Borderline Personality Disorder

Borderline PersonalityDisorderTheoretical models andtreatmentsProf. Eduardo KeeganUniversidad de Buenos Aires

Problems with Applying StandardCBT to Personality Disorders(Young, Klosko, Weishaar, 2003)The patient does not comply with protocolStandard CBT assumes that patients aremotivated to reduce symptoms, learn skillsand solve problems and that, therefore,with a little encouragement they willcomply with all treatment procedures.

The patient lacks the ability to identify andmonitor his/her emotions and communicatethem to the therapistStandard CBT assumes that patients cando this with minimum training. Manypatients use cognitive and affectiveavoidance as a coping strategy for negativeaffect.Standard CBT takes for granted that the patient canchange his/her problematic cognitions andbehaviours through empirical analysis, logic,experimentation, gradual steps and repetition.This is not enough when dealing with PDpatients.

Standard CBT assumes that the patient can relateeffectively with the therapist after a few sessionsSince interpersonal issues are normally the coreof the problem, the therapeutic relationship isone of the best domains in which to assess andtreat these patients.Patients with personality disorders are rigidTherefore, they respond much less tocognitive-behavioural strategies. Theychange more slowly.

Standard CBT assumes that the patient hasproblems that are readily identifiable astargets for treatmentThe problems of these patients are illdefined,chronic and pervasive.

Clinical Consequence• As in any relationship, BPD patients maynot mention or manifest their problematicbehaviours or experiences at thebeginning of therapy.• Failing to recognise the presence of BPDusually leads to the application of astandard CBT protocol for an Axis Idisorder.• This may not work adequately, frequentlyleading to a rupture of the therapeuticalliance.

Clinical Consequence• Careful diagnosis and conceptualizationare essential.• Even if you decide to (or have to) targetthe Axis I disorder, it is of great importanceto be aware of the presence of BPD inAxis II.

Diagnosis – A Little History• The term borderline was coined bypsychoanalysts in order to explain thepresence of psychotic symptoms in anotherwise neurotic patient.• Different diagnostic criteria werepostulated in the works of Stern (1938),Deutsch (1942), Schmideberg (1947),Rado (1956), Esser and Lesser (1965),Grinker, Werble and Drye (1968)

Diagnosis – A Little History• DSM-IV criteria rely mostly on the“eclectic-descriptive” approach byChatham (1985) and the work ofGunderson (1984).• Borderline patients have a reputation ofbeing difficult and untreatable.• How do therapists feel about them? Let’shave a look at the history of diagnosticcriteria.

Schmideberg’s criteria (1947)• Unable to tolerate routine and regularity.• Tends to break many rules of socialconvention.• Often late for appointments and unreliableabout payment.• Unable to reassociate during sessions.• Poorly motivated for treatment.

Schmideberg’s criteria (1947)• Fails to develop meaningful insight.• Leads a chaotic life in which somethingdreadful is always happening.• Engages in petty criminal acts, unlesswealthy.• Cannot easily establish emotional contact.

Rado’s criteria (1956)• Impatience and intolerance of frustration• Rage outbursts• Irresponsibility• Excitability• Parasitism• Hedonism• Depressive spells• Affect hunger

Esser and Lesser (1965)• Irresponsibility• Erratic work history• Chaotic and unfulfilling relationships thatnever become profound or lasting.• Early childhood history of emotionalproblems and disturbed habit patterns.• Chaotic sexuality, often with frigid andpromiscuity combined.

A Person Drowning in the SeaDiagnostic Criteria (Keegan, 2007)• Makes frantic efforts to attract attentionand keep afloat• Brought problem on himself byirresponsibly swimming too far away• Presents high arousal and extremeemotional behaviour

A Person Drowning in the Sea(Keegan, 2007)• Entitlement (e.g., the person is unwilling towait for life guard to finish lunch beforeperforming rescue)• Clings desperately to life guard, puttingboth lives at risk• Idealizes saviour, forgets him/her thefollowing day

DSM-IV CriteriaA pervasive pattern of instability of interpersonalrelationships, self-image and affects, andmarked impulsivity beginning by early adulthoodand present in a variety of contexts, as indicatedby five (or more) of the following:(1) Frantic efforts to avoid real or imaginedabandonment. Note: Do not include suicidal orself-mutilating behaviors covered in Criterion 5

DSM-IV Criteria• DSM-IV criteria are more neutral, lessjudgemental about the patient’s behaviour.• But they do not pay too much attention tocognitive aspects (e.g., black-and-whitethinking).• Young (2003) has questioned the validityof these criteria, suggesting that they are alist of coping responses to the pathologicalmodes that are the core of the disorder.

