Psychotherapy © 2013 American Psychological Association

2015, Vol. 52, No. 1, 45–55 0033-3204/15/$12.00 DOI: 10.1037/a0035158

Brief Cognitive Therapy for Avoidant Personality Disorder

Clare S. Rees and Rhian Pritchard
Curtin University

Avoidant personality disorder (APD) is associated with a high level of impairment in multiple areas of
functioning. However, research on the treatment of APD is scarce, and there is an absence of empirically
evaluated effective treatment approaches available. This study offers a preliminary investigation of the
use of brief cognitive therapy to treat APD. Two individuals, both with a principal diagnosis of APD, but
who also possessed a number of comorbidities, participated in 12 weekly sessions. A series of diagnostic
symptom severity, global functioning, and self-report measures were completed at pretreatment, post-
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treatment and at 6-week follow-up. In addition, regular monitoring of each participant’s strength of belief
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in 4 personally identified cognitions associated with APD was completed. Reductions in APD symptoms,
associated negative affect, and increases to quality of life were observed for both participants at
posttreatment and follow-up phases. Results suggest that brief cognitive therapy may be an effective
treatment for APD and that further studies with larger samples are warranted.

Keywords: avoidant personality disorder, cognitive therapy, brief therapy

Avoidant personality disorder (APD) is characterized by a long-
standing pattern of social inhibition, feelings of inadequacy, and
hypersensitivity to negative evaluation, with the individual’s main
coping strategy involving avoidance of situations in which they
could be negatively evaluated. Research on the treatment of APD
is scarce, and there is an absence of empirically evaluated effective
treatment approaches available (Emmelkamp et al., 2006; Feske &
Chambless, 1995). This is problematic, given the persistence of the
disorder, high level of associated functional impairment (Heim-
berg, Holt, Schneier, Spitzer, & Liebowitz, 1993), and the high
prevalence of APD in the community, which has been reported to
be present in ⬃10% of mental health clinic outpatients (DSM–IV–
TR, 2000).
As APD is classified as a personality disorder (DSM-V, 2013),
existing models of personality disorder can be applied to under-
standing APD. Beck and colleagues (Beck, Freeman, & Davies,
2004) have highlighted the critical role that schemas (or core
beliefs) have in maintaining personality disorders. Similarly,
Young (1990) has proposed that early maladaptive schemas (EMS)
develop in childhood and continue to influence information pro-
cessing into adulthood and are key factors in the maintenance of
personality disorders. Although each of these models provides
useful perspectives as to the development and maintenance of
personality disorders in general, they are not specific to APD. We
argue that to advance treatment research for APD, it is important
to be guided by a more specific theoretical model.
This article was published Online First December 30, 2013.
Clare S. Rees and Rhian Pritchard, Cognition and Psychopathology
Research Group, School of Psychology and Speech Pathology, Faculty of
Health Sciences, Curtin University, Perth, Western Australia.
Correspondence concerning this article should be addressed to Clare
S. Rees, School of Psychology and Speech Pathology, Faculty of Health
Sciences, Curtin University, Kent Street, Bentley,Western Australia,
6845. E-mail: c.rees@curtin.edu.au
45
There are a number of symptoms, behavioral patterns, and
cognitions associated with APD that overlap with and are also
associated with Social Phobia (SP). A key shared feature of both
disorders is the fear of negative evaluation. This has resulted in the
view that SP and APD are overlapping constructs that have only
minor differences with respect to severity of dysfunction (Brown,
Heimberg, & Juster, 1995; Emmelkamp et al., 2006). Despite the
significant overlap between the two disorders, SP has received the
greatest amount of research attention both from a theoretical and a
treatment perspective.
Clark and Wells’ (1995) cognitive model of SP has grown out of
earlier cognitive models of anxiety and depression (Beck, Shaw,
Rush, & Emery, 1979; Beck, Emery, & Greenberg, 1985) that
identify distorted cognitions as the key determinant of subsequent
negative emotional responses. However, the model places partic-
ular importance on self-focused attention and the use of safety
behaviors in maintaining social anxiety. The authors identify three
major cognitive assumptions that are considered to maintain social
anxiety: (1) having excessively high standards for social perfor-
mance, (2) conditional beliefs concerning the consequences of
performing in a certain way, and (3) unconditional negative beliefs
about the self. According to the model, individuals engage in
counterproductive processes, which prevent them from discon-
firming their maladaptive beliefs. One major counterproductive
process is the tendency toward self-focused attention at the ex-
pense of more accurate externally focused attention. Owing to the
inward focus, the individual magnifies interoceptive information
