger and acts of violence
and improve interpersonal relationships. Men with ASPD often held beliefs that could interfere with the devel-
opment of a therapeutic relationship. The beliefs were hypothesized to have arisen from experiences of being
humiliated in childhood and adolescence as well as having experienced neglect and abuse. Equally, therapists
needed to be aware that in developing a compassionate formulation of the patient’s problems, they should not
minimize the potential for violence. Supervision of both process and content had a greater importance than in
other CBT models, and supervision required recordings of clinical sessions to enable this to happen. Copyright
© 2009 John Wiley & Sons, Ltd.

Introduction been away from analytically based therapies

Psychological interventions for personality disor-
ders have been, and remain, the cornerstone of
treatment for personality disorders (PDs) (National
Institute for Health and Clinical Excellence
(NICE, 2009). In more recent times, the trend has
towards cognitive behavioural approaches, in part,
because of the poverty of outcome information
with analytic approaches and the difficulty in
engaging particular personality-disordered popula-
tions in this approach. This has seen an explosion
of an evidence base of structured psychological

Copyright © 2009 John Wiley & Sons, Ltd 4: 86–95 (2010)

DOI: 10.1002/pmh

therapies for borderline personality pathology (see
Scottish Government, 2009), including cognitive
therapy for personality disorders (CBTpd) but a
relative dearth in antisocial personality disorder
(ASPD).
CBTpd has been shown in those with a
diagnosis of borderline personality disorder to be
effective in reducing symptom distress, anxiety,
dysfunctional beliefs and suicidal acts (Davidson
et al., 2006). CBTpd was also associated with
reduced cost compared with the usual treatment
(Palmer et al., 2006). There is therefore face valid-
ity to hypothesizing that such an approach could
be successfully adapted to use in other personality
disorders such as ASPD. As the NICE guideline
for ASPD noted (NICE, 2009), there is very little
information on the efficacy of therapy. The thera-
peutic approach described here was developed
and assessed using single case methodology and in
a pilot, randomized, controlled trial in ASPD
(Davidson, 2007; Davidson & Tyrer, 1996; Davidson
et al., 2009). The randomized trial provided the
opportunity to examine the process of therapy and
reflect on the challenges this group presents for
those undertaking CBTpd for ASPD. This paper
presents insights gained about both the content
and the process of CBTpd and summarizes some
of the adjustments from ‘standard CBT’ necessary
in this clinical context.
The Men with ASPD Treated with Cognitive
Therapy (MASCoT) trial
We carried out an exploratory, randomized, con-
trolled trial. This was carried out in a community
setting with 52 adult men diagnosed with ASPD,
all of whom had admitted acts of aggression in the
6 months prior to the study. The study is explained
in detail elsewhere (Davidson et al., 2009). In brief,
all the men were voluntary patients and had given
their informed consent to take part in the trial
that was approved by local research ethics com-
mittees. They were randomized to CBTpd or to
treatment as usual (TAU). They were all men, on
average, 39 years old, single, poorly educated,
Copyright © 2009 John Wiley & Sons, Ltd
CBT for antisocial personality disorder 87
unemployed and had below average literacy skills.
This patient group had multiple complex needs.
Many of these needs were unmet (Crawford, Sahib,
Bratton, Tyrer, & Davidson, in press, unpublished
data).
Under the trial conditions, the therapy was
time-limited to either six or 12 months for prag-
matic reasons relating to trial conditions and to
assess what duration of therapy would be accepta-
ble to the participants. All the patients were seen
individually for therapy. Group therapy was not
considered a realistic option as patients with ASPD
are, in general, paranoid and hostile to others,
initially guarded about sharing information and
extremely sensitive to perceived criticism. It was
therefore likely they would have dropped out of
treatment if the trial had required a group format,
either completely or as a component of the therapy.
In the pilot trial, 44% attended more than 10 ses-
sions of CBT. In the pilot, half the CBTpd group
were randomized to 6 months of therapy, thus,
limiting the number of sessions offered. The
average number of sessions attended by the CBTpd
group as a whole was 16 sessions (range 10–30).
The primary aim of the study was to reduce
verbal and physical acts of aggression. At 12
months, both groups reported a decrease in the
occurrence of acts of verbal or physical aggression.
