Personalizing psychotherapy for personality disorders: Perspectives from control-mastery theory.

Abstract

While several empirically supported models for treating personality disorder (PD) are available, researchers and clinicians have continued to advocate for the personalization of psychotherapy to the particular needs and characteristics of the individual patient with severe personality pathology. Control-Mastery Theory (CMT; Gazzillo, 2016; Silberschatz, 2005; Weiss, 1993; Weiss, Sampson, & The Mount Zion Psychotherapy Research Group, 1986) provides a useful framework for understanding personality pathology, and for guiding treatment with individualized case formulation. The present article introduces the basic concepts of CMT and their application in personalizing psychotherapy for patients with severe PDs. According to CMT, patients come to therapy in order to disprove the pathogenic beliefs that obstruct their pursue of healthy and adaptive developmental goals. These pathogenic beliefs were developed to adapt to early traumatic experiences, but end up causing further suffering, inhibitions, and symptoms. For this reason, patients test these pathogenic beliefs within the therapeutic relationship in search of corrective emotional experiences that disprove them. Among patients with severe PDs, such beliefs may be reciprocally contradictory and may be enacted in therapy in multiple different ways, often challenging therapists to respond appropriately. CMT suggests that therapists’ formulation regarding a given patient’s plan—including the nature of the patient’s goals, traumas, pathogenic beliefs, and testing strategies—allow for a personalized approach that will optimize therapy effectiveness.

Spectrum, rate and unmet needs of sociomedical interventions in outpatient psychotherapy

“…However, it is important that sociomedical interventions within psychotherapy have to be understood as individualized/personalized treatment options, which can differ in their usefulness and their meaning from one patient to the other. The same sociomedical intervention can have a different effect and indication depending on the needs, context and also the cooperation of the patient (Gazzillo et al, 2020). For example, while the contact to the patient's employer, in order to optimize cooperation and thus positive long‐term health consequences for the patient, can be interpreted as an act of care by one patient, another patient might interpret this intervention as an act of violation against his autonomy and privacy.…”

“…This concerns preferably self-help groups, psychoeducative courses, job reintegration measures, legal guardians, and sports clubs. However, it is text and also the cooperation of the patient (Gazzillo et al, 2020).…”

The intertwined path of perfectionism and self‐criticism in a client with obsessive‐compulsive personality disorder

“…Early in therapy, Lea tested whether her therapist was both trustworthy and non‐judgmental as she hoped, or as critical and scornful as she would expect (Gazzillo, Dazzi, Kealy, & Cuomo, 2020). Her first test was the question she frequently asked the therapist: “Is there an easy way to learn a technique to solve this problem?” When exploring these types of questions, Lea seemed to imply, as usual, that she had to solve any problem by herself.…”

“…In the moment she avoided eye contact with her therapist. The therapist considered this a sign that she was testing him as to whether he was harshly judging her weaknesses (consistent with her father's attitude), or instead was accepting her in a benevolent way, allowing her to show vulnerability, consistent with her desired for response from the other (Gazzillo et al, 2020). Accordingly, the therapist decided to validate Lea's emotions, saying he was sorry to hear her distress and that they could talk about these memories whenever she felt comfortable to do so.…”

Identifying patient verbal coaching in psychotherapy

“…They are extremely painful, frightening and debilitating and lead to fear, anxiety, pathological guilt, self‐destructive behaviours and ongoing psychological disorders. CMT assumes that patients—even those with personality disorders and other challenging or difficult behaviours—are motivated both consciously and unconsciously to work on their problems and to disconfirm pathogenic beliefs (Gazzillo et al., 2020). Weiss (1993) proposed the concept of the patient's plan to reflect their motivation to relinquish pathogenic beliefs, arguing that progress in therapy occurs when the therapist responds to the patient in a way that undermines or disconfirms the patient's belief(s).…”