while blocking useful external social information. This results in
the development of an unfavorable impression of the self. A
further counterproductive process is the use of safety behaviors.
Safety behaviors (such as not holding a cup in front of another
person for fear of visible shaking) result in the individual conclud-
ing that the nonoccurrence of the feared outcome (i.e., rejection)
was only due to the presence of the safety behavior as opposed to
the absence of any real threat in the first place. Finally, the model
proposes that individuals with SP tend to overestimate how neg-
 46 REES AND PRITCHARD
atively people judge their social performance and engage in coun-
terproductive pre- and postevent processing.
Treatment focuses on disconfirming negative beliefs by direct
observation of the social situation, rather than of oneself, in-
session role-plays, cognitive-restructuring techniques, and behav-
ioral experiments (Clark et al., 2003). To date, this treatment has
been shown to be effective in four randomized controlled trials
(Clark et al., 2003, 2006; Mortberg, Clark, Sundin, & Wistedt,
2007; Strangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003)
and compares favorably with treatment using selective serotonin
reuptake inhibitors (SSRIs) (Clark et al., 2003; Mortberg et al.,
2007), exposure (EXP) combined with training in applied relax-
ation (Clark et al., 2006) and group versions of the cognitive
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therapy (CT) treatment program (Mortberg et al., 2007; Strangier
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et al., 2003).
Despite the high prevalence and clear impairment associated
with APD, as mentioned, remarkably few empirical treatment
studies have been reported in the literature. One explanation for the
paucity of treatment studies looking at APD is the generally held
view that personality disorder treatment requires longer, more
intensive intervention compared with Axis I disorders (Hope,
Herbert, & White, 1995). It is possible that such a view may have
created an obstacle for conducting treatment trials owing to the
perceived expectation that they must be long, intensive, and, thus,
costly. However, a small number of treatment studies have been
conducted which suggest that it may in fact be possible to provide
effective treatment for APD that is not lengthy or particularly
costly. Therefore, continuing research aimed at finding an effec-
tive treatment approach for APD would be an important step
forward (Emmelkamp et al., 2006; Fehm, Pelissolo, Furmark, &
Wittchen, 2005).
Alden (1989) examined the efficacy of a 10-week Cognitive
Behavior Therapy (CBT) group treatment program for individuals
with APD and found that those who completed this treatment
program displayed significantly greater improvement compared
with a waitlist group and reported less interference due to social
anxiety and greater satisfaction with social activities. A study by
Emmelkamp and colleagues (2006) compared the effectiveness of
brief dynamic therapy and CBT. Clients who received CBT-based
treatment showed significantly more improvement, in comparison
with clients treated with brief dynamic psychotherapy. In another
study, Feske and Chambless (1995) found that clients with SP who
had an additional diagnosis of APD were more severely impaired
and had poorer treatment outcomes following exposure-based
CBT compared with clients with a diagnosis of SP only. However,
despite generally poorer treatment outcomes, those clients with the
additional diagnosis of APD still showed symptom improvement.
The results of these studies suggest that reasonably brief interven-
tions for APD can result in symptom improvement. It should be
noted that only the Alden (1989) and Emmelkamp et al. (2006)
studies were specifically designed for clients with primary APD,
and only one of these examined individual therapy. As such, it is
clear that more empirical studies investigating the effectiveness of
treatment for APD are required.
The aim of the present study is to examine the effectiveness of
brief cognitive therapy for APD based on Clark and Wells’ (1995)
model of SP. Clark and Wells’ (1995) original controlled trial of
their program used 16 treatment sessions (Clark et al., 2003;
Mortberg et al., 2007) and has been demonstrated to be effective
with the use of 14 (Clark et al., 2006) and 10 sessions (McManus,
Peerbhoy, Larkin, & Clark, 2010). It should be highlighted that
these studies were with clients diagnosed with primary SP and not
APD. The present study aimed to administer the CT program
originally designed for SP within 12 treatment sessions for clients
with primary APD.
Based on the literature, it was hypothesized that participants
would improve significantly on measures of cognitions associated
with APD. It was also hypothesized that participants would expe-
rience clinically significant decreases in symptoms of social anx-
iety and fear of negative evaluation and increases in quality of life
and positive affect at posttreatment, and that these gains would be
maintained at 6-week follow-up.
Method
Design
As this study aimed to trial an innovative approach to treating
APD, a multiple baseline single case experimental design was
selected. The use of multiple baseline designs to investigate the
impact of new approaches to treatment has a long history in
