A Time Series Evaluation Of The Treatment Of Histrionic Personality Disorder With Cognitive Analytic Therapy

Copyright © The British Psychological Society
Reproduction in any form (including the internet) is prohibited without prior permission from the Society
A time series evaluation of the treatment
of histrionic personality disorder with cognitive
analytic therapy
Stephen Kellett*
Keresforth Centre, Barnsley PCT, UK
The central aim of this study was to assess the effectiveness of cognitive analytic therapy
(CAT) with a patient presenting with Histrionic Personality Disorder (HPD).
The methodology employed an A/B single case time-series experimental design, with
additionally 6 months of continuous follow-up in the experimental measures. Five HPD
experimental variables were collected on a daily basis, creating 357 days of continual data
for analysis, across various phases of assessment baseline (A), treatment (B) and follow-
up. The therapy contract was 24 sessions of CAT, with 4 additional follow-up sessions,
spread over the 6-month’s post-therapy period. Three out of the five HPD experimental
variables (focus on physical appearance, emptiness and child inside) displayed statistically
significant phase of treatment effects. Graphing of such data indicated that a ‘sudden
deterioration’ occurred at the point of termination, with eventual recovery and
maintenance of the progress made during the intervention. A battery of validated clinical
measures were also completed at assessment, termination and final follow-up
sessions; analysis of the general measures illustrated clinically significant change,
indexing personality integration and reductions to depression. The study is discussed in
terms of methodological and clinical limitations, the central importance of process issues
and effective termination in HPD, plus the potential utility of CAT in the treatment of
HPD presentations.
Although there has been much debate and disagreement concerning the aetiology of
HPD (Pfohl, 1995), there is consistency across clinicians, researchers and theoreticians
regarding the typical cognitive, affective and interpersonal symptoms of HPD.
By consensus, HPD appears marked by a chronic proclivity towards an interpersonal
style which is defined by excessive attention-seeking and unwarranted/disproportionate
emotionality. Such factors typically manifest in limited and stereotyped behavioural
repertoires, dominated by sexually seductiveness and theatricality. As Horowitz (2004,
p. 189) states ‘people with this disorder seem to overvalue communication, at the
expense of self-definition and autonomy’ and continue to display such interpersonal
tendencies, despite the frequency of ‘often disastrous personal consequences’
* Correspondence should be addressed to Dr Stephen Kellett, Department of Clinical Psychology, Keresforth Centre, Barnsley
S70 6RS, United Kingdom (e-mail: Stephen.Kellett@barnsleypct.nhs.uk).
The
British
Psychological
Society
389
Psychology and Psychotherapy: Theory, Research and Practice (2007), 80, 389–405
q 2007 The British Psychological Society
www.bpsjournals.co.uk
DOI:10.1348/147608306X161421

(Horowitz, 1997, p. 94). The defence mechanism of denial and a general global
perceptual style limiting attention to detail are prevalent in HPD presentations
(Horowtiz, 1991, 1997).
The DSM-IV (APA, 1994) diagnostic criteria for HPD reflect the consensus and
places HPD within dramatic/impulsive cluster of personality disorders (PD). HPD is
primarily regarded as a female disorder (Hartung & Widiger, 1999), although the
evidence for such a strong sex difference according to diagnosis is mixed and has been
challenged (Hamburger, Lilienfeld, & Hogben, 1996; Lilienfeld, VanValkenburg, Larntz,
& Akiskal, 1986). Schwartz (2001) and Horowitz (1997) both note that the intensity
and severity of presenting HPD symptoms can vary markedly from case to case,
regardless of the gender of the client. Clients may seek help due to their feelings of
depression for example, rather than their awareness or dissatisfaction with apparent
histrionic traits (Horowitz, 1991). Histrionic traits leave clients prone to associated
difficulties, with high comorbidity rates illustrated with anxiety (Blashfield & Davis,
1993), somatization (Reich, 1987), dissociative disorders (Boon & Draijer, 1993; Millon,
1994) and dysthymia (Pepper et al., 1995).
Formulations of HPD tend to originate in the psychodynamic and psychoanalytic
schools (Hingley, 2001), although brief psychodynamic (Dorfman, 2000), radical
behavioural (Koerner, Kohlenberg, & Parker, 1996), cognitive (Beck & Freeman, 1990),
cognitive-behavioural (Kraus & Reynolds, 2001; Rasmussen, 2005), functional analytic
(Callaghan, Summers, & Wieldman, 2003), interpersonal (Benjamin, 1996) and the use
of hypnosis (McNeal, 2003) approaches are also available. Across all such schools
(including that of radical behavioural), therapeutic emphasis is firmly placed upon
interpersonal processes, with overly diffuse identities (Horowitz, 2004) and
conflicting states of mind (Horowitz, 1997), playing important maintaining roles in
HPD presentations. Horowitz (1997) posited a three-phase approach to the treatment of
HPD; (1) state stabilization, (2) modifying communication style and (3) modification of
interpersonal reactions, patterns and schemas. Hoglend (1996) noted that very little is
known about the effectiveness of specific therapist interventions in HPD, such as the
phase change suggested by Horowitz (1997).
In terms of treatment efficacy and effectiveness and associated evidence-based and
practice-based evidence, there are scant methodologically sound scientific investi-
gations of therapeutic outcome in HPD. In terms of efficacy, randomized control trials
are absent, adding to relative general clinical ignorance (in comparison to the Axis 1
disorders) regarding evidence-based practice issues (Bateman & Fonagy, 2000). The vast
majority of HPD effectiveness evidence is firmly based in the traditional narrative case
study approach, which unfortunately tends to lurk on the bottom rung of scientific
credibility (Hilliard, 1993). An exception to this trend in HPD was provided by Callaghan
et al. (2003) using ‘functional analytic’ psychotherapy. Sessions were coded according
to functional criteria and statistically significant reductions in histrionic behaviours in a
single-subject design were illustrated.
The current study employed a single-case time series experimental design to evaluate
the effectiveness of a cognitive-analytic therapy (CAT; Ryle, 1991, 1997, 2004; Ryle &
Kerr, 2002) intervention with HPD. Such time-series approaches have capabilities to
detect the statistical significance of small, but reliable effects, in key experimental
measures (Savard et al., 1998). Time-series experimental methodologies have been
judged by the APA taskforce on empirically supported clinical practice, to be equivalent
to that of the evidence elicited from RCTs (Chambless & Hollon, 1998), despite the
obvious differences in methods and overall aims.
390 Stephen Kellett