Such a finding is common for exploratory CBT
trials that explore the feasibility of therapy in a
specific group of patients. Trends in the data sug-
gested that problematic drinking, disordered social
functioning and dysfunctional beliefs about others
improved more in the CBTpd group than in the
TAU group. This suggests that this therapy may
be applicable in a public heath setting, and an
understanding of the process issues may help to
inform further research and evaluation.
Therapists and supervisors
The therapists were three women and four men.
All were experienced health service staff who had
worked in adult mental health for a minimum of
5 years post-qualification. None had specific expe-
4: 86–95 (2010)
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88 Davidson et al.
rience of working with forensic patients other than
that gained through training. Two were psychia-
trists, three were either counselling or clinical
psychologists at a Doctoral level and two were
CBT-trained therapists with nursing and occupa-
tional therapy professional backgrounds. None
had previously used CBTpd for ASPD, but five
were experienced CBT therapists and two had
been involved as therapists in a previous trial
of CBTpd for borderline personality disorder
(Davidson et al., 2006). As such, all understood
the general theory of cognitive-based therapies,
using the model of CBT in therapy with clients
and the components of CBT delivery.
Receiving regular individual and then group
supervision once the trial patients were at a later
stage of therapy was essential to ensure adherence
to the CBTpd model and to aid the development
of CBTpd skills in therapists. All of the therapists
had 3 days of initial training in the CBTpd model
at the beginning of the trial followed by a further
2 days of group training. Supervision was carried
out by Doctoral-level clinical psychologists (PT
and KD), including the originator of the protocol
(KD). Both supervisors were therefore highly expe-
rienced in the CBTpd model and in addition, had
carried out a previous trial in which they super-
vised therapists with borderline personality disor-
der (Davidson et al., 2006). Provided consent had
been obtained from the patient, the therapist’s
recorded CBT sessions and a random sample of
audio recordings were assessed by the supervisors
for adherence to the therapy protocol and to allow
the assessment of therapist competence using the
Cognitive Therapy Rating Scale (Young & Beck,
1980). All of the therapists were rated as being
within the competent range on this scale.
The general principles of the CBTpd model
CBTpd is a collaborative, problem-focused CBT,
with particular emphasis on the patient–therapist
relationship. The patient’s dysfunctional beliefs
and behavioural strategies, understandable given
Copyright © 2009 John Wiley & Sons, Ltd
their histories, were considered non-adaptive to
their current situation, a supposition found in CBT
for most disorders. The therapy aimed to help the
patient develop news ways of thinking and behav-
ing and improve interpersonal and intra-personal
functioning. As such, CBTpd mirrored the central
tenets of CBT for Axis I disorders.
Formulation in CBTpd for ASPD
All cognitive therapy emphasizes the key role of
formulation in guiding therapy, especially in the
treatment of personality disorder (Beck, Freeman,
Davis, & Associates, 2004; Davidson, 2007). The
therapists aimed to develop a compassionate
CBTpd formulation, one that required an under-
standing of the patient’s view of himself and of
others and how he might suffer yet think and
behave in a manner that was harmful to other
people. Using the CBTpd model, all of the thera-
pists obtained a thorough history of the patients’
current and past problems in the context of a per-
sonal history over several initial sessions. Although
we did not know in detail the past histories of
those referred to TAU, it became evident that
those who were randomized to CBTpd had often
experienced trauma and deprivation during their
childhood. Developing a compassionate formula-
tion was relatively straightforward in this group of
patients as a result. However, it was, with some
patients, more challenging to derive this formula-
tion collaboratively. The therapists’ formulation,
which pointed to the patients having fixed nega-
tive beliefs about themselves and about others,
underdeveloped behavioural strategies, and none
of the necessary skills required to develop more
reciprocal relationships with others were, from the
patient’s perspective, based on the hard reality of
life of their early childhood and adolescent experi-
ences of violence and neglect within the family
home. Beliefs, such as ‘others are out to get me’
and ‘if I trust people, they will humiliate me’, were
in juxtaposition with being able to readily form a
collaborative, equitable relationship. Explicitly
revealing these core beliefs associated with vulner-
4: 86–95 (2010)
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ability and powerlessness risked activating defen-
sive or aggressive behavioural responses in the
patients. This potentially challenged the collabo-
rative nature of deriving a formulation, potentially
placed the therapist at risk and threatened the
therapeutic relationship. For the majority of
patients, however, this was the first time that they
had experienced someone taking a careful, and
lengthy, account of their past in a therapy situa-
tion. The formulation was delivered in the form
of a coherent narrative, hypothesizing why they
developed the problems they were currently expe-
riencing. The compassionate and collaborative
features of the formulation, emphasized in CBTpd,
although challenging, provided the patients with
ASPD the opportunity to develop the capacity to
understand the perspective of another and actively
participate in change. As such, these components
of the formulation were an essential component of
the therapy in this trial.