psychology (Barlow & Hersen, 1973; Salkovskis, Clark, & Hack-
mann, 1991). Data collection was based on four individualized
therapeutic targets for change, which were monitored throughout
baseline, treatment, and follow-up phases. This design methodol-
ogy involved the direct application of the intervention (CT) to each
target for change in such a way that one target was addressed at a
time, while the others were held constant. This was done to make
it possible to identify whether changes in a target occurred in line
with the introduction of an intervention, as opposed to other
extraneous variables, therefore enabling the attribution of any
observed changes to be more likely due to the intervention. Visual
inspection of graphed data (strength of belief targets) was used to
assess for change in the treatment targets, as this is a well-accepted
method in single case design (Kazdin, 1982). In addition to this,
we used clinical significance and reliable change analysis of the
standardized outcome measures used in the study.
Participants
Participants were recruited through flyers mailed out to local
general practitioners, psychiatrists, and psychologists, requesting
referrals to a study researching treatment for APD. Assessment and
treatment occurred at the Curtin University Adult Psychology
Clinic. Referred clients were assessed for APD using the Struc-
tured Clinical Interview for DSM–IV (SCID-IV; First, Spitzer,
Gibbon, & Williams, 1996) and the Brief Fear of Negative Eval-
uation questionnaire (B-FNE; Leary, 1983), along with clinical
interview.
Clients were accepted into the study if they met the following
criteria: (a) Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; DSM–IV; American Psychiatric Association, 2000) crite-
ria for APD, (b) APD was considered to be the main presenting
problem; (c) no past or current psychosis or eating disorder; (d)
agreement not to start any additional treatment during the trial; (e)
no current report of self-harm or suicidal ideation; and (f) ⬎18
years of age. Clients who did not meet inclusion criteria were
offered individual treatment at the Curtin Clinic, or referred to
 BRIEF THERAPY FOR APD
another appropriate service. Two clients met inclusion criteria for
the present study and were offered treatment. The details of each
are presented subsequently.
Participant A. Participant A was a 51-year-old Caucasian
female with a diagnosis of APD, who reported that associated
symptoms interfered with her life to a very severe level and “affect
everything I face.” She reported a lifelong history of difficulties
with interpersonal interactions and concerns regarding negative
evaluation. Participant A currently lived alone and reported that
she had not had a close or intimate relationship for the past 10
years. In addition to a diagnosis of APD, Participant A also met
diagnostic criteria for SP, major depressive disorder, and depen-
dent personality disorder.
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Participant A had been consulting a clinical psychologist over
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the course of four sessions, for assistance with depressive symp-
toms, which she suspended for the duration of this research to
comply with inclusion criteria. The type of therapy used was not
reported. She reported that she had never seen anyone for assis-
tance with social anxiety as she “has always thought it was just
me.” During initial assessment, Participant A appeared to be
anxious, as evidenced by her constant hand wringing and tense
posture. She reported that she wished to pursue this treatment
owing to experiencing a great deal of trouble interacting with
people, particularly in group situations. Participant A reported
experiencing a number of unhelpful beliefs, such as expecting that
she would “say the wrong thing or something stupid or immature.”
She also reported the belief that people often do not like her and
that she can pick up on such vibes.
Participant B. Participant B was a 49-year-old Caucasian
male with a diagnosis of APD, who reported that associated
symptoms interfered with his life to a severe level. He reported a
lifelong history of difficulties with interpersonal interactions and
concerns regarding negative evaluation, recalling always hiding
behind his mother as a child. Participant B was recently divorced
and living alone during the week, having custody of his children on
weekends. He was not in a close or intimate relationship at the time
of assessment. In addition to a diagnosis of APD, Participant B
also met diagnostic criteria for SP, major depressive disorder and
dependent personality disorder.
Participant B was consulting a clinical psychologist over the
course of approximately six sessions, for assistance with depres-
sive symptoms, which he suspended for the duration of this re-
search to comply with inclusion criteria. The type of therapy used
was not reported. He reported that he had never seen anyone for
assistance with social anxiety, as it had not been too disabling
because he had “always been able to hide behind” his wife, before
their divorce. During initial assessment, Participant B appeared to
be anxious, as evidenced by marked avoidance of eye contact. He
elected to take part in the study owing to experiencing a great deal
of trouble interacting with people, which had become increasingly