Present study
This study presents the assessment, case description, treatment and outcome of a
patient presenting with HPD. The outcome methodology was a single-case experimental
design (SCED) with ‘A/B’ experimental designs recommended in the evaluation of
complex clinical presentations (Turpin, 2000). The client reported chronic and
widespread histrionic symptomatology, with such symptoms constituting the
experimental measures within the case (Morley, 1994, 1996). The methodology
replicated the Kellett (2005) SCED, in order to identify whether sudden gains or
deteriorations in symptoms could be identified and tracked during identified phases of
the CAT intervention and then contextualized in terms of the content of the therapy
delivered. As the project was evaluating the impact of an established form of
psychotherapy in an N ¼ 1 sample, research ethics guidelines stated that it was not
necessary to obtain formal ethical approval (Cooper, Turpin, Bucks, & Kent, 2005).
However, the function of the self-monitoring and recording was explained to the client
and informed, written consent was gained prior to the initiation of data collection.
The advantages of a CAT approach in an SCED context, is that there are distinct
phases of therapy which can be demarcated, compared and contrasted (see
intervention and results sections), in order to analyse for trends, effect sizes and
turning points across chapters of therapy. A number of methodological SCED design
issues were considered and met in the current case; stable, extended multiple
baselines (Barlow & Hersen, 1984; Huitema, 1985), daily recording of measures
minimizing possible distortions of memory (Farmer & Nelson-Gray, 1990), measures
indexing topographically distinct symptoms within the case (Coulton & Solomon,
1977), measures continuously repeated across baseline, intervention and follow-up
periods (Bloom, Fisher, & Orme, 2003; Kazdin, 1981) and a single well specified
intervention (CAT; Ryle, 1991, 1995, 1997, 2004; Ryle & Kerr, 2002). It was impossible
to exhibit ‘reversibility’ via withdrawing treatment in the current case, due to the
obvious ethical concerns (Hayes, 1981; Long & Hollin, 1995).
Experimental hypotheses were as follows: (1) HPD behaviours would significantly
reduce as a result of the intervention, (2) HPD behaviours would remain reduced across
follow-up, (3) sudden gains would be illustrated following the introduction of specific
therapy devices, namely the narrative reformulation and the sequential diagrammatic
reformulation (SDR – see intervention section) and (4) the intervention would have a
beneficial effect on personality structure and general aspects of mental health. Sudden
gains in an SCED context do not match the Tang and DeRubeis (1999) definition of an 11
BDI (Beck, Steer, & Brown, 1995) point drop between sessions, but rather graphical
evidence of sharp shifts according to intervention in time series data (Kazdin, 1981).
Method
Experimental measures
The experimental design comprised an A/B multiple baseline time-series design to
evaluate the 24 þ 4 session CAT intervention, with continual data collection across CAT
assessment baseline (A), CAT treatment (B) and 6-month follow-up phases. ‘Multiple
baseline’ refers to the measurement of differing experimental variables (Bilsbury &
Morley, 1979); in the current case, key HPD symptoms. The effectiveness of the CAT
intervention phase (B) was judged via the extent to which the HPD experimental
variables reduced during the intervention and by whether any positive changes were
Cognitive analytic therapy for HPD 391

subsequently sustained in the follow-up period (Bloom et al., 2003). The collection of
experimental variables throughout such an extended follow-up period is unusual in SCED
practice (Kazdin, 1981; Kellett, 2005), but did facilitate a thorough analysis of the impact
of termination in the current case, a key issue in the treatment of HPD clients (Horowitz,
1991). The experimental variables were designed primarily to reflect DSM-IV (APA, 1994)
diagnostic criteria for HPD, which were reworded to facilitate accurate recognition and
recording by the client (Concoran & Fisher, 2000). Five experimental variables were
designed; three HPD variables and two additional variables concerning the client’s poor
sense of identity, which has been emphasized in the HPD literature (Horowitz, 2004;
Pfohl, Stangl, & Zimmerman, 1984). Table 1 describes item wording, associated HPD
diagnostic criteria/HPD concept, rating frequency and scaling technique. Data were
collected for a 3-week (i.e. 21 days, straddling sessions 1–3) period of the baseline
assessment (A), for 26 weeks (i.e. 182 days, straddling sessions 4–24) during intervention
(B) and for 22 weeks (i.e. 154 days) straddling the four follow-up sessions in that period.
Such prescribed, structured and extended follow-up is wholly consistent with CAT
practice for PD presentations (Ryle, 1997, 2004). Therefore, data collection duration
totalled 357 continuous days or 51 weeks of experimental data. The number of
observations in the baseline satisfied requirements for adequate baseline duration
(Barlow & Hersen, 1984; Huitema, 1985). The data essentially details a year in the life of a
client with HPD undergoing CAT treatment.
Measures of general psychological functioning
The patient completed a range of validated self-report measures of psychological
functioning at initial assessment session, termination of treatment and also at final
follow-up session. Measures were selected with two identified purposes; first,
assessment of general mental health and second, assessment of personality structure.
As part of the general assessment of mental health, the Brief Symptom Inventory
Table 1. Description of case experimental measures
Actual wording HPD criteria/concept Frequency Scale
Item 1 ‘I have felt a
strong need
to be noticed
today.’
(DSM-IV:301.50.1) Is
uncomfortable in situations in
which he or she isn’t centre of
attention
Daily 0 ‘not at all’ to 9
‘all the time’
Item 2 ‘I have been
focused on
my physical
appearance
today.’
(DSM-IV:301.50.4) Consistently
uses physical appearance to
draw attention to self
‘all the time’
Item 3 ‘I have been a
flirt today.’
(DSM-IV:301.50.2) Interaction
with others is often
characterized by sexually
seductive or provocative
behaviour
‘all the time’
Item 4 ‘I have felt
empty today.’
Diffuse identity Daily 0 ‘not at all’ to 9
‘all the time’
Item 5 ‘I have felt like a
child today.’
Diffuse identity Daily 0 ‘not at all’ to 9
‘all the time’
392 Stephen Kellett