Forming a collaborative therapeutic relationship
Cognitive therapy for ASPD, in common with
cognitive therapy for other disorders, seeks to
develop a collaborative relationship with shared
goals. The development of a shared formulation
strengthened the therapeutic relationship both in
terms of the validation of the men’s experiences
and ‘inner life’, and in the provision of accurate
empathy, something they had rarely, if ever, expe-
rienced previously. The willingness of the thera-
pist to work practically on difficult day-to-day
problems, as well as the relevant underlying psy-
chological underpinnings, helped develop credibil-
ity in the relationship, and keep the therapy ‘real’.
However, these aims were not readily met with
some of the patients at an early stage of therapy
because of the patient’s pathology. Our patients
with ASPD typically held beliefs such as ‘I cannot
trust other people’, ‘others will try to exploit or
humiliate me’ and ‘others are more powerful than
me’. Being able to communicate freely and having
respect for another person’s perspective even if
there is disagreement is a fundamental condition
Copyright © 2009 John Wiley & Sons, Ltd
CBT for antisocial personality disorder 89
of developing a reciprocal relationship. In ASPD,
this understanding of relationships is seldom part
of the patient’s experience. This had an immediate
impact on both the process and content of the
therapy. This needed to be recognized by the ther-
apists, who were often initially naïve to the patient’s
beliefs about others. Some of the therapists noted
the patient’s apparent or real reluctance to form
a collaborative relationship in the beginning of
therapy. This was a reflection of the patient’s
normal style of engaging with strangers, based on
the types of beliefs mentioned earlier. In addition,
reaching shared goals early on in therapy was often
problematic. The therapists usually developed a
formulation that pointed to a patient having fixed
negative beliefs about himself and about others,
underdeveloped behavioural strategies and none of
the necessary skills required to develop more recip-
rocal relationship with others. From the patient’s
perspective, however, beliefs such as ‘others are out
to get me’ and ‘if I trust people, they will humiliate
me’ are incompatible with being able to readily
form a collaborative, equitable relationship and
were often based on their early childhood and
adolescent experiences of violence and neglect
within the family home. Believing that he was
vulnerable and powerless, acting in a manner that
denigrated others and acting aggressively towards
others was regarded as an over-compensatory strat-
egy developed since childhood and adolescence to
cope with this vulnerability. Many of the patients
with ASPD had not been given the opportunity
to develop the capacity to understand the perspec-
tive of another or be empathic. In addition, the
patients often thought that it was other people
who were responsible for their difficulties in rela-
tionships, a form of schema avoidance. For example,
‘s/he should do what I want’ and ‘s/he will not
understand me’. These types of beliefs were found
to interfere with the patients identifying that their
own behaviour may need to change, at least at the
onset of therapy.
At least initially, attempting to set goals in
therapy with the patients with ASPD was occa-
sionally problematic as some of the patients could
4: 86–95 (2010)
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90 Davidson et al.
not recognize that there was a deficit. Second, it
required that the patient has some understanding
that his current behavioural strategies were not
adaptive or necessarily useful in the here and now
and that alternatives that might improve relation-
ships without rendering him more vulnerable
existed. Additionally, the patients initially often
did not want to admit vulnerability as this, in their
experience, might lead to humiliation.
Counter-transference and transference issues
Counter-transference and transference are not
terms commonly used in cognitive therapy, whereas
analytic therapy would utilize these concepts
as mechanisms for understanding and change
(Gunderson, 2008). The theoretical underpin-
nings in the analytic psychotherapeutic approach
are at odds with the theory of the mind on which
cognitive models are based (Clark, 1995). Cognitive
therapies do not include theoretical components
such as the inaccessible unconscious, the primacy
of passive, unconscious emotive drivers or the need
for an understanding of the patient that is hidden
from them. However, some cognitive processes
may not be within conscious awareness. The inter-
personal issues raised in a cognitive therapeutic
framework are better thought of as part of a thera-
peutic belief system (Rudd and Joiner, 1997). This
helps to avoid any theoretical confusion that is
inevitable by borrowing terms from a different
therapeutic modality.
