This commentary begins by briefly reviewing and expanding upon some relevant factors of personality disorders that present challenges for clinicians. These factors include: lack of routine screening and assessment of personality disorders in routine clinical care; the vast heterogeneity both between and within personality disorder diagnoses; the high rates of comorbid psychological disorders; and the ego-syntonic nature of many personality disorders, which leads many clients to seek treatment for problems other than their personality disorders. The remainder of the commentary then outlines recommendations for clinicians to follow in their treatment of clients with personality disorders. It provides recommendations for the assessment, case conceptualization, treatment goal and target formation, target hierarchy creation, intervention selection, implementation and evaluation, and the creation and maintenance of rapport and therapeutic alliance when working with personality-disordered clients.

In recent years, several cognitive behavioral therapies have been developed to meet the specific challenges involved in treating personality disorders. Cognitive and behavioral treatment (CBT) is best represented as a family of therapies, including manualized treatment packages (or “branded” CBTs) and principle-driven interventions. This chapter reviews cognitive and behavioral intervention options for patients suffering from personality dysfunction. First, the authors provide an overview of the “branded” CBTs tested with personality disorder populations, including dialectical behavior therapy, schema focused therapy, and cognitive therapy for personality disorders. For clinicians who wish to use a cognitive behavioral approach, they then discuss how CBT case conceptualization can be used to inform a flexible and responsive treatment based on the empirically-supported treatments for personality disorders. In this approach, clinicians would formulate a treatment plan that applies cognitive and behavioral strategies, interventions, and principles of change from these empirically-supported “branded” CBTs. For example, the authors discuss ways in which the CBT principle of exposure may be considered for application across different personality disorders. Finally, they discuss the potential value in application of mindfulness and acceptance strategies with personality disorders.

The commentaries from Gold, Yen, Hughes and Rizvi highlight the challenges associated with using cognitive behavioral therapies to treat individuals with personality disorders (PDs). In this rejoinder, the authors extend upon these observations by arguing the importance of a modular, principle-driven approach to assessment and treatment of PDs. First, they discuss how there is a greater demand for treatments beyond the current “branded” CBTs and their empirical basis. In light of this limitation, clinicians need to flexibly use empirically-supported principles of change to treat processes underlying personality dysfunction. This approach requires careful case formulation and identification of behaviorally-specific targets of treatment using validated screening tools. This approach to treatment may be a useful way of meeting the demands for both patient care and current trends in national health care payor reform.