(BSI; Derogatis, 1993), Beck Depression Inventory-II (BDI-II; Beck et al., 1995) and the
Inventory of Interpersonal Problems-32 (IIP-32; Barkham, Hardy, & Startup, 1994) were
completed. The personality assessment was undertaken via the Personality Structure
Questionnaire (PSQ; Pollock, Broadbent, Clarke, Dorrian, & Ryle, 2001) and the short
version of the Young Schema Questionnaire (YSQ-SV; Young, 1998).
Assessment and diagnostic details
The aim of the following section is to describe the histrionic procedures described by
the client and the associated diagnosis of HPD. Kath (pseudonym, aged 21) was referred
by a psychiatrist for psychological assessment, due to non-responsiveness to
antidepressant medication. Kath was seen for a screening appointment, in order to
consider her for treatment, which alerted the therapist, the author, of a generally
histrionic style and she was placed on a waiting list for CAT. Prior to the baseline period
(A), the client was formally assessed with the SCID-II (Spitzer, Robert, Gibbon, &
Williams, 1997) in order to verify HPD suspicions. The client met the SCID-II (Spitzer
et al., 1997) diagnostic criterion for HPD.
The client described a lifelong tendency regarding a chronic need to be centre of
attention in social contexts, which she described as a persistent ‘need to be noticed’
(experimental variable 1; DSM-IV: 301.50.1). When not the centre of attention, she
reported feeling ignored, isolated, alone and somewhat lost; which tended to stimulate
overt, theatrical and sexualized behaviours in a crude attempt to once again attain
attention. Kath stated that she ‘demanded’ the attention of all others at all times. She
stated that she could not interact with men without sexual overtones; with her
behaviour in male company tending to be highly sexualized and dominated by what she
described as ‘flirting’ (experimental variable 3; DSM-IV: 301.50.2). During the early
assessment and intervention sessions, the client would frequently initiate crude
attempts at flirting, whilst also finding it extremely difficult to qualify statements, with
any supporting personal details (DSM-IV: 301.50.5). Whilst the centre of attention (i.e.
‘noticed’), Kath stated that she felt free from anxieties and that she ‘basked’ in the
attention of others. Her need for attention disrupted her occupational functioning, with
Kath reporting receiving verbal and written warnings concerning her time management
of tasks at work. Kath described that should she be faced with negative events (which
were often the result of histrionic procedures), she reported a tendency to catastrophise
any personal consequences in a highly emotive style (DSM-IV, 301.50.8).
When shown attention by men (she was heterosexual in orientation), her
suggestibility was high and impulse control low, creating many sexually risky brief (i.e.
typically, but not exclusively, one night) relationships. Such events were typically fuelled
by frequent binge-drinking and tended to result in marked shame and self-disgust. Kath
stated that she was highly competitive during social situations, when she perceived
other people gaining, what she perceived, as the available fund of interpersonal
attention. Competitiveness appeared to be typically translated into behavioural
theatricality. In order to try to dominate social attention during everyday situations, Kath
tended to wear inappropriate clothing. During the early sessions, the client would arrive
to sessions wearing clothes which caused administrative staff to comment on her highly
sexualized and dramatic appearance. During socializing occasions, Kath reported that
she would wear scanty and revealing clothes as a matter of course, in order to draw
attention towards herself. Kath stated that she would only consider buying ‘designer’
clothes, as this made her more noticeable. The client stated that her physical

appearance (experimental variable 2; DSM-IV: 301.50.4) was her defining characteristic
and that she considered herself to be both highly attractive and vivacious, with most
other people being ‘ugly bores’. She stated that she would never consider leaving the
house without being fully ‘made-up’ with cosmetics. Beyond her physical self, Kath
stated that she had little idea who she was as a person, and that she had little or no
defining aspects of self-identity. She reported frequent intense feelings of being ‘empty’
(experimental variable 4) and feeling like ‘a small child inside’ (experimental variable 5),
when not the centre of others attention. Kath described a pattern in social relationships
of quickly striking-up intense relationships and that during the initial embryonic stages
of such relationships, she would become completely overinvolved in the life of the other
person. Kath described such relationships as being rapidly highly emotionally intimate,
then slowly descending into volatility, hostility and rejection, when others slowly tired
of her theatricality; with Kath then reporting tending to rapidly move onto to the next
‘best-friend’ or lover (DSM-IV; 301.50.8).
From assessment to formulation: The multiple self-states model in HPD
The aim of this section is to describe and link assessment details to the sequential
diagrammatic reformulation (SDR; Ryle, 1995; see Figure 1) employed in the management
of the case, with reference to the multiple self-states model (MSSM; Ryle, 1997) of
personality disturbance in CAT. Essentially, SDRs are ‘maps’ of key self-states and the
procedures that link them, presented in diagrammatic form during therapy, in order to
increase recognition skills and encourage exits from damaging procedures. The MSSM
conceptualizes psychological distress as being created by the operation of dissociated
self-states and associated state switching, containing a limited range of contrasting role
patterns (Ryle, 1997, 2004); which create in the HPD context inhibited means of
information processing (Shapiro, 1965) and poor identity (Horowitz, 2004). Assessment
prompts are available to elicit key state information (Ryle, 1995) and in the current case
were initially abandoned, abused, bullied, rejected and controlled.
As is evident from Figure 1, five key differentiated self-states emerged from the
reformulatory process. Theclientdescribed a childhood duringwhich she waschronically
sexually abused by her sole male sibling, whom was also described as the favoured child in
the family. Kath stated that her brother would force her sister to hold her down, whilst he
sexually abused her (see abusing to abused self-state in Figure 1). Kath stated that she
attempted to signal to her parents that she was being abused, by use of dramatic behaviour
at the time. This signalling, which she described as a desperate attempt to draw attention
to herself, gradually escalated, but essentially failed, over an extended period of time.
When Kath finally found the courage to tell her parents about the abuse, her claims were
initially rejected by both parents, only later to be only cursorily considered, with her
brother never being perceived to be adequately punished for his behaviour (see
ignoring/rejecting to ignored/rejected self-state in Figure 1). Kath stated that each parent
tended to enforce a strict code of conduct for the female siblings (which greatly
emphasized personal appearance), whilst tending to allow her brother a wider range of
activitiesandbehaviours (seecontrollingtocontrolledself-stateinFigure1).Inthecontext
of the dysfunctional family environment, Kath reported that she was chronically bullied
throughout primary and secondary education, due to dyslexic tendencies (see critical
bully to passive victim self-state in Figure 1). As an adult, Kath reported significant
problems with distrust of emotional closeness and dependency. Relationships tended to
be terminated rapidly by others resulting in loss and desperation or alternatively
394 Stephen Kellett