Using CBTpd with individuals who have ASPD
has many of the characteristics of CBT for Axis I
disorders, but the patient’s problems inevitably
raised interpersonal problems, some of which were
played out within the patient–therapist relation-
ship. These patients had difficulties in forming and
maintaining relationships as a result of the assump-
tions they made about themselves and others. At
times, this had a marked impact on therapy. For
example, sensitivity to issues of neglect and aban-
donment were seen in responses to missed or can-
celled appointments, even when it was the patient
himself who had defaulted. Examples of transfer-
Copyright © 2009 John Wiley & Sons, Ltd
ence were when patients responded to a therapist’s
suggestions as if they were being critical or judge-
mental. In turn, this led the therapists to believe
they were being unfair and punitive towards the
patient. Additionally, the development of a thera-
peutic relationship involved a level of perceived
intimacy different from the patient’s usual ways
of relating to others. To ensure professional and
interpersonal boundaries were maintained, the
therapists had to be particularly aware of these
issues. Disentangling or understanding such a
process was important for the therapists, who were
trying to maintain a therapeutic relationship with
the patient. The development of this understand-
ing was often the focus of supervision. The thera-
peutic relationship also acted as a relationship
laboratory where some of these issues could be
explored by asking the patient about his thoughts.
For example, the therapists could explore what
thoughts about himself occurred to the patient
when upset by something that had been said in
therapy and also, what they thought the therapist
was thinking. This provided a live problem and
helped model an adaptive response to thoughts
that might be, for example, hostile or paranoid.
Although working on the patient’s cognitions,
especially when the emotional tone was ‘hot’
within a cognitive framework, was often highly
productive, the therapists also needed to be aware
when such an exploration of thoughts might be
potentially damaging to the therapeutic relation-
ship, given the formulation of the patient’s
problems.
Forgetting the risk?
One risk we encountered was the potential that
the therapists risked ‘forgetting’ that their patients
with ASPD had a history of violence towards
others in the past and that this propensity for
violence may initially remain undiminished. It was
as if what was happening in therapy in the here
and now was divorced from the patient’s known
and documented history of violence. This seemed
to happen as a result of having developed an
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empathic formulation of the patient’s current and
past difficulties and the patient appearing to be
making good progress and being more able to form
a collaborative relationship with the therapist.
Through the individualized CBTpd formulation,
the therapists fully acknowledged the patient’s
deprivation both physically and emotionally and
sought to ‘understand’ the patient’s subculture and
the rules that they lived by. The therapist’s capac-
ity to tolerate listening to the patient’s accounts of
violence increased as therapy progressed, but the
therapists needed to be aware of when their own
professional and moral value system was being
accessed to understand that their sense of what is
right and wrong was potentially threatened. This
was a balancing act that required a high level of
awareness of the process of therapy while under-
standing how patients might interpret the thera-
pist’s words and actions.
To do this, the therapist needed to elicit
accounts of past and present violence and set a
tone in the therapeutic relationship that increased
the likelihood that the patient could discuss
matters of violence openly. The therapist needed
to be acutely aware of not condoning violence but
allowing as open a discussion of this as was possi-
ble. The therapists observed that the patients were
likely to be sensitive to signs of revulsion and fear
in them and that the patients monitored their
facial expressions and other reactions closely. Some
of the patients appeared to get a vicarious sense of
pleasure from telling the therapist about acts of
violence. At the other end of the spectrum, some
of the patients appeared to find the therapists’
understanding and empathic interactions threat-
ening. It was not uncommon for the patients to
become suspicious of the motives of their thera-
pists—stating for example, ‘You (i.e. the therapist)
are trying to pump me for information.’ In this
way, the process of therapy actually increased the
risk of violence at times. Therefore, it was impor-
tant that the therapists were aware of tensions
within sessions especially in the early phase of
therapy and the need to adjust and shorten ses-
sions without disrupting the flow of therapy itself.
Copyright © 2009 John Wiley & Sons, Ltd
CBT for antisocial personality disorder 91
Supervision, using audio recordings of the sessions,
was vital in this process. In CBTpd, the therapists
aimed to understand the situations that were likely
to lead to the patients becoming aggressive so that
the patients could also develop a better under-
standing of these situations, develop skills to avert
aggressive responses and learn new more adaptive
ways of behaving that encouraged more reciprocal
relationships.