problematic and isolating since his divorce. Participant B reported
a number of unhelpful cognitions, such as a strong belief that he
would say the wrong thing and embarrass himself. He believed that
people often find him boring and that if he was to speak, people
would ridicule him. He reported feeling inadequate all of the time
and stated that he did not speak because he would “rather have
people think I’m shy than boring.” Participant B reported avoiding
social interaction as much as possible. For example, while watch-
ing his children’s soccer games, he would stand at the opposite end
47
of the pitch to avoid any potential interaction. Furthermore, before
their divorce, Participant B reported experiencing severe anxiety
leading up to any of his wife’s social functions and would often
start arguments or feign illness to avoid attending.
Measures
Strength of belief. Four personalized statements were identi-
fied for each participant based on their central concerns. Partici-
pants were required to complete these single item measures, three
times a week as a measure of change during baseline, treatment,
and follow-up phases. Participants were required to choose a
number on a scale from 0 to 8 that best represented how strongly
they believed the statement during the past 24 hr.
Structured Clinical Interview for the DSM–IV. The
SCID-IV is a semistructured interview frequently used in both
routine clinical practice and in clinical research to aid diagnosis
(First et al., 1996). To ensure APD was the primary diagnosis, the
Interference of Severity Scale (ISS), adapted from the Anxiety
Disorders Interview Schedule (Brown, DiNardo, & Barlow, 1994),
was use to supplement the SCID. The ISS ranges from 0 to 8, with
clients rating how much they feel the symptoms described interfere
in their life.
Depression Anxiety and Stress Scale-21. The Depression
Anxiety and Stress Scale-21 (DASS-21) is a 21-item self-report
scale designed to measure the three related negative emotional
states— depression, anxiety, and stress (Lovibond and Lovibond,
1995). An example item is—“I found myself getting upset rather
easily.” This measure possesses good reliability (internal consis-
tency .94) and validity (construct validity rs ⫽ .81; Antony,
Bieling, Cox, Enns, & Swinson, 1998).
Quality of Life Enjoyment and Satisfaction Questionnaire.
The Quality of Life Enjoyment and Satisfaction Questionnaire
(Q-LES-Q) is an 18-item self-report questionnaire designed to
measure a respondent’s satisfaction with specific life domains,
such as physical health and social relationships (Ritsner, Kurs,
Gibel, Ratner, & Endicott, 2005). Each item is scored on a 5-point
scale, with higher scores indicating presence of a greater degree of
life satisfaction. Ritsner et al. examined the test–retest reliability of
the Q-LES and reported that the interclass correlation was .91.
Additionally, they report moderate to high internal consistency
ranging from .74 to .97.
Brief Fear of Negative Evaluation Scale. The B-FNE scale
is composed of 12 items relating to fearful or worrying cognitions
and is used to determine the degree to which a person experiences
apprehension relating to the prospect of being evaluated negatively
(Leary, 1983). Higher scores indicate presence of a greater fear of
negative evaluation and therefore symptom severity. The B-FNE
has good validity (Weeks et al., 2005) and reliability (Collins,
Westra, Dozoisb, & Stewart, 2004). An example item is—“I am
frequently afraid of other people noticing my shortcomings.”
The Working Alliance Inventory. The Working Alliance
Inventory (WAI) was administered posttreatment to participants to
gain an estimate of the quality of the alliance between therapist and
participant (Horvath and Greenberg, 1989). This measure gener-
ates a total alliance score based on therapist and client responses,
as well as three subscores assessing agreement on in-session tasks,
treatment goals, and development of a mutual bond. Higher scores
indicate a greater quality of working alliance. Assessing the work-
 48 REES AND PRITCHARD
ing alliance is considered to be particularly important to the
treatment of APD, as this has been identified as a crucial factor in
the change process (Beck et al., 2004). In Horvath and Greenberg’s
early work, the WAI was reported to have a reliability of .93, as
well as acceptable levels of convergent validity (above .82).
Procedure
The project was approved by the Curtin University Human
Research Ethics Committee. Of the two individuals who expressed
interest, both were deemed suitable, and were invited to attend the
clinic to receive their record booklet and instructions regarding
monitoring items. Following this session, participants completed a
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2-week baseline phase, where participant responses to personal-
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ized monitoring items were obtained three times per week as a
measure of strength of belief in current cognitions before com-
mencing treatment. Subsequently, participants began the treatment
phase that involved 12, 50-min sessions, followed by a 6-week
follow-up phase where participants continued to rate their re-
sponses to assess maintenance of gains after completion of treat-
ment. Participants then attended a follow-up session to complete