Figure
1.
Sequential
diagrammatic
reformation
for
HPD
case.

relationships were terminated by Kath, due to her fears regarding interpersonal and
emotional intimacy (see abandoning to abandoned self-state in Figure 1).
CAT intervention: Theory and practice
CAT is a structured time-limited focal psychotherapy; PD clients receive 24 weekly
sessions and four sessions of follow-up, with the follow-up sessions spread over a
6-month period (Ryle, 1997). The content and structure of CAT with PD clients have
been clearly defined, with the timing and use of specific therapeutic CAT tools clearly
specified (Ryle, 2004). Therefore, the ‘tools’ of CAT will only be described in brief here.
After a period of three assessment sessions (i.e. the baseline ‘A’ in the current
experimental design), the patient receives a prose reformulation concerning their
current difficulties. This is in the form of a letter that is read to the patient, reformulating
the origins of their distress and stating target problems and procedures. In the current
case, four target problems were described (1) need to be noticed, (2) pacing of
relationships, (3) focus on physical appearance and (4) trust issues. The letter was
presented to the patient at session 4, which was week 4 of the time series and
constituted the start of the treatment phase (‘B’) in the SCED. The SDR was constructed
in part over the next 4 sessions and delivered at session 7 (week 7 of the time series).
CAT involves the active use of the SDR in constructing therapeutic ‘exits’ from the roles
and procedures identified on the SDR. The exits designed and completed in the current
case were as follows; (1) less self and other criticism, (2) ability to interact with others
without wearing make-up or provocative clothes, (3) reduction of reassurance seeking
from others, (4) ability to tolerate not being the centre of attention and enjoyment of
social contact when not the centre of attention, (5) appropriate pacing of relationships,
(6) expression of painful affect, (7) developing plans for behaviours, as opposed to
being purely reactive and (8) expression of anger related to abuse and rejection. For
session 24 in CAT, both client and therapist prepare and read a ‘goodbye letter’. The
function of the letter from the therapist is to summarize achievements made in the
therapy, to signal challenges that appear to lie ahead for the patient and acknowledge
the abandonment issues that can be aroused at termination of therapy (Ryle, 1997).
Results
Due to the time series design, the issue of serial dependency in the experimental
variables was considered. Examination of the data reveals that within each experimental
variable and across each of the three phases, data were autocorrelated (Huitema &
McKean, 1991). Data were therefore transformed to remove the autocorrelation and in
order to enable relevant parametric analyses to be performed. The ‘emptiness’
experimental variable is reported in Figure 2. For ease of interpretation, the emptiness
experimental measure has been summarized into a summed total weekly score.
Graphical data indicates a general pattern of reduction in the intensity of the emptiness
experienced by the client over the course of the intervention, to be followed by a sharp
spike at the point of termination, with a gradual reduction over the course of the follow-
up period. There is little evidence in the graphed data of ‘sudden gains’ in terms of
responsivity to specific therapeutic interventions, but evidence of a ‘sudden
deterioration’ at the point of termination. Other experimental measures displayed
similar graphical trends, with graphs available from the author, on request.
396 Stephen Kellett

Table 2 contains the results for the experimental measures summarized into phases.
ANOVA was employed to assess for differences between phases. Results indicate that
there was a significant effect of phase on the physical focus, emptiness and child inside
experimental variables. Figure 2 described the ‘emptiness’ results, in order to illustrate
the shape of change in a variable with statistical differences between phases. The need
to be noticed and flirting variables were non-significant, indicating no statistical
differences between the phases, although the flirting variable was close to being
statistically significant (F ¼ 2:77, p ¼ :07).
In order to facilitate a more thorough analysis of the phase data, mean differences
between phases were calculated using t tests, the results of which are presented in
Table 3. Effect sizes and associated percentage differences are also presented in brackets
in Table 3 and were calculated to estimate the magnitude of the difference between the
phases of the time series. Large effect sizes are apparent; there was over a 40% reduction
in histrionic intensity across four out of the five HPD variables between assessment and
intervention. Comparison of the intervention with the follow-up phases across the
experimental variables indicated that, in general, neither significant improvement, nor
deterioration in histrionic symptoms occurred. An exception to this trend is evident in
the physical focus symptom. The physical focus measure significantly deteriorated over
Figure 2. Weekly summed ratings of ‘emptiness’ across the baseline, intervention and follow-up period.
Table 2. Means, SDs and comparison of phases in experimental HPD variables
Baseline Intervention Follow-up ANOVA
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Need to be noticed 46.50 (0.86) 39.13 (6.51) 39.23 (7.16) 1.69
Physical appearance 56.83 (6.02) 40.96 (5.80) 45.14 (7.73) 7.49*
Flirting 46.00 (0.86) 37.46 (6.46) 37.18 (5.69) 2.77
Emptiness 49.83 (2.56) 37.40 (6.35) 37.64 (5.53) 6.19*
Child inside 49.17 (2.36) 34.67 (6.36) 37.55 (5.43) 8.61*
*p ¼, :001.