The timing of enquiry about violence was
important. Some of the patients tested out the
therapist at an early stage of the therapy by almost
uncontrollably telling the therapist about acts of
violence they had allegedly carried out. The thera-
pist, unsure of the patient’s core beliefs about
others at this stage, hypothesized core beliefs such
as ‘others will reject me’. Acting on this hypothe-
sis, some therapists did not attempt to minimize
these outpourings about violence as they thought
that this might be regarded as rejection by patients.
Uncontrollable outpourings of violence increased
arousal levels in some of the patients and this
required containment without abruptly halting
the process or seemingly not allowing any future
discussion of these acts. Managing to modulate the
patient’s affect at this stage appeared to be helpful.
The containment of affect within sessions was
facilitated by maintaining control of the session by
keeping a calm stance, keeping one’s voice low and
acknowledging that the patient’s account of vio-
lence was being taken seriously.
There were clearly other times within sessions
when the therapists had to intervene and close
down the descriptions of violence. These were
times when the patient’s account of an incidence
of violence was becoming repetitive, when the
arousal level of the patients indicated that the
patient was gaining pleasure from the account
without any suggestion of some reflection of the
consequences of the act or when the patient was
simply describing a list of violent acts without any
suggestion that they were attempting to gain an
understanding of these acts with the therapist
acting as an audience of the account. In short, the
therapists had to recognize when this occurred
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92 Davidson et al.
through active reflection and processing what was
happening in therapy in the here and now—
whether the recounting of violence had a thera-
peutic purpose or dislocated from the therapy and
would derail the therapeutic process.
This required the therapists to remain aware of
both emotional and descriptive content within the
therapeutic dyad. Both the content of what was
being said in therapy and the ongoing interper-
sonal process between the patient and the thera-
pist had to be simultaneously attended to by the
therapist. The therapists had to have an overview
of the direction of the therapy that would be
helpful or unhelpful and therefore be able to influ-
ence what might happen next or at least be able
to have some prediction of what is likely to occur
should they say or do something. This was a chal-
lenging process and is an area that requires more
specific focus in order to improve therapy for this
group.
Risk management
This group of patients not only posed a risk to
others but also to themselves. The therapists
needed to repeatedly evaluate and monitor the risk
to the patient, to others and to themselves during
therapy. All therapies took place in safe clinical
settings where other members of the staff were
present and aware of the risk involved. Ground
rules were established about carrying weapons into
therapy sessions and about sobriety.
We were aware of the possibility that a thera-
pist might feel that there was a conflict between
the importance of eliciting information on the one
hand and leading the patient to incriminate
himself on the other. In the UK, where the trial
took place, the therapists had a legal responsibility
to report information that related to a serious
crime. All of the patients who participated in the
trial had given an informed consent to disclose of
such information. One of the statements they
endorsed on the consent form in order to be
included on the trial was ‘I understand that if I
inform the researcher or therapist of an unreported
Copyright © 2009 John Wiley & Sons, Ltd
crime, or about a crime about to be committed,
this information will have to be passed on to the
relevant authority. However, I also understand
that I will not be asked to provide such informa-
tion unless I wish to.’ This stance on privacy, not
confidentiality, was important to ensure that core
paranoid beliefs were not reinforced while at the
same time, maintaining legal and professional
responsibilities.
Behavioural change
One of our key targets in the trial was to reduce
violence in men with ASPD. Through the formu-
lation, overdeveloped and underdeveloped behav-
ioural strategies became apparent. The patients’
insight into their maladaptive behaviours and
awareness of alternative ways of behaving was
limited and often, only partial. Perhaps, not sur-
prisingly, given the level of emotional and social
deprivation, neglect and abuse experienced by
these men, the major deficits in self-nurturance
and self-protection, and interpersonal and social
skills including assertiveness skills were priorities
for behavioural change. There were practical
aspects to promoting behavioural change. For
example, when conducting behavioural experi-
ments or activity scheduling, the patients often
had limited income, poor literacy skills and lived
in areas with limited resources or where other
people may have posed a significant threat to
them. Initially, behavioural change experiments
were often more prescriptive than in other forms
of CBT as patients usually had a limited experi-
ence of trying to alter their behaviour and a limited
repertoire of behaviour because of their overdevel-
oped behavioural strategies, which were clearly
maladaptive in their current circumstances. The
therapist had to carry out a detailed functional
analysis of a problematic situation, convey to the
patients how a different response from them might
potentially elicit a more positive response from
others and encourage or even persuade the patients
to practice more adaptive skills that could be used
in the situation to gain a better outcome. Only
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after the patient had understood the value of
behavioural experimentation—often by testing
out if a different behavioural response would elicit
a positive reaction from a person and by experienc-
ing its positive impact—did they more fully engage
with the process of hypothesis testing within
behavioural experimentation.