DSM-IV Criteria(2) A pattern of unstable and intense interpersonalrelationships characterized by alternatingbetween extremes of idealization anddevaluation(3) Identity disturbance: markedly and persistentlyunstable self-image or sense of self(4) Impulsivity in at least two areas that arepotentially self-damaging (e.g., spending, sex,substance abuse, reckless driving, bingeeating). Note: Do not include suicidal or selfmutilatingbehaviors covered in Criterion 5

DSM-IV Criteria(5) Recurrent suicidal behavior, gestures orthreats, or self-mutilating behavior(6) Affective instability due to a markedreactivity of mood (e.g., intense episodicdysphoria, irritability, or anxiety lasting afew hours and only rarely more than a fewdays)(7) Chronic feelings of emptiness

DSM-IV Criteria(8) inappropriate, intense anger or difficultycontrolling anger (e.g., frequent displays oftemper, constant anger, recurrent physicalfights)(9) transient, state-related paranoid ideationor severe dissociative symptoms

Prevalence of BPD(DSM-IV, 1994)• 2% of the general population (estimated)• 10% of psychiatric outpatients• 20% of psychiatric inpatients• 30% to 60% prevalence in clinicalpopulations with personality disorders

Course of BPD• Chronic instability at the beginning ofadulthood, with episodes of intenseemotional and behavioral dysregulation,and intense use of mental healthresources.• Deterioration and risk for suicide aregreater in the early years of adulthood,declining after 30 years of age.• They achieve more stability in theirrelationships and work in the 4th/5thdecade of their lives.

Family Pattern of BPDBPD is five times more frequent in firstdegreerelatives of BPD sufferers,compared to the general population.

Organization of DSM-IV Criteria(Linehan, 1993)Self Dysfunction: inadequate sense of self,sense of emptiness.Behavioral Dysregulation: impulsive, selfdamaging,and/or suicidal behaviors.Emotional Dysregulation: emotional lability,problems with anger.Interpersonal Dyregulation: chaoticrelationships, fears of abandonmentCognitive Dysregulation: depersonalization,dissociation, delusion.

Jealous Guy (Lennon, 1971)I was dreaming of the past,And my heart was beating fast,I began to lose control,I began to lose control,I didn’t mean to hurt you,I am sorry that I made you cry,I didn’t want to hurt you,I am just a jealous guy.

Jealous Guy (Lennon, 1971)I was feeling insecure,You might not love me anymore,I was shivering inside,I was shivering inside,I didn’t mean to hurt you,I am sorry that I made you cry,I didn’t want to hurt you,I am just a jealous guy.

Jealous Guy (Lennon, 1971)I was trying to catch your eye,Thought that you was trying to hide,I was swallowing my pain,I was swallowing my pain,I didn’t mean to hurt you,I am sorry that I made you cry,I didn’t mean to hurt you,I am just a jealous guy,Watch out, I am just a jealous guy,Look out baby, I am just a jealous guy.

Subtypes and Cognitive Profiles ofBPD(Layden, Newman, Freeman, Morse, 1993)• Since there are so many ways in which criteriafor BPD can be met, it is reasonable to assumethe existence of subtypes of BPD.• Their cognitive profile can be somewhatdifferent. This helps in achieving a more precisecognitive conceptualization.• Two people with BPD can share the sameabandonment schema, but may developdifferent assumptions or compensatorystrategies.

Subtypes of BPD• Assumption: I must not be too close toanybody, since sooner or later that person willabandon me.• Resulting behaviour: emotional and socialavoidance.• Assumption: I must make everything possiblefor someone to love me, and I must alsooverwhelm him with my presence and passion,since this is the only way to keep him near me.• Resulting Behaviour: Overtly seductive andhistrionic behaviour.

Clinical Consequence• The identification of the schema will beidentical in both cases, but the changestrategy will be different in each case.• The goal, however, is similar: to reducethe expectation of being abandoned, tomoderate the emotional and behaviouralresponses (maintaining factors) and todevelop healthier, more stablerelationships.