final questionnaires, ask questions, and discuss results of therapy.
Both clients attended all sessions. The principal investigator, a
Clinical Psychologist trainee in her second year of training, con-
ducted all assessment and treatment sessions. Each session was
videotaped for the purpose of use during regular supervision with
a senior clinician (first author) to ensure that treatment protocol
was adhered to.
Treatment
The cognitive therapy approach used in this study was based on
Clark and Wells’ (1995) model of the maintenance of SP, which
uses a variety of procedures aimed at reversing factors identified in
the model that are considered to maintain client symptoms of SP.
This exact procedure was used simply focusing on the factors
maintaining APD symptoms rather than SP symptoms. The main
steps in the treatment protocol are as follows: (a) development of
a personal version of the model for each client using their own
thoughts, safety behaviors, and attentional strategies; (b) safety
behaviors and self-focused attention experiments where key safety
behaviors are identified, with their adverse effects being demon-
strated through experimental exercises where clients role-play
difficult social situations while using inward focusing of attention
along with safety behaviors, followed by role-play with attention
focused externally while dropping safety behaviors; (c) shifting
focus of attention to the social situation where clients are encour-
aged to focus their attention externally to reduce problematic
self-monitoring and to obtain more accurate information about
how others respond to them; (d) video feedback to modify distorted
self-imagery where clients view videos of themselves engaging in
safety behaviors, where they engage in feared social tasks under an
instructional set designed to make the discrepancy between client’s
negative distorted self-images and their objective social perfor-
mance evident; (e) behavioral experiments in which clients specify
feared outcomes and test out whether they occurred; (f) identifi-
cation of problematic anticipatory and post event processing
where discussion reveals disadvantages of anticipatory and post
event processing; and (g) dysfunctional assumptions are identified
and modified by behavioral experiments and cognitive-
restructuring techniques (Clark & Wells, 1995). Four treatment
phases were used where the above strategies were applied to each
of the client’s specific beliefs one at a time, that is, phase 1 focused
on challenging one distinct belief before moving onto the next in
phase 2 and so forth.
Results
Overall Diagnostic, Symptom Severity, and
Self-Report Measures
The criteria suggested by Jacobson and Truax (1991) was used
to determine clinically significant change. Using this method, it is
necessary to demonstrate that the posttest score on a particular
variable is closer to the mean of the nonclinical population than to
the mean of the clinical population (Jacobson & Truax, 1991). In
cases where the variances of the two populations are unequal, the
cutoff is calculated using the following formula (Jacobson &
Truax, 1991):
s0M 1 ⫹ s1M 0
cutoff(c) ⫽
s0 ⫹ s1
Where s0 is the standard deviation of the nonclinical population,
s1 is the standard deviation of the clinical population, M0 is the
mean of the nonclinical population, and M1 is the mean of the
clinical population. Additionally, the reliable change index (RCI)
was used to ensure that any changes observed are real and not due
to testing effects. The RCI is calculated by subtracting the partic-
ipant’s posttest score from the pretest score and dividing it by the
standard error of difference between the two test scores (for more
information see Jacobson & Truax, 1991). If the RCI is ⬎1.96, the
change is considered to be real. These two criteria can be used to
determine if the participant has recovered (i.e., exceed cutoff and
the RCI), has improved but not recovered (i.e., exceed RCI but not
the cutoff), or whether there has been no change or the condition
has deteriorated (i.e., does not exceed RCI, regardless of whether
cutoff is exceeded). The means, standard deviations and test–retest
reliability coefficients (or internal consistency coefficients) re-
quired for calculation of clinical significance cutoff scores and
RCIs were taken from the literature. For the DASS-21, Antony et
al. (1998) study was used. Ritsner et al. (2005) study provided the
required information for the Q-LES-Q and the study by Duke,
Krishnan, Faith, and Storch (2005) was used for the B-FNE.
Tables 1 and 2 depict changes in the negative emotional states, fear
of negative evaluation, and participant quality of life, for Partici-
pant A and B, respectively.
Depression, anxiety, and stress. As can be seen in the tables,
both participants evidenced improvement in symptoms at post and
follow-up, but this was variable, with some gains being lost by
follow-up.
Fear of negative evaluation. Both participants were within
the extreme clinical range for fear of negative evaluation at pre-
treatment, and made clinically significant and reliable changes at
posttreatment, which were maintained at follow-up, classifying
both participants as recovered.
Quality of life. Both participants were within the clinical
range for poor quality of life enjoyment and satisfaction at pre-
 BRIEF THERAPY FOR APD 49