Cognitive change
The patient’s beliefs, which may have been adap-
tive and made sense of their situation in the past,
may no longer be so in their current situation.
Changing beliefs about their selves and about
others to be more adaptive and realistic was a
major goal of CBTpd with this group of patients
and required persistence on the therapist’s part.
Standard CBT techniques were useful here, but
beliefs were more readily altered as a result of
behavioural change in itself. The therapeutic rela-
tionship was also a vehicle for change in that pre-
viously held beliefs, such as others are dismissive
or contemptuous, could be undermined. Indeed,
specifically discussing the patient–therapist rela-
tionship and using it as an example of positive
change was a powerful cognitive tool. It was also
important that the therapists were aware of and
identified times when the patient’s beliefs were
likely to be an accurate appraisal of their situation
and therefore when it was not appropriate to fully
challenge these. For example, others may wish to
cause harm and others within their social/cultural
environment may lose respect for them if they do
change their use of violence and aggression. A
more appropriate method of change in these cir-
cumstances was, for example, a cost–benefit analy-
sis of the behaviour in question.
Realistic change and what to do when you are
‘stuck’ in therapy?
Therapists get ‘stuck’ in delivering CBT, and from
time to time, this was the case in this study. The
reasons were complex. For example, they
sometimes felt at their limit of knowledge and
Copyright © 2009 John Wiley & Sons, Ltd
CBT for antisocial personality disorder 93
experience or they may have shared some of
the same dysfunctional beliefs as their patients.
Supervision was essential to facilitate reflection on
the process and content of therapy. The therapists
generally reported getting stuck with the patients
with personality disorder in a variety of circum-
stances. During the trial, this often occurred when
a therapist had lost the focus provided by the for-
mulation. The therapist was not fully aware of this
and was responding to the demands of the patient
who was experiencing an immediate but unrelated
crisis that could be resolved without making it the
full focus of a therapy session. An example of this
was a patient and a therapist becoming preoccu-
pied with the details of an impending court appear-
ance to the exclusion of an overview of how the
cognitions and behaviours related to this crisis
fitted with the formulation. The therapists on
occasions also had unrealistically high expecta-
tions of what the patient could realistically achieve
in the time period of the therapy.
Avoidance of issues that increased affective dis-
turbance and distress was common. In some ways,
this may seem surprising given that these patients
often report distress and anger and sound angry.
The patients were, however, often adept at avoid-
ing distress that would increase feelings of vulner-
ability or humiliation. As the therapists did not
wish to ‘distress’ their patients and sought to keep
affect to a manageable level within the therapy,
collusion with the patients’ avoidance was a con-
stant challenge. The role of the supervisor, who
was in a position to take an overview of the case
through the shared understanding of the formula-
tion, assisted the therapists to identify and safely
manage such avoidance.
This patient group tended to have difficulty
taking a medium- to long-term view of what they
wished to achieve in terms of goals. They had little
experience of being goal-directed and tended to be
reactive to situations. They usually had low expec-
tations of themselves, founded on past experiences
of failure in a multiplicity of areas such as educa-
tion, employment and maintaining relationships.
They also had difficulty in articulating wishes and
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94 Davidson et al.
desires and in being specific about what they
wanted to change. One patient, for example, spoke
of wanting to ‘have a better life’ without being able
to articulate what this different life might be like.
They also tended to place responsibility for change
on others rather than themselves.
Conclusions
The view from the ground, in working with these
antisocial, poorly educated, socially and economi-
cally disadvantaged, and violent men was that
doing CBTpd was helpful in reducing antisocial
behaviours and changing thinking. Our pilot study
was small, and larger randomized controlled trials
are needed to fully test out the efficacy of this
treatment. Our reflections suggest therapists need
to be risk-aware while carrying out therapy and
need to be skilled at modifying session content and
their behaviour to control levels of high affect.