Subtypes of BPD• Avoidant/Dependent bordelinepersonality• Histrionic/Narcissistic borderlinepersonality• Antisocial/Paranoid borderlinepersonality

Avoidant/Dependent BPD• They are very anxious and have low self-esteem• The incompetence schema prevails (Young1990)• They believe they can’t face the challenges oflife, therefore they avoid problems andchallenges.• Thus, they don’t mature, reinforcing theincompetence schema and the feelings ofhopelessness and helplessness.• Their beliefs are: I can’t take care of myself,others must make decisions for me, I can’t livealone.

• They are hypersensitive to criticism.• Their high level of demand is a greatburden for their relationships.• They are afraid of losing their identity andautonomy if they relate to somebody.• Thus, they can put an end to theirrelationships in order to survive asindividuals. They fear that their ideas,aspirations and needs will beoverwhelmed by the assertive peoplearound them.

• They repeat the same pattern in therapy,oscillating between withdrawing andmaking excessive demands on thetherapist.• They avoid thinking of sensitive material(cognitive avoidance).• Attempts at teaching them skills can beread as “trying to get rid of them”.• They have problems with homework, thatmakes them anxious.

Histrionic/Narcissistic BPD• Characterised by marked mood lability,stormy relationships, overwhelming needsof care and affection and extreme angerwhen their needs are not met.• They oscillate between and idealising andvilifying their therapists.• They resort to exhibitionistic behaviours ormelodramatics to hold on to love and care.• Their abandonment and unlovabilityschemas are salient.

• They are the most likely of any subtypes tomake suicidal threats and gestures as cries forhelp or as ploys to manipulate the therapists orothers.• They have serious difficulties in understantingboundaries in interpersonal relationships.• They think their needs are evident to others, thatthey require immediate attention and that theyare congruent with the needs of the nurturer.• They oscillate between demanding a symbioticrelationship and believing that nobody will beable to help them (punishing the other).

• They seek stimulation, excitement andnovelty around them intensely, but theyhate to generate changes withinthemselves.• They seek continuous reassurance andapproval to support a fragile self-esteem.They think the love of others will solve allof their problems.• They idealise a person and becomedeeply disappointed at the smallest hintthat this person will not be able to meet alltheir needs.

• Impulsivity, impatience and low frustrationtolerance are the hallmark of this subtype.They readily express their anger to thosewho have –in their perception- wrongedthem.• They believe a lot in their emotions (theyare highly valued) and very little insensible, rational thinking.

Antisocial/Paranoid BPD• Boys will be boys, bad boys, bad boys.• They show a marked disregard for the formaland informal rules that regulate social behaviour.• They break these rules to their own benefit, togain money, power and stimulation at somebodyelse’s expense.• They have a grandiose view of their selfimportance,together with an attitude of opendefiance.

• Their interests always come first; the needor desires of others have no importancefor them.• They show a pervasive mistrust of others’motives. They are always alert to thepotential threats of others, whether real orimaginary.• Jealousy and anger are extreme andeasily triggered. Criticism is taken withgreat animosity and indignation.

• The grandiose presentation of selfdisguises a deep feeling of self-doubt.• They get involved in the same impulsive,hostile and destructive behaviours of the“pure” antisocial or paranoid person, butfor different reasons.• Antisocials seek self-benefit. BPDs tend toact out their pain and hostility, hurtingthemselves and others.• “I don’t care what happens to me, so I cando as I please”.

• Hostility, suspiciousness and recklessnessare the hallmark of the subtype. They havea malevolent view of others (mistrustschema) and a false sense of power.• They tend to use and abuse those whothey love.• They rarely have stable relationships.

• They do not feel close to anyone, but areextremely possessive, demanding andjealous in their relationships.• Anger is the most common expressedemotion, frequently under the form ofrecklessness or physical attacks on others(engaging in frequent fights).

• Gunderson and Zanarini (1987) havepostulated that this subtype would betypically male.• A tendency to suicide could correlate witha tendency to homicide.• They cannot tolerate boredom and arethus inclined to substance abuse,increasing their impulsivity and lack of selfcontrol.• They show contempt for themselves(badness schema) in the form of selfdestructivebehaviours.

Characteristics of BPDLinehan’s Model (1993)Emotional VulnerabilitySelf-InvalidationUnrelenting CrisesInhibited GrievingApparent Competence

Emotional VulnerabilityA pattern of pervasive difficulties inregulating negative emotions, includinghigh sensitivity to negative emotionalstimuli, high emotional intensity, and slowreturn to emotional baseline, as well asawareness and experience of emotionalvulnerability. May include a tendency toblame the social environment forunrealistic expectations and demands.