Copyright
©
The
British
Psychological
Society
Reproduction
in
any
form
(including
the
internet)
is
prohibited
without
prior
permission
from
the
Society
Table 3. Comparison of mean differences and effect sizes between phases on HPD variable
Need to be noticed Physical focus Flirting Child inside Empty
Baseline versus CAT
intervention
t ¼ 5:36**
(21.17; 37.90%)
t ¼ 4:33*
(22.73; 49.70%)
t ¼ 5:96**
(21.30; 40.30%)
t ¼ 7:83**
(22.35; 49.10%)
t ¼ 6:42**
(22.02; 47.80%)
Baseline versus
follow up
t ¼ 4:53**
(1.06; 35.50%)
t ¼ 3:03
(21.54;43.80%)
t ¼ 6:71**
(21.62; 44.70%)
t ¼ 6:49**
(22.22; 48.70%)
t ¼ 6:44**
(22.28; 48.90%)
CAT intervention
versus follow-up
t ¼ 20:05
(0.01; 0.39%)
t ¼ 22:08*
(0.62; 23.20%)
t ¼ 0:15
(20.04;1.59%)
t ¼ 21:68
(0.48; 18.40%)
t ¼ 20:14
(0.04; 1.59%)
*p ¼, :05; **p ¼, :01.
398
Stephen
Kellett

the course of the follow-up, with a 23.20% increase in physical focus in comparison to
the intervention phase.
The scores on the general measures are summarized in Table 4. As the measures
employed have been psychometrically validated, it was possible to assess clinical
significance using Jacobson’s reliable change index (RCI; Jacobson & Truax, 1991). The
RCI determines whether recorded change in a measure as a result of intervention is
greater than the change that would be expected due to measurement error. In Table 4
the figures in bold represent clinically significant change between time points, with
mean scores indicating the direction of the change. It was not possible to calculate RCI
results for the YSQ, due to a lack of relevant published psychometric information.
The measures suggest that significant clinical change occurred between assessment
and termination on most of the measures, with neither further clinically significant
improvement (nor deterioration) in the measures between termination and follow-up.
The general psychometric picture is one of clinically significant improvement in mental
health and an associated degree of personality integration due to treatment, with neither
further improvement nor deterioration in such measures at follow-up.
Discussion
The data provided conditional support for the original hypotheses. The first hypothesis
stated that the CAT intervention would reduce the intensity of the HPD symptoms, with
reductions being maintained across the follow-up phase. Graphing of the ‘emptiness’
data, illustrated a ‘sudden deterioration’ was evident at the point of termination. Such a
marked negative fluctuation appears unlikely to be the result of repeated testing or
sudden changes in the reliability of the measure (Kazdin, 1981). In short, the sudden
deterioration appeared directly related the clients experience of the ending of therapy.
The importance of and difficulties with termination issues in the management of HPD has
previously been identified (Horowitz, 1997). The current study has, for the first time,
provided empirical evidence of the difficulties experienced by HPD clients regarding the
cessation of therapy contracts. Indeed, termination issues in the case were apparent from
the first moments of therapy, with the client dramatically stating that she required 24
years in therapy, and not 24 sessions on offer. Despite termination being closely discussed
and explicitly planned for throughout the therapy, the client evidently reacted extremely
negatively to termination, despite the therapist consistently linking the experience of
termination to the ‘abandoning-abandoned’ self-state, as consistent with CAT theory and
Table 4. Summary statistics for outcome measures (Bold ¼ Clinically significant reduction on
measure)
Assessment Termination Follow-up
BDI-II 25 12 8
BSI-GSI 1.42 0.30 0.51
BSI-PSDI 1.92 1.23 1.17
BSI-PST 39 13 23
IIP-32 2.06 1.56 1.00
PSQ 35 23 20
YSQ-SV 4.28 3.09 3.18

practice (Ryle, 1995, 1997, 2004). It appears that over the follow-up period, with the
support of the follow-up sessions, the client managed to negotiate the termination of the
therapy in a more effective manner, as evidenced in the graphical data. It is interesting to
note that on the data collection forms during a 2-week period following the termination,
the client added in an extra scale self-titled ‘feeling lonely’ and rated accordingly.
Transformation of the time series data enabled statistical analyses, which revealed
differences between the experimental variables, not immediately apparent on visual
inspection of the graphical data. Use of ANOVA in SCED has been criticized (Toothaker,
Banz, Noble, Camp, & Davis, 1983) due to the probability of producing a type 1 error
(i.e. an erroneous inference of a significant difference between phases), due to
autocorrelation in the time series. In the current case, transformation of the data
removed the autocorrelation and therefore reduced the possibility of a type 1 error
(Bloom et al., 2003). Three out of the five experimental variables (physical appearance,
emptiness and child inside) illustrated a significant effect of phase. The ‘diffuse identity’
experimental variables (i.e. emptiness and child inside), common in HPD presentations
(Horowitz, 2004) responded well, indicating maturational processes taking place.
Anecdotally, the client reported feeling ‘6 or 7’ years of age emotionally at the point of
assessment, which had increased to ‘17 or 18’ at the point of the final follow-up.
Despite the physical appearance variable responding well to the CAT intervention
phase, there was evidence of a marked increase in physical focus in the follow-up
period. The effect size calculation indicated a 23.30% increase in physical focus
occurring during the follow-up phase. It is possible that increase in physical focus was
due to the client becoming pregnant towards the end of the CAT intervention phase, in a
relationship that she had initiated with a work colleague. The client reported significant
concerns regarding the effect of the pregnancy on her physical presentation. The whole
issue of the pregnancy became implicated in HPD processes, with the client appearing
to relate to the impending arrival of the child as a threat regarding her means of
attracting attention to herself and also plans to constantly dress the child in a dramatic
manner. In terms of the pregnancy’s effect on the client and the therapy, then the client
appeared somewhat oblivious or in denial as to the emotional/psychological
significance of bearing and raising a child. The therapist had to work to try to enable
the client to think about the impact of the pregnancy at a psychological level or in terms
of the degree of life-change that caring for a child would entail. The pregnancy may have
been the product of an unconscious desire for avoiding ‘finishing’, as a child would
ensure continuity in the client’s life and an avoidance of any endings for a considerable
time. It is interesting to note that in relation to the SCED measures that the client
physically actually had a ‘child inside’ once she became pregnant and that this may have
influenced associated ratings.
The second hypothesis stated that the intervention would have a positive effect on
comorbid mental health issues, via analyses of the traditional outcome measures.
The PSQ results indicate that the intervention was clinically effective in terms of initial
integration of the previously diffuse personality, which was also mirrored in the schema
questionnaire results. The client was referred due to the presence of depression, with
the depression measure indicating a clinically significant reduction in depressive
symptoms between assessment and termination, which was maintained in the follow-up
period. This change was also mirrored in the BSI results. The IIP-32 results did not
illustrate clinically significant change due to the intervention, although interpersonal
scores did reduce. The original test–retest results for the IIP-32 are worryingly low,
which may account for the lack of significant RCIs in the current analysis. It appears that
400 Stephen Kellett