Table 1
Clinical Significance of Change and RCI for Participant A Over Pretreatment, Posttreatment, and Follow-Up Phases

Reliable Cutoff Follow-up Reliable Cutoff

Measure Pre score Post score changea Cutoff achieved Outcome score changea achieved Outcome

DASS-21
Depression 38 0 Yes 9.4 Yes Recovered 32 Yes No Unchanged
Anxiety 36 0 Yes 4.76 Yes Recovered 20 Yes No Improved
Stress 34 8 Yes 11.07 Yes Recovered 32 Yes No Improved
B-FNE 60 28 Yes 46.98 Yes Recovered 24 Yes Yes Recovered
Q-LES-Q 1.88 4.76 Yes 3.3 Yes Recovered 4.71 Yes Yes Recovered
a
Reliable change (improvement) indicated by RCI of ⬎1.96.
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treatment. Both Participant A and B made clinically significant and findings were obtained for both participants in this study and most
This document is copyrighted by the American Psychological Association or one of its allied publishers.

reliable changes at posttreatment, which was maintained at follow-
up, classifying them as recovered.
Personalized Monitoring Items
Figures 1 (a–d) and 2 (a–d) present the strength of belief data
for personalized monitoring items for Participant A and B, respec-
tively. Visual inspection of the graphical data reveals a sizable
reduction in strength of belief in each personalized monitoring
item for both participants, which occurs after the introduction of
treatment and remains stable through to follow-up. This demon-
strates that reductions across all targets were associated with the
introduction of treatment. However, decrease in strength of belief
did not coincide with the introduction of treatment specifically
targeting a certain item but rather occurred relatively consistently
across items.
Discussion
In this study, two clients with a primary diagnosis of APD,
along with severe symptoms and poor quality of life, responded
remarkably well to only 12 weeks of psychotherapy. This is an
important and positive finding because it directly contrasts the
widely held view that individuals with personality disorders al-
ways require lengthy and intensive treatments. Although the study
design limits the strength and generalisability of conclusions that
can be made about the impact of this brief treatment for APD, it
nonetheless provides strong preliminary support and flags the
potential value of pursuing this line of research.
In case study designs such as this, the criteria for judging
clinically significant improvement is strict and tends to lean to-
ward the conservative side. Thus, the fact that clinically significant
were sustained at follow-up is a particularly powerful result. From
a theoretical perspective, the positive symptom improvements
obtained provide support for the applicability of Clark and Wells’
(1995) cognitive model of SP to understanding and treating APD.
This brief cognitive intervention uses a number of different ther-
apeutic strategies such as the use of attention shifting and behav-
ioral experiments to target the cognitive distortions understood to
maintain social anxiety and avoidant behaviors. Perhaps the stron-
gest support for the model obtained in the present study is the fact
that both participants showed the greatest changes in their scores
on the Fear of Negative Evaluation scale that directly assesses the
beliefs known to maintain social anxiety. For each client, these
beliefs reduced substantially, and they were classified as recovered
on this scale, with those changes being maintained at the 6-week
follow-up. Changing these beliefs was the focus of this interven-
tion, and the positive changes seen on the Fear of Negative
Evaluation Scale were accompanied by corresponding improve-
ments in each of the clients’ personalized strength of belief ratings.
Although strength of belief ratings did improve across treatment for
both clients, changes occurred more quickly for Participant A than for
Participant B. This is best explained by the fact that Participant A
placed herself in social situations regularly before attending therapy.
However, she found that she was not benefiting from the naturalistic
exposure. Once treatment began, Participant A continued to place
herself in social settings, however, utilizing principles addressed in
session at the same time (e.g., dropping safety behaviors and focusing
externally). In contrast, Participant B had always avoided social
situations and continued to do so until his core belief (item four) was
addressed. It is believed that while Participant B understood all of the
principles in session, his ability to engage in social interaction behav-
ioral experiments was blocked by his unconditional negative self-

