Why target personality features
instead of symptoms?
Over the past decade, mental health researchers and clinicians have grown disillusioned with the DSM system of understanding psychological disorders. Specifically, the DSM system assumes that each diagnosis represents a discrete entity, each requiring a different treatment protocol. Learning a different treatment for each DSM disorder creates a large training burden for clinicians. Moreover, treatment tied to a single diagnosis cannot adequately support patients with more than one condition - the rule, not the exception.
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There is emerging evidence that similarities across DSM disorders outweighs differences between them. There appears to be a limited number of personality features that underlie most, if not all, mental disorders. Developing treatment modules to target 5 or 6 personality features (versus countless DSM symptoms) represents a more parsimonious approach to addressing comorbid symptoms for both patients and clinicians. Moreover, targeting the core dysfunction maintaining symptoms is more potent. Finally, personality-focused treatment modules can be selected based on patient presentation (only relevant modules need be delivered), making this approach personalizable.
What are the personality features we target with Compass?
The Five Factor Model (FFM) of personality is, perhaps, the most well-known conception of individual differences. This model supposes that all differences between people can be summarized on five dimensions: Neuroticism (vs emotional stability), Agreeableness (vs antagonism), Extraverson (vs introversion), Conscientiousness (vs. Disinhibition), and Openness (vs closedness) to Experience.
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Recently, models of psychopathology have emerged that lean heavily on the FFM. For example, the "trait model" of DSM-5's Alternative Model of Personality Disorders (located in the section of Emerging Models and Measures) characterizes personality disorders by describing their elevations and deficits on FFM domains. Borderline personality disorder, for example, is described as high neuroticism (negative affectivity), low agreeableness (antagonism), low conscientiousness (disinhibition). Similarly, the Hierarchical Taxonomy of Psychopathology (HiTOP) locates almost all DSM disorders beneath 6 higher-order targets that largely resemble the FFM personality domains.
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Currently, we have developed Compass modules to address neuroticism, (low) agreeableness, and (low) conscientiousness because these traits account for the most variance in psychopathological symptoms. We have largely tested these modules in the context of patients with borderline personality disorder, however they treatment components apply to wide range of psychopathology. We plan to expand Compass to address low Extraversion (detachment) and high Openness (psychoticism) in the future.​
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How does Compass address personality?
Neuroticism. This trait refers to the tendency to experience negative emotions frequently and intensively. Aversive reactions (e.g., "its weak to feel this way," "I hate this feeling") to negative emotions prompt the use of emotionally avoidant coping strategies (e.g., self-injurious behaviors, binge eating, substance use) that paradoxically result in more frequent and intense negative emotions (i.e., exacerbating and maintaining neuroticism; Bullis et al., 2019). By contrast, sustained decreases in the frequency of negative emotions, achieved by targeting aversive/avoidant responses to emotions, may constitute decreases in negative affectivity. Transdiagnostic behavioral interventions targeting aversive reactivity have been associated with significantly larger decreases in neuroticism than symptom-focused protocols (Sauer-Zavala, Fournier, et al., 2020) and improvements in negative affectivity in transdiagnostic treatments may even predict symptom reduction. Thus, we target neuroticism by encouraging patients to approach their emotions, rather than avoid them.
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(Low) Agreeableness/Antagonism. This trait is characterized by distrust, manipulativeness, and oppositionality (Mullins-Sweatt et al., 2012), and is associated with strained interpersonal relationships (Anderson et al., 2007; Kotov et al., 2010; Miller et al., 2003). Higher levels of antagonism are associated with insecure attachments to childhood caregivers, which can manifest in adulthood as behaviors that function to protect a person in interpersonal contexts perceived as threatening (Young et al., 2006). Here, attachment insecurity represents an actionable functional mechanism linking the personality trait of antagonism to externalizing symptoms, akin to the role of aversive reactivity in the relation between neuroticism and negative emotions. Emerging research suggests that improving patients’ ability to consider others’ perspectives, along with challenging negative schemas about oneself and others, improves attachment security in adults (Levy et al., 2006; Vogt & Norman, 2019). We target antagonism by encouraging perspective taking, limiting black-and-white thinking, conducting behavioral experiments in relationships, and cultivating mindful awareness of others.
