Rep36 Understanding Personality Disorder

2.1.3 Behavioural and cognitive-behavioural
approaches
Where psychodynamic theories are based in
observations of distressed individuals undergoing
therapy, behavioural approaches originate in
observations of animal and human learning in
psychological research. Applied behaviour
analysts believe that behaviour is controlled by its
antecedents and consequences in the
environment, behaviours with positive effects
being reinforced or strengthened, those with
aversive effects being weakened. These principles
are basic to behavioural intervention strategies
for developing adaptive social and coping skills.
A functional analysis is necessary to determine
the personal and environmental factors that are
controlling behaviour and therefore need to be
the targets of intervention.
Behaviourists are critical of concepts of
personality disorder and traits, seeing them as
uninformative labels that simply describe the
form but not the function of behaviour (Follette,
1997). Problematic behaviours serve different
purposes for different individuals and on
different occasions. Rather than diagnosing
personality disorder, the need is to determine
the groupings of response that share the same
function for the particular individual. For
example, suicide attempts, lashing out at others,
substance abuse, dissociation, and withdrawal
may all function to avoid emotional intimacy that
has in the past led to hurt and rejection.
Interventions should be guided by experimental
research on behaviour.
Cognitive-behavioural approaches share these
basic principles but accord greater significance
to cognitive activities in controlling behaviour,
drawing on computer analogies of how
information is processed. Attitudes, beliefs, and
expectations are acquired through social
learning processes of observation and
reinforcement, but then come to influence how
we interpret and react to environmental events. 
Cognitive-behavioural therapy (CBT) is
concerned with ameliorating dysfunctional
emotional and social reactions through
educational and behavioural skills training
procedures such as cognitive restructuring,
relaxation training, social skills training, self-
control methods, and problem-solving
techniques. The aim is to provide the person
with strategies for coping with problematic
situations. Because the focus is on problem
behaviours as they occur in specific contexts,
CBT makes little use of concepts of personality
traits or disorders. 
Some therapists, however, see personality
disorders as descriptions of unskilled or
ineffective interpersonal behaviours that
produce either social isolation (lack of positive
social reinforcement) or aversive behaviours
from others (social punishment; Marshall &
Barbaree, 1984). The criteria identifying
personality disorders are hence seen as
dysfunctional exaggerations of normal
behaviours that can be related to behavioural
categories dealt with by CBT. Avoidant
personality disorder, for example, can be
construed as a combination of inappropriate
assertive responses, dysfunctional social
cognitions, and social anxiety. Social and
cognitive skills training may therefore be
appropriate interventions for people with a
personality disorder.
Dialectical Behaviour Therapy (DBT) for
borderline personality disorder is the most
explicit application of CBT to personality
disorder (Linehan, 1994). DBT integrates CBT
with Zen and dialectical philosophical principles
of the synthesis of opposites. Treatment targets
the parasuicidal behaviours of borderline
patients. Linehan’s biosocial theory sees
borderline disorder as a dysfunction of the
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emotional regulation system stemming from
biological irregularities interacting with an
adverse, invalidating (rejecting) environment.
The consequences are difficulties in labelling
and regulating emotions and trusting one’s own
experience as valid, and self-mutilation functions
to reduce intolerable painful emotion.
Emotional dysregulation takes the form of rapid,
intense reactions, and these produce the
characteristic problems in relationships, sense of
self, impulse control, and cognitive distortion. 
Skills training and problem-solving
techniques are applied in group treatment to
improve interpersonal conflict resolution,
distress tolerance, and emotion regulation, but
these are balanced by individual supportive
techniques (reflection, empathy, acceptance)
from Eastern philosophies (Zen) and the use of
meditation. Dialectical strategies also pervade
therapy. These include teaching the patient
more balanced patterns of thinking and behaviour
and balancing therapist strategies of change with
acceptance of the patient’s experience.
DBT has been used effectively to reduce
parasuicidal behaviours, and is currently being
extended to other self-defeating behaviours
such as substance abuse and aggression. It is
not, however, a generalised approach to
personality disorder.