Table 2
Clinical Significance of Change and RCI for Participant B Over Pretreatment, Posttreatment, and Follow-Up Phases

Reliable Cutoff Follow-up Reliable Cutoff

Measure Pre score Post score changea Cutoff achieved Outcome score changea achieved Outcome

DASS-21
Depression 32 12 Yes 9.4 No Improved 14 Yes No Improved
Anxiety 20 2 Yes 4.76 Yes Recovered 2 Yes Yes Recovered
Stress 32 16 Yes 11.07 No Improved 12 Yes No Improved
B-FNE 47 34 Yes 46.98 Yes Recovered 41 No Yes Recovered
Q-LES-Q 2.18 2.94 Yes 3.3 No Improved 3 Yes No Improved
a
Reliable change (improvement) indicated by RCI of ⬎1.96.
 50 REES AND PRITCHARD
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Figure 1. (A) Participant A. Weekly monitoring of strength of belief in the statement “In a group situation I
will be unable to speak, be interesting or make sense,” over baseline, treatment, and posttreatment phases. (B)
Participant A. Weekly data monitoring of strength of belief in the statement “I need to go over social situations
in my mind before entering the situation,” over baseline, treatment, and posttreatment phases. (C) Participant A.
Weekly data monitoring of strength of belief in the statement “I need to go over social situations in my mind
after they have occurred,” over baseline, treatment, and posttreatment phases. (D) Participant A. Weekly data
monitoring of strength of belief in the statement “I’m not worthwhile as a person,” over baseline, treatment, and
posttreatment phases.

belief. After this point in therapy, he began engaging in social situa-
tions, while using the principles addressed in session. Participant B’s
data reveal a clear reduction in strength of belief consistently across
items from this point, with this effect being strengthened during the
follow-up phase.
Differences in the belief change process for the two clients
mirrors what we know from the general cognitive model of
personality disorders (Beck, Freeman, & Davies, 2004). That is,
that several different levels of cognition exist, from the level of
automatic thoughts through to core beliefs or schemas. Success-
ful cognitive therapy aims to target the cognitions understood to
be maintaining disorder. For some clients, particularly those
with personality disorders, targeting core beliefs and working at
the schema level is regarded as imperative (Young, 1990).
Participant B’s response to therapy supports the schema model
of personality disorders, as his progress did not occur until after
the sessions in which his unconditional negative self-belief was
challenged.
 BRIEF THERAPY FOR APD 51
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 1. (continued)

Both participants completed all sessions of the therapy, which is
especially important, given the reported tendency for individuals
with this diagnosis to drop out prematurely. In fact, CT is associ-
ated with lower premature termination rates (0% reported by Clark
et al., 2003) compared with treatment involving exposure, where
termination rates of 20% to 30% have been reported (Hofmann,
2004; Scholing & Emmelkamp, 1993). An important observation
made by the therapist regarding client attendance was that both
clients indicated feeling relieved that their “real” issues were
finally being addressed in therapy. For each client, previous psy-
chotherapy had tended to focus on their depressed mood and failed
to attend to the underlying and long-standing social anxiety and
avoidance. This sense that their issues were being properly at-
tended to was expressed as a very important part of the therapeutic
contact.
In addition, it has been suggested that individuals with diagno-
ses of APD possess a hypersensitivity to the possibility of negative
evaluation by the therapist that often appears to contribute to
premature termination (Renneberg, Goldstein, Phillips, & Chamb-
less, 1990). Part of attending therapy involves disclosing personal
information, which has the potential to leave one open to evalua-
tion. This hypersensitivity could lead to inaccurate perceptions and
recollections of therapist reactions to the client, which could lead
to distress and/or early termination. Indeed, in this study the
therapist was particularly cognizant of the vital importance of the
therapeutic relationship and the communication of unconditional
positive regard. The therapist worked hard to create a safe and
accepting setting for the clients where they felt able to engage in
role-plays with the therapist and able to share their upsetting
cognitions about rejection. The therapist provided the clients with
 52 REES AND PRITCHARD
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 2. (A) Participant B. Weekly monitoring of strength of belief in the statement “In a group social
situation, people think I am uninteresting and am an idiot,” over baseline, treatment, and posttreatment phases.
(B) Participant B. Weekly monitoring of strength of belief in the statement “Before entering a social situation
I get anxious thinking about how much I am going to embarrass myself,” over baseline, treatment, and
posttreatment phases. (C) Participant B. Weekly monitoring of strength of belief in the statement “In social
situations, it’s better if I don’t speak as people will judge and criticize me if I do,” over baseline, treatment, and
posttreatment phases. (D) Participant B. Weekly data monitoring of strength of belief in the statement “I am
inferior to most other people,” over baseline, treatment, and posttreatment phases.