Among the more serious problems faced by the
therapists is the potential for frequent recounting
of violence leading to habituation. In certain cir-
cumstances, this can threaten the moral compass
of therapists. Deriving an empathic and compas-
sionate formulation was essential given the per-
sonal and social histories of these men, and
developing it collaboratively can be both challeng-
ing and a fulcrum for cognitive change. The overall
formulation was essential in therapy to avoid fire-
fighting multiple crises and provided an overall
direction to therapy. Regular, skilled, supportive
supervision was an essential part of carrying out
therapy, more so than in CBT for other disorders.
Without this, the therapy, therapeutic relationship
and outcomes would have been likely to deterio-
rate. Additionally, it was not enough to have verbal
accounts of therapy, as recording sessions allowed
supervision to focus on process issues that were as
important as the content in CBTpd for ASPD.
Although this therapy is personally challenging, it
provided the opportunity to enable changes in
people whom society often marginalizes, stigma-
tizes and ignores. As such, it warrants further
exploration.
Copyright © 2009 John Wiley & Sons, Ltd
Acknowledgements
The study was supported by a grant from the
Medical Research Council, reference number
G0400922. The study sponsor was Research
Manager, NHS Greater Glasgow and Clyde. Trial
registration Current Controlled Trials: ISRCTN
89922377.
References
Beck, A. T., Freeman, A., Davis, D. D., & Associates (2004).
Cognitive therapy of personality disorders (2nd ed.). New
York: The Guilford Press.
Clark, D. (1995). Perceived limitations of standard cognitive
therapy: A consideration of the efforts to revise Beck’s
theory and therapy. Journal of Cognitive Psychotherapy, 9,
153–172.
Crawford, M. J., Sahib, L., Bratton, H., Tyrer, P., & Davidson,
K. (2009). Service provision for men with antisocial per-
sonality disorder who make contact with mental health
services. Personality and Mental Health.
Davidson, K. M. (2007). Cognitive therapy for personality dis-
orders: A guide for clinicians (2nd ed.). Hove: Routledge.
Davidson, K. M., & Tyrer, P. (1996). Cognitive therapy for
antisocial and borderline personality disorders: Single
case series. British Journal of Clinical Psychology, 35,
413–429.
Davidson, K. M., Tyrer, P., Tata, P., Cooke, D., Gumley, A.,
Ford, I., Walker, A., Bezlyak, V., Seivewright, H.,
Robertson, H., & Crawford, M. J. (2009). Cognitive
behaviour therapy for violent men with antisocial
personality disorder in the community: An exploratory
randomized controlled trial. Psychological Medicine, 39,
569–578.
Davidson, K., Norrie, J., Tyrer, P., Gumley, A., Tata, P.,
Murray, H., & Palmer, S. (2006). The effectiveness of
cognitive behaviour therapy for borderline personality
disorder: Results from the BOSCOT trial. Journal of
Personality Disorders, 20, 450–465.
Gunderson, J. G. (2008). Borderline personality disorder. A
clinical guide (2nd ed.). Washington, DC: American
Psychiatric Association.
National Institute for Health and Clinical Excellence
(NICE). (2009). Guidelines on the treatment of adults with
antisocial personality disorder. NICE clinical guideline 77.
London: NICE.
Palmer, S., Davidson, K., Tyrer, P., Gumley, A., Tata, P.,
Norrie, J., Murray, H., & Seivewright, H. (On behalf of
the BOSCOT group). (2006). The cost-effectiveness of
4: 86–95 (2010)
DOI: 10.1002/pmh

cognitive behaviour therapy for borderline personality
disorder: Results from the BOSCOT trial. Journal of
Personality Disorders, 20, 466–481.
Rudd, M., & Joiner, T. (1997). Countertransference and the
therapeutic relationship: A cognitive perspective. Journal
of Cognitive Psychotherapy, 11, 231–250.
Scottish Government. (2009). Mental health in Scotland. A
Guide to delivering evidence-based psychological therapies in
Scotland. ‘The matrix’. www.scotland.gov.uk/topics/health/
health/mentalhealth/ servicespolicy/matrixfeb2009
Copyright © 2009 John Wiley & Sons, Ltd
CBT for antisocial personality disorder 95
Young, J. E., & Beck, A. T. (1980). Cognitive Therapy Rating
Scale: Manual. Philadelphia: Centre for Cognitive
Therapy.
Address correspondence to: Prof. Kate Davidson,
Faculty of Medicine, University of Glasgow,
Gartnavel Royal Hospital, 1055 Great Western
Road, Glasgow, UK. Email: k.davidson@clinmed.
gla.ac.uk
4: 86–95 (2010)
DOI: 10.1002/pmh