Self-InvalidationA tendency to invalidate or fail to recognizeone’s own emotional responses, thoughts,beliefs and behaviors. Unrealistically highstandards and expectations for self. Mayinclude intense shame, self-hate and selfdirectedanger.

Unrelenting CrisesA pattern of frequent, stressful, negativeenvironmental events, disruptions androadblocks –some caused by theindividual’s dysfunctional lifestyle, other byan inadequate social milieu, and many byfate and chance.

Inhibited GrievingThe tendency to inhibit, avoid or overcontrolnegative emotional responses, especiallythose associated with grief and loss,including anger, guilt, shame, panic andanxiety.Patients may seem to “survive” loss quitewell, only to experience difficulties later on.

Active PassivityTendency to passive interpersonal problemsolvingstyle, involving failure to engageactively in solving of own life problems,often together with active attempts tosolicit problem solving form others in theenvironment; learned helplessness,hopelessness.

Apparent CompetenceA tendency for the individual to appeardeceptively more competent, capable oreffective than he/she really is; usually dueto failure of competencies to generalizeacross expected moods, situations andtime, and failure to display adequatenonverbal cues of emotional states., inmany situations.

Apparent Competence (cont.)Due to emotional instability, they cansometimes cope with certain situations orchallenges and sometimes they cannot.Some BPD patients perform well at workor are creative, intelligent, and artistic, butthey may not be so at times. This createsconfusion in people around them.

Young’s ModelSchemas and Modes• Young’s original model (1990) posited thatpersonality disorders were the result of theprevalence of certain –and different- schemas(unconditional, rigid, basic cognitive structures).• BPD patients scored high on almost all of the 16schemas of the Schema Questionnaire. Itbecame evident that a more inclusive unit ofanalysis was necessary.• The original model was a trait rather than statemodel. This could hardly account for the everchangingbehaviour of BPD patients.

• Schema modes are the emotional statesand the coping responses –adaptive ormaladaptive- that we experiment at agiven time. They are the schemas orschema operations that are active in aperson at a given time.• Schema modes are triggered by vitalsituations to which we are hypersensitive.• The object of the therapy is to move froma maladaptive schema mode to anadaptive one (the healthy adult).

• A mode is the conceptual answer to thequestion “what group of schemas orschema operations is the patient enactingat this present moment?”• A dysfunctional schema mode is activatedwhen certain dysfunctional schemas orcoping responses have emerged, givingplace to painful emotions, avoidance ordysfunctional behaviours that take controlof a person’s functioning.

• A schema mode is an aspect of the self,involving schemas or schema operationsthat has not been fully integrated withother areas of the self.• They can thus be described in terms of thedegree in which they are dissociated fromthe rest of the self.

Origins of BPD – A Hypothesis(Young, Klosko & Weishaar, 2003)Biological FactorsThe temperament of BPD patients ischaracterised by intense and labile emotionality.This would represent a biological predispositionto the disorder.The higher frequency of BPD in women could bea result of temperamental differences or of thehigher frequency of sexual abuse or ofsubmission and restraint in the expression ofanger.It could also be that BPD is less diagnosed inmen.

Environmental FactorsFamily environment is unsafe andunstableFamily environment is characterised byemotional deprivationFamily environment is harshly punitive andrejectingFamily environment is subjugating.

Schema Modes and BPD• Young (2003) postulates five schemamodes:• The Abandoned Child• The Angry and Impulsive Child• The Punitive Parent• The Detached Protector• The Healthy Adult

The Abandoned Child• It is the part of the patient that feels the pain andthe terror associated to most of the schemas(abandonment, abuse, deprivation,deffectiveness, and subjugation).• The patients is fragile and childish. They aresad, desperate, frantic, lost. They feel terriblyalone and are obssesed with finding a parentalfigure that takes care of them. They idealise theirnurturers and have fantasies of being rescued.They desperately seek not to be abandoned bytheir carers.

The Angry and Impulsive Child• This mode prevails when the patient is furious oracts impulsively because their basic needs arenot met. Young believes it is the less frequentone, but it is the one that therapists mostassociate with BPD patients.• Patients make demands that suggest they feelentitled or that they are spoiled, alienating themfrom others. They really reflect desperateattempts to meet their emotional needs.• It is activated as a result of the unresolvedtensions between the activation of the PunitiveParent and the Detached Protector.

The Punitive ParentIt is the internalized voice of the parent, thatcriticizes or punishes the child.• The patient becomes a cruel nemesis of himself.• The voice punishes the child for doingsomething “wrong”, like expressing needs orfeelings.• It is the internalization of the hatred, anger orcontempt of one or both parents, together withthe submission of the patient.

