Childhood experiences, coupled with an innate, biologically-determined disposition,

establish our initial beliefs about the world. These initial beliefs evolve into fairly stable,
core beliefs that shape people's perceptions and interpretations of subsequent
experiences. When these preconceived beliefs are faulty, distorted, or biased, we may
end up drawing incorrect, irrational conclusions about the meaning of external events
(particularly interpersonal interactions). We may subsequently behave in ways that
cause us unnecessary distress and suffering.

You may recall, people with personality disorders have characteristic patterns of
thinking that get them into trouble. This is because their ways of thinking tend to be
somewhat extreme, inflexible, and distorted. CBT is particularly helpful for people with
personality disorders because of its emphasis on identifying and changing dysfunctional
thinking patterns. In particular, core beliefs underlying those patterns are exposed and
challenged. Thus, cognitive-behavioral therapy functions to identify and challenge
automatic and faulty interpretations of the environment that are driven by core beliefs.
A person corrects these faulty interpretations of the environment by replacing them with
more accurate, rational interpretations. With a more accurate interpretation, new, more
accurate core beliefs are formed. This is because there is a circular causality between
people and their environment: The environment has an effect upon me, and I have an
effect upon my environment. These new, positive experiences allow the person to
update their core beliefs about the world. This in turn enables them to have more
positive and affirming experiences and so on. As core beliefs become more rational
and less biased, the client's appraisals of the meaning of events becomes more
accurate. This results in emotional and behavioral reactions that are less exaggerated
and problematic.

There are several steps to this corrective process. First, the therapist and participant
work together to identify the problematic thinking patterns. This is accomplished by
asking the therapy participant to keep track of troubling events. Participants record their
thoughts in response to these events. In other words, the therapy participant records
what they say to themselves during these events. Next, the participant would learn to
consider whether there are alternative interpretations of the same event. The ultimate
goal of this process is to interrupt the automatic but distorted thoughts as they occur,
while learning to consider alternative, more accurate interpretations of these same
events. With practice and gradual success, the recovering person begins to feel better
and behave differently. Because they are behaving differently, people respond to them
more favorably. This sets the stage for more accurate core beliefs to form about
themselves-in-the-world.

Let's return to the example of the clumsy foot stepper and the man with a Paranoid
Personality Disorder. His core belief, the-world-is-a-dangerous-place, causes him to
misinterpret other people's behaviors as hostile and exploitive, with the intent of causing
him harm. CBT would begin by asking him to record situations in which he felt
threatened and to record his immediate thoughts and feelings when these situations
occur. So one day when the clumsy foot stepper accidently stepped on our hypothetical
man with Paranoid Personality Disorder, he might find himself thinking: "There we go
again. That person just stepped on my foot intentionally. They want to hurt me. I better
stand up for myself and get back at them. I'll show them! Just who do they think they are
anyway?" The therapist would ask this client to consider alternatives to the conclusion
the foot-stepper was intentionally trying to harm him, such as to consider that perhaps
the foot-stepper was simply clumsy.
The therapist would also ask the therapy participant to rationally examine the evidence
that led to the conclusion the foot-stepper was intentionally trying to harm him. For
instance, how likely is it that someone would go out of their way to intentionally step on
a stranger's foot, just for the sheer fun of it? Why would the foot-stepper single out this
one person to step on? If they truly had malicious intent, wouldn't they be stepping on
many other people's feet? Once the therapy participant acknowledges his 'malicious
intent theory' is flawed, the next step is to question, what caused him to think of this
unlikely explanation? In so doing, the client comes into contact with the core belief, the-
world-is-a-dangerous-place, and learns to challenge that belief. Over time, the core
belief is repeatedly challenged and is subsequently replaced with a core belief that is
more realistic, flexible, and adaptive. As the dysfunctional core belief evolves into a
more adaptive one, the therapy participant begins to behave in ways that are less
hostile and aggressive. In so doing, other people respond in kind. This new, positive
experience of being treated well by other people further solidifies the new, more
accurate belief, that most people are safe and usually kind.