sufficient opportunity to express such concerns and encouraged the cli-
ents to do so. The therapist was then able to provide corrective informa-
tion as to the fact that she was not negatively judging the clients.
As such, a very powerful aspect of the treatment was the oppor-
tunity for the clients to experiment with being themselves in front
of another person without fear of negative judgment. Participant A
described the experience of attending the sessions as “I felt safe to
be myself” and “I felt that I was fully understood.” Participant B
expressed a feeling of “acceptance and understanding by the
therapist.”
Changes in the symptoms of anxiety, depression, and stress
occurred at posttreatment but later moderated to return close to
pretreatment levels. There are two points to make about this
finding. First, it is unsurprising that general levels of anxiety,
depression, and stress did not change significantly on a permanent
basis, as they were not direct targets of the intervention. Second,
 BRIEF THERAPY FOR APD 53
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 2. (continued)

the return of these symptoms to near pretest levels in the follow-up
period could be owing to the fact that both clients enjoyed attend-
ing therapy, and it is possible that following therapy they did not
continue to engage in as many social interactions. Thus, the social
interaction of therapy itself may have been contributing to the
improved mood symptoms.
APD has a profoundly negative impact on a person’s quality of
life and is associated with marked distress and significant impair-
ment in multiple areas of functioning. Given that, it is especially
noteworthy that both clients showed significant improvements in
their general quality of life. Assessment of quality of life outcome
is considered to be particularly important, given the world health
organization’s recent focus on defining mental health, not just as
the absence of diagnostic symptoms but in terms of improvements
to individual’s quality of life (Power, Bullinger, & Harper, 1999).
Significant reductions in social anxiety may account for these
improvements to quality of life, as it is suggested that participants
are more likely to engage in pleasurable activities and interactions
without experiencing so much distress.
Some general limitations of the study must be acknowledged.
First, while great care was taken to ensure that treatment was pure
CT, one can never entirely rule out the possibility that some
treatment effects could have been due to habituation. However, no
direct EXP habituation rationale was used. Second, the same
therapist who evaluated the outcome data also conducted all as-
sessment and treatment components. This may have had an effect
on the validity of study results; however, it also means that the
therapist was consistent across participants. This is considered to
be a relative strength, as many studies are limited by therapist
effects, where multiple therapists across participants can account
 54 REES AND PRITCHARD
for a portion of the outcome variance (Clark et al., 2006). As noted
earlier, case studies do not account for the potential of other
unmeasured variables to have produced the changes noted. Further
controlled trials are needed to strengthen conclusions about the
effectiveness of this intervention.
Further studies investigating mechanisms of change would be a
valuable addition to the literature, particularly studies investigating
the role of relationship factors between the therapist and client in
determining treatment outcome. Owing to the nature of APD, this
is considered to be particularly relevant. Specific factors for in-
vestigation may include the degree of warmth in the relationship
and therapist promotion of the client’s confidence and autonomy.
There are several important clinical implications that emerge
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
from this study. First, these findings would strongly suggest that
This document is copyrighted by the American Psychological Association or one of its allied publishers.
clients who have a primary diagnosis of APD be offered a focused
intervention that targets their unhelpful cognitions both at the level
of automatic thoughts and core beliefs. Feedback from the clients
in this study indicates that this type of focus is welcomed and
represents a departure from previous therapy experiences whereby
therapists have focused more on the clients’ comorbid Axis I
conditions such as depression. A second and related point is that
even though many clients have long-standing difficulties such as in
the case of APD, these problems are still amenable to treatment.
Based on the observations of the therapeutic process of this study,
special attention to the creation of a safe and nonjudgmental
therapeutic relationship is paramount when engaging clients in CT
for APD.
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