The Detached Protector• The patient blocks all of his/her emotions,disconnects from others and functions in arobotic-like manner.• It is the défault mode of BPD patients.• They may seem normal and “good” patients,acting appropriately, but suppressing their needsand feelings.• Its presence can be detected bydepersonalization, feelings of emptiness,boredom, substance abuse, binges, selfmutilation,robotic compliance and feeling blank.

The Healthy Adult• Very weak and underdeveloped in mostBPD patients, since they have notacquired a soothing, caring parental mode(thus, their intolerance of separation).• The therapist models the healthy adultmode until the patient learns to do it byhimself/herself.• Implication 1: therapy is about learning tobehave like healthy adults• Implication 2: therapists can act likehealthy adults.

BPD as Dialectical Failure(Linehan, 1993)Borderline and suicidal individualsfrequently vacillate between rigidly heldyet contradictory points of view, and areunable to move forward to a synthesis ofthe two positions.They tend to see reality in polarizedcategories of either-or, rather than all.

BPD as Dialectical FailureThis tendency has been termed splittingby psychoanalysis (Kernberg, 1984).This process is known in cognitive modelsas schema vacillation (Young, 1990).

Borderline Behavioral Patterns: The ThreeDialectical DimensionsUnrelentingCrisesEmotionalVulnerabilityActivePassivityBiologicalSocialApparentCompetenceSelf-invalidationInhibitedGrieving

Biosocial Theory: A DialecticalTheory of BPD Development(Linehan, 1993)BPD is primarily a dysfunction of theemotion regulation system, resulting frombiological irregularities combined withcertain dysfunctional environments, aswell as from their interaction andtransaction over time.

Social-Behavioral Model of Suicidal Behavior:An Environment- Person SystemAgeSocialSupportSexLifeChangeDemographicFactorsRaceCognitiveSystemSuicidalIdeationSuicidalModelsEnvironmentalSub-systemSuicidalConsequencesOvert MotorSystemParasuicideSuicideBehavioralsubsistemPhysiological/AffectiveSystem

Emotion Dysregulation and BorderlineBehavior Patterns. The Biosocial TheoryEmotion Regulation DysfunctionInvalidating EnvironmentEmotional Vulnerability(Affective Instability)BehaviorInstabilityInterpersonalInstabilitySelfInstabilityCognitiveInstability

Biosocial Theory: A DialecticalTheory of BPD Development(Linehan, 1993)Invalidating environments during childhoodcontribute to the development of emotionaldysregulation, also failing to teach thechild how to tolerate emotional distress,and when to trust his own emotionalresponses as reflections of validinterpretations of events.

Biosocial TheoryAs adults, borderline individuals adopt thecharacteristics of the invalidatingenvironment.They tend to:(a) invalidate their own emotionalexperiences(b) look to others for accurate reflectionsof external reality(c) oversimplify the ease of solving life’sproblems

Biosocial TheoryThese behaviors leads to unrealistic goals,use of punishment rather than reward, andself-hate following failure to achieve thesegoals.They become self-invalidating.

Clinical Implications of theBiosocial TheoryIf we consider BPD as a dialectical failure,then treatment must focus on overcomingan either-or perception of reality and self,enabling the patient to achieve a holisticperception instead.One basic principle in this endeavour is toobserve an adequate (and difficult)balance between acceptance and change.

Temperament and EnvironmentThomas and Chess have suggested thatgoodness of fit or poorness of fit of thechild with the environment is crucial forunderstanding later behavioral functioning.

Invalidating EnvironmentsAn environment in which communication ofprivate experiences is met by erratic,inappropriate, and extreme responses.The expression of emotions is not validated,instead, it is often punished, and/ortrivialized.The individual’s interpretation of his ownbehavior, including the experience of theintents and motivations associated withbehavior, are dismissed.

Invalidating EnvironmentIt tells the individual that he is wrong inboth the description and analysis of hisown experiences, particularly in his viewsabout what causes his own emotions,beliefs and actions.

Invalidating EnvironmentIt attributes experiences to sociallyunacceptable characteristics or personalitytraits. The environment may insist that theperson feels, likes or has done somethingdifferent from what the person thinks hefeels, likes or has done.

Invalidating EnvironmentsThey are generally intolerant of displays ofnegative affect, at least when notaccompanied by public events supportingthe emotion.The attitude communicated is that anyonewho tries hard enough can