In addition to changing the core beliefs that cause faulty interpretations, CBT can be
useful for modifying habitual, damaging patterns of thinking that may not necessarily
result from a core belief. One such pattern is called black-or-white thinking. This pattern
is also known as all-or-nothing thinking. We previously used the example of a woman
with a Borderline Personality Disorder whose partner had forgotten their anniversary.
The same CBT steps can be used to make corrections to this pattern of thinking. The
therapist and client begin to identify this pattern. The therapy participant records her
internal thoughts about this event such as, "How could he possibly forget our
anniversary? He must not love me anymore, otherwise he would have remembered.
Oh my gosh, he must be having an affair! How could this be happening to me? I can't
believe it - my husband hates me!"
Next the therapist guides her to consider alternative reasons someone might forget an
anniversary. The therapist will also challenge her conclusion, "He must hate me." In
particular, she will be asked to consider evidence that refutes that conclusion.. The
therapist might remind her that her husband just took her on a romantic trip to Bermuda
for Valentine's Day. The therapist may also ask her to recall other occasions when she
felt loved by her husband.

Next, she will learn to replace extreme black-or-white statements with more moderate
statements, allowing for shades of grey. "Well, that was pretty thoughtless to forget our
anniversary but it doesn't mean he hates me. He's been under so much stress at work
lately, and when we took our trip to Bermuda he was so loving and
romantic." Overtime, this change in thinking leads to more positive feelings and less
reactant behaviors. For instance, rather than angrily accusing her husband of having an
affair, she might calmly express her disappointment that their anniversary passed by
unacknowledged. This would certainly result in a different outcome than making wild
accusations of an affair.

Thus far, we have been focusing on the cognitive portion of cognitive-behavioral therapy
as these interventions have the most direct application to personality disorder. However,
a second set of interventions are more behavioral in nature and are very effective in the
treatment of anxiety disorders. You may recall that Cluster C personality disorders are
characterized by anxiety. Therefore these behavioral interventions are readily applicable
to the anxious/fearful Cluster C personality disorders (Avoidant, Dependent, and
Obsessive-Compulsive Disorders). One such behavioral intervention is called exposure
therapy. In order to explain the application of exposure therapy to personality disorder it
is useful to briefly describe this process. However, the interested reader may wish to
have a more detailed explanation of these techniques and the principles that underlie
their effectiveness. This information is available in our article entitled, Understanding
Anxiety and Anxiety Disorders.
As the name implies, exposure therapy involves exposing the person to a fearful
situation. With exposure fears eventually subside through a process called
habituation. Habituation refers to the process by which a person's behavioral and
sensory responses diminish after continued exposure to the stimulus that activated
those responses. We all have experienced habituation. For example, think of jumping
into an ice cold swimming pool. After you remain in the pool awhile, it no longer feels ice
cold. That's habituation at work!

Now let's review how exposure therapy functions to eliminate irrational fears. This is
achieved by creating opportunities for a corrective experience to take place. Consider
the person with an Avoidant Personality Disorder. They avoid social situations because
they fear that people will ridicule, reject, and/or criticize them. Because they avoid social
situations, there is no opportunity to correct this faulty assumption. Using the techniques
of exposure therapy, the recovering person would be encouraged to participate in social
situations despite the fact that their fear will initially make them highly uncomfortable.
With prolonged exposure, habituation causes this high degree of discomfort to subside.
From this exposure to social situations, the person learns their fear and anxiety were
unfounded; i.e., that nothing terrible has happened to them. This realization enhances
their relaxation and calm.

In addition to these techniques, the person may be directed to focus their attention
outwardly on other people, rather than inwardly. This inward focus only serves to
heighten their experience of anxiety. They may also be asked to attend social skills
training group to help them navigate these social interactions more skillfully and
comfortably. These skills can include conversational techniques, and learning to attend
to social cues by correctly interpreting other people's responses and facial
expressions. The acquisition of these skills can be quite important because someone
who has avoided most social situations is likely to be missing these important
skills. Research has shown that exposure techniques can be quite effective for people
with Avoidant Personality Disorders (Herbert, 2007).