as the client learnt to recognize histrionic tendencies and be mindful of associated
negative outcomes, then the reduction to histrionic tendencies appeared to have a
positive associated effect on general aspects of mental health.
Previous SCED research using CAT (Kellett, 2005) illustrated sudden gains at key
therapeutic junctures, such as the reformulation letter and the SDR. In the current case,
sudden gains were absent, with the client tending to make progress later in the
intervention phase in a fairly incremental manner. It appears that such data are further
evidence of the slow pace of psychotherapeutic change for PD clients. The client began
to make progress in reducing stereotyped histrionic responses later in the contract,
based on working with the information in the SDR, not as a result of the SDR itself. Evans
and Parry (1996) did note that the effectiveness of reformulation in CAT is based on the
therapist and client collaboratively working together on and producing the letter and
diagram, rather than a product of the actual finished articles themselves. The client
required much scaffolding and support around changing typical histrionic responses
and could not simply use the SDR in a self-directed manner. Scaffolding is a behavioural
psychotherapy term in which the therapist attempts to increase behaviours via closely
supporting the client in any efforts to alter behaviour, whilst being mindful of a
hierarchy of potential development (Sherin, Reiser, & Edelson, 2004). For example, the
ability of the client to socialize without drawing attention to herself with dramatic and
sexualized clothes and make-up was the result of building hierarchies of exposure to the
behaviour, initially based in attendance at sessions without make-up and dressed in a
non-provocative manner.
Horowitz (1991, 1997, 2004) emphasized that the psychotherapy of HPD clients is
likely to be eroticized and stormy, with the client tending to employ histrionic responses
liberally to the therapy situation itself. Despite not explicitly referencing reciprocal
roles, there appears a core reciprocal role in Horowitz’s writings on HPD, of that of a
‘sexy star’ to that of an ‘interested suitor.’ The intervention sessions with the client did
indeed prove very difficult to negotiate and manage, due to the client frequently
occupying such a position. The lack of sexual boundaries in the client’s childhood and
adolescence appeared to dictate a style of interaction, based on an overly flirtatious and
sexualized manner. Feedback on this to the client and the apparent mismatch between
the purpose and the process of the therapy appeared partially successful in reducing
such HPD behaviours. The experiencing of and staying with painful affect particularly in
relation to the sexual abuse tended to produce a torrent of abuse from the client at
subsequent sessions, with such reactions being conceptualized as re-enactments of
abusing–abused and bully–victim reciprocal roles. In terms of understanding and
managing counter-transference reactions during the sessions, the SDR proved
invaluable in terms of managing the therapeutic relationship, such as not responding
to being placed in the passive victim role by the client, with a show of aggression,
retaliation or contempt.
An issue of concern in any SCED evaluating psychotherapy using an A/B design is the
neutrality of the ‘baseline’ (A) established in the data, upon which the judgment of the
effectiveness of the intervention (B) rests. This issue has been previously identified in
CAT study investigating the impact of reformulation (Evans & Parry, 1996). In the
current study the baseline was established during the CAT reformulation process
(3 sessions), during which information was collated to produce the reformation letter
(delivered at session 4 in the current case, signifying the start of the intervention phase).
Reformulation does entail the engagement and containment of the client, is therefore
active and constitutes the start of CAT and therefore may have reduced observed

treatment effects in the current study. An acknowledged weakness in the current study
was therefore the collection of the baseline data during the pre-reformulation
assessment phase. Bloom et al. (2003) emphasize that as long as the intervention phase
contains differing components to the baseline phase, the fact that the baseline is not
technically neutral is not a major confound in SCED psychotherapy evaluations. The
long, stable and technically neutral baselines established laboratory animal SCEDs
(Crosbie, 1993) are difficult to achieve in psychotherapy (Evans & Parry, 1996), as the
early stages of therapy entail active engagement of the client and enlisting a degree of
hope. Future SCEDs may attempt at establishing pre-assessment baselines with clients,
although this does entail meeting with clients to produce client-centred measures of
distress and therefore could be experienced by the client as therapeutically active.
The exclusive reliance on self-report in both the experimental measures and the
traditional outcome measures represents a methodological concern, with the
possibility that the patient provided data that kowtowed to ‘experimental demand’
(Hersen, 1978). However, the client did appear to display her displeasure regarding
termination, which reduces the possibility of the client simply providing the type of
information that the therapist wanted to hear and record. Indeed the choice of the
experimental measures is a potential area of debate in the current case. The measures
were selected and designed by the clinician to measure HPD processes, but were
designed in close alliance with the client. The client was most keen to rate the measures
of identity disturbance (empty and child inside), but could see the rationale for
including measures of interpersonal behaviour, such as flirting, even when the client
saw these as less on an issue at assessment. Any client would not persevere with such
an intensity of rating, should the items hold no personal relevance. The reliability of
experimental measurement is always an issue in such ipsitive type approaches.
However, the physical focus experimental variable did appear sensitive to the client’s
concerns about the impact of the pregnancy upon her physical presentation in the
follow-up period. During the intervention, the client did appear to begin to ‘pace’ the
evolving relationship much more effectively with her partner, rather than throwing
herself into the relationship, as had been the situation pre-intervention. The pregnancy
was not a planned event, but neither was it a product of histrionic tendencies.
The addition of time-series information from informant sources would strengthen any
SCED methodology considerably. In terms of the outcome measures employed in the
case, the inclusion of a measure focal to histrionic tendencies in addition to more
projective type measures would have also proven useful in retrospect.
This SCED, in conclusion, has illustrated the partial effectiveness of CAT with a case
of HPD. The study enhances understanding of HPD as it provides the first empirical
clues as to the rate and shape of change of HPD processes during treatment and provides
evidence that cognitive-analytic theory can effectively formulate HPD presentations.
At the termination of the therapeutic contract, the client clearly remained prone to
histrionic responding, although she did report being more mindful of her need to be
noticed, able to tolerate not being the centre of attention and interacted in a much more
adult and rational manner. The experimental design in particular has highlighted the
importance of managing termination issues with HPD clients and, in particular, in the
context of a medium-term and focal form of psychotherapy. The general quality of
evidence regarding outcome in HPD is a cause for concern and could be improved by
the increased application of such small n or N ¼ 1 experimentally based evaluation
type methodologies. RCT type approaches with HPD are unlikely, due to the
complexities of recruiting to adequately controlled, sufficiently statistically powered,
402 Stephen Kellett