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(Low) Conscientiousness/Disinhibition. This trait, also referred to as trait impulsivity, is characterized by sensation-seeking (the tendency to seek out novel and thrilling experiences), lack of deliberation (the tendency to act without thinking), lack of persistence (an inability to remain focused on a task), and urgency (the tendency to act rashly in response to positive and negative emotional experiences; Cyders et al., 2007; Whiteside et al., 2005). Researchers have suggested that individuals’ expectancies about their performance on certain tasks, along with how much they value these actions, predict conscientious behaviors (e.g., paying bills on time, subjugating impulses that would be gratifying in the short-term; Eccles, 2009). Others have suggested that trait impulsivity is maintained by high reward orientation such that disinhibited individuals will continue to pursue rewards (e.g., relief from negative emotions, substance-related highs) despite negative consequences (Carver & White, 1994; Gray, 1987). Thus, intervention strategies that focus on values, provide immediate (reinforcing) feedback on progress, and engage performance expectancies may be particularly useful for this trait (Magidson et al., 2014).
What skills are included in Compass?
Values Identification
We begin treatment by helping clients identify their values across 11 life domains. This information is used to address identity disturbance (with our BPD clients) and to serve as a motivator - clients evaluate the degree to which their current actions line up with their valued life directions
Skills for Thinking
Clients apply cognitive flexibility to emotional situations, interpersonal difficulties, and triggers for impulsive action. Core beliefs, dimensions of trust, and identifying the thoughts that underlie urges
Skills for Doing
Classic behavior change skills (alternative actions, exposure) are employed to approach emotions, move toward goals in relationships, and keep one's long-term goals in mind when faced with urges for impulsive actions.
Skills for Being
Mindful awareness (a nonjudgmental, present-focused stance) is applied to emotional experience, interpersonal conflicts, and urge surfing.
Compass Developers
BPD COMPASS
BPD Compass is an evidence-based treatment for borderline personality disorder developed by experts who specialize in studying & treating this condition. Manualized and short-term (delivered across 18 or fewer sessions), BPD Compass was developed with clinicians in mind. Given that at least 10% of people seeking outpatient therapy have BPD, we sought to create an easy-to-learn (yet effective) intervention that could be delivered in generalist settings (e.g., private practice, community mental health, academic medical centers, college counseling centers).
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BPD Compass uses cognitive behavioral skills to directly target the personality features that underlie BPD symptoms: (1) the tendency to experience strong emotions, (2) difficulty feeling secure in relationships, & (3) impulsivity. People with BPD can exhibit any combination of these personality, so BPD Compass is modular. In other words, clinicians can personalized the elements (i.e., modules) delivered based on patient presentation. The treatment also includes values exploration to address the identity disturbance common in BPD.
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BPD Compass has been tested in a clinical trial with nearly 100 people with BPD. Results suggest that, on average, patients experience large reductions in BPD symptoms. They also experience decreases in comorbid symptoms (e.g., PTSD) and improvements in quality of life.
Why CBT?
An important consideration for maximizing widespread dissemination of an intervention is the burden placed on clinicians to deliver it. Compass is a manualized cognitive-behavioral treatment (CBT) with a patient workbook and therapist guide (coming soon to the public). By providing clear guidance on the application of this treatment for clinicians in a familiar format (i.e., workbook chapters corresponding to session-by-session material), any mental health provider that is inclined to work through Compass with their patients will be able to more quickly learn and apply it. We do offer consultation/training service, we explicitly view these offerings as enriching one’s practice, rather than necessary to provide the treatment. Finally, we elected to use a cognitive-behavioral approach given that CBT is reported as the primary theoretical orientation by most providers in typical mental health service settings (Wolitzky-Taylor et al., 2019) and most training programs for clinical psychology focus on developing student competencies in delivering CBT (Heatherington et al., 2012). Although we believe that adopting a manualized, CBT approach increases the disseminablility of Compass, it is important to note that the eclectic use of other theoretical orientations is not precluded; indeed, psychodynamic or interpersonal techniques that use the patient’s relationship with their therapist as a vehicle for new learning can be integrated within structured CBT exercises (Westen, 2000).