group-based experimental designs. SCED approaches appear to offer an effective
compromise position between the realities and limits of everyday clinical practice and
the daunting methodological requirements of RCT type approaches, in less common
mental health problems. SCEDs appear to particularly offer an opportunity for studying
in detail responsivity of HPD patients to treatment.
References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: American Psychiatric Association.
Barkham, M., Hardy, G. E., & Startup, M. (1994). The IIP-32; a short version of the inventory of
interpersonal problems. British Journal of Clinical Psychology, 35, 21–35.
Barlow, D. H., & Hersen, M. (1984). Single case experimental design (2nd ed.). New York:
Pergamon Press.
Bateman, A. W., & Fonagy, P. (2000). Effectiveness of psychotherapeutic treatment of personality
disorder. British Journal of Psychiatry, 177, 138–143.
Beck, A. T., & Freeman, A. (1990). Cognitive therapy of personality disorders. New York: Guilford
Press.
Beck, A. T., Steer, R. A., & Brown, G. K. (1995). BDI-II manual. San Antonio, US: The Psychological
Corporation, Harcourt Brace & Co.
Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders (2nd ed.).
New York: Guilford Press.
Bilsbury, C. D., & Morley, S. (1979). Obsessional slowness; a meticulous replication. Behaviour
Research and Therapy, 17, 405–408.
Blashfield, R. K., & Davis, R. T. (1993). Dependant and histrionic personality disorders. In
P. B. Sutker & H. E. Adams (Eds.), Comprehensive handbook of psychopathology
(pp. 395–409). New York: Plenum Press.
Bloom, M., Fischer, J., & Orme, J. G. (2003). Evaluating practice: Guidelines for the accountable
professional (4th ed.). Boston, USA: Allyn & Bacon.
Boon, S. & Draijer, N. (1993). The differentiation of patients with MPD or DDNOS from patients
with cluster B personality disorder. Dissociation, 6, 126–135.
Callaghan, G. M., Summers, C. J., & Weidman, M. (2003). The treatment of histrionic and
narcissistic personality disorder behaviours: A single-subject demonstration of clinical
improvement using functional-analytic psychotherapy. Journal of Contemporary
Psychotherapy, 33, 321–339.
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of
Consulting and Clinical Psychology, 66, 7–18.
Concoran, K., & Fisher, J. (2000). Measures for clinical practice: A sourcebook adults (3rd ed.,
Vol. 2) New York: Free Press.
Cooper, M., Turpin, G., Bucks, R., & Kent, G. (2005). Good practice guidelines for the conduct
of psychological research within the NHS. British Psychological Society, Research Ethics
Practice Working Party of the Training Strategy Group, Leicester, UK.
Coulton, C. J. & Solomon, P. L. (1977). Measuring outcomes of intervention. Social Work Research
and Abstracts, 13, 3–9.
Crosbie, J. (1993). Interrupted time-series analysis with brief single-subject data. Journal of
Derogatis, L. R. (1993). Brief symptom inventory: Administration scoring and procedures
manual (3rd ed.). Minneapolis, MN: National Computer Systems.
Dorfman, W. I. (2000). Histrionic personality disorder. In H. E. Hersen & M. Biaggio (Eds.),
Effective brief therapies: A clinician’s guide (pp. 355–370). San Diego, US: Academic Press.
Evans, J., & Parry, G. (1996). The impact of reformulation in CAT with hard to help clients. Clinical
Psychology and Psychotherapy, 3, 109–177.

Farmer, R., & Nelson-Gray, R. O. (1990). The accuracy of counting versus estimating event
frequency in behavioural assessment: The effects of behaviour frequency, number of
behaviours monitored and time delay. Behaviour Assessment, 12, 425–442.
Hamburger, M. E., Lilienfeld, S. O., & Hogben, M. (1996). Psychopathy, gender and gender roles:
Implications for antisocial and histrionic personality disorders. Journal of Personality
Disorders, 10, 41–55.
Hartung, C. M., & Widiger, T. A. (1999). Gender differences in the diagnosis of mental disorders:
Conclusion and controversies of the DSM-IV. Psychological Bulletin, 123, 260–278.
Hayes, S. C. (1981). Single case experimental design and empirical clinical practice. Journal of
Hersen, M. (1978). Do behavior therapists use self-report as a major criteria? Behavioral Analysis
and Modification, 2, 328–334.
Hilliard, R. B. (1993). Single case methodology in psychotherapy process and outcome research.
Journal of Consulting and Child Psychology, 61, 373–380.
Hingley, S. M. (2001). Psychotherapy for histrionic personality disorder. Journal of Psychotherapy
Practice and Research, 6, 93–107.
Hoglend, P. (1996). Analysis of transference in patients with personality disorders. Journal of
Personality Disorders, 10, 122–131.
Horowitz, M. J. (1991). Hysterical personality style and the histrionic personality disorder.
Northvale, NJ: Jason Aronson.
Horowitz, M. J. (1997). Psychotherapy for histrionic personality disorder. Journal of
Psychotherapy Practice and Research, 6, 93–107.
Horowitz, M. J. (2004). Diffuse identity and lack of long-term direction: The histrionic personality
disorder and other related disorders. In L. M. Horowiz (Ed.), Interpersonal foundations of
psychopathy. Washington, DC: American Psychological Association.
Huitema, B. E. (1985). Autocorrelation in applied behavioural analysis: A myth. Behavioural
Assessment, 7, 107–118.
Huitema, B. E., & McKean, J. W. (1991). Autocorrelation estimation and inference with small
samples. Psychological Bulletin, 110, 291–304.
Jacobson, N. S., & Traux, P. (1991). Clinical significance; a statistical approach to defining change
in psychotherapy research. Journal of Abnormal Psychology, 59, 12–19.
Kazdin, A. E. (1981). Drawing valid inferences from case studies. Journal of Consulting and
Clinical Psychology, 49, 183–192.
Kellett, S. (2005). The treatment of Dissociative Identity Disorder with cognitive analytic therapy;
experimental evidence of sudden gains. Trauma and Dissociation, 6, 55–81.
Koerner, K., Kohlenberg, R. J., & Parker, C. R. (1996). Diagnosis of personality disorder: A radical
behavioural alternative. Journal of Consulting and Clinical Psychology, 64, 1169–1176.
Kraus, G., & Reynolds, D. J. (2001). The ABC’s of the cluster B’s: Identifying, understanding and
treating cluster B personality disorders. Clinical Psychology Review, 21, 345–373.
Lilienfeld, S. O., VanValkenberg, C., Larntz, K., & Akiskal, H. S. (1986). The relationship of
histrionic personality disorder to antisocial personality disorder and somatization disorders.
American Journal of Psychiatry, 143, 718–722.
Long, C. G., & Hollin, C. R. (1995). Single case design: A critique of methodology and analysis of
recent trends. Clinical Psychology and Psychotherapy, 2, 177–191.
McNeal, S. (2003). A character in search of character: Narcissistic personality disorder and ego
state therapy. American Journal of Clinical Hypnosis, 45, 233–234.
Millon, T. (1994). Personality disorders: Conceptual distinctions and classification issues. In
P. T. Costa & T. A. Widiger (Eds.), Personality disorders and the five-factor model of
personality. Washington, DC: American Psychological Association.
Morley, S. (1994). Single case methodology in psychological therapy. In S. J. E. Lindsay &
G. E. Powell (Eds.), The handbook of adult clinical psychology. London: Routledge.
Morley, S. (1996). Single case research. In G. Parry & F. N. Watts (Eds.), Behavioural and mental
health research: A handbook of skills and methods. Hove, UK: Psychology Press.
404 Stephen Kellett

Pfohl, B. (1995). Histrionic personality disorder. In J. W. Livesley (Ed.), The DSM-IV personality
disorders (pp. 173–192). New York: Guilford Press.
Pfohl, B. Stangl, D. & Zimmerman, M. (1984). The implications of DSM-III personality disorders for
patients with major depression. Journal of Affective Disorders, 7, 309–318.
Pepper, C. M., Klein, D. N., Anderson, R. L., Riso, L. P., Ouimette, P. C., & Lizardi, H. (1995). DSM-
III-R Axis II comorbidity in dysthymia and major depression. American Journal of Psychiatry,
152, 239–247.
Pollock, P. H., Broadbent, M., Clarke, S., Dorrian, A., & Ryle, A. (2001). The Personality Structure
Questionnaire (PSQ): A measure of the multiple self-states model of identity confusion in
cognitive analytic therapy. Clinical Psychology and Psychotherapy, 8, 59–72.
Rasmussen, P. R. (2005). The histrionic prototype. In P. R. Rasmussen (Ed.), Personality-guided
psychology, personality-guided cognitive-behavioural therapy (pp. 147–166). Washington,
DC: American Psychological Association.
Reich, J. (1987). Sex distribution of DSM-III personality disorders in psychiatric out-patients.
American Journal of Psychiatry, 144, 181–187.
Ryle, A. (1991). Cognitive analytic therapy: Active participation in change. Wiley: Chichester.
Ryle, A. (1995). Cognitive analytic therapy: Development in theory and practice. Chichester:
Wiley.
Ryle, A. (1997). Cognitive analytic therapy and borderline personality disorder: The model and
the method. Chichester: Wiley.
Ryle, A. (2004). The contribution of cognitive analytic therapy to the treatment of borderline
personality disorder. Journal of Personality Disorders, 18, 3–35.
Ryle, A., & Kerr, I. (2002). Introducing cognitive analytic therapy: Principles and practice.
Chichester: Wiley.
Savard, J., Laberge, B., Gauthier, J. G., Fournier, J. P., Bouchard, S., Baril, J. G., et al. (1998).
Combination of fluoxetine and cognitive therapy for the treatment of major depression among
people with HIV infection: A time series analysis investigation. Cognitive Therapy and
Research, 22, 21–46.
Schwartz, R. C. (2001). Psychotherapeutic diagnosis and treatment of histrionic personality
disorder. Annals of the American Psychotherapy Association, 4, 12–14.
Shapiro, D. (1965). Neurotic styles. New York: Basic Books.
Sherin, B., Reiser, B. J., & Edelson, D. (2004). Scaffolding analysis; extending the scaffolding
metaphor to learning artefacts. Journal of Learning Sciences, 13, 387–421.
Spitzer, M. B., Robert, L., Gibbon, M., & Williams, J. B. W. (1997). Structured clinical interview for
the DSM-IV personality disorders (SCID-II). Washington, DC: American Psychiatric Press.
Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in CBT for depression.
Journal of Consulting and Clinical Psychology, 67, 894–904.
Toothaker, L. E., Banz, M., Noble, C., Camp, J., & Davis, D. (1983). N ¼ 1 designs: The failure of
ANOVA-based tests. Journal of Educational Statistics, 8, 289–309.
Turpin, G. (2000). Single case methodology and psychotherapy evaluation; from research to
practice. In C. Mace, S. Moorey, & B. Roberts (Eds.), Evidence in the psychological therapies.
London: Brunner-Routledge.
Young, J. E. (1998). The Young Schema Questionnaire: Short Form [On-line]. Available: www.home.
sprynet.com/sprynet/schema/ysqs1.htm.
Received 7 April 2006; revised version received 14 August 2006

A Time Series Evaluation Of The Treatment Of Histrionic Personality Disorder With Cognitive Analytic Therapy

Recommended

Recommended

More Related Content

Similar to A Time Series Evaluation Of The Treatment Of Histrionic Personality Disorder With Cognitive Analytic Therapy

Similar to A Time Series Evaluation Of The Treatment Of Histrionic Personality Disorder With Cognitive Analytic Therapy (20)

More from Tye Rausch

More from Tye Rausch (20)

Recently uploaded

Recently uploaded (20)

A Time Series Evaluation Of The Treatment Of Histrionic Personality Disorder With Cognitive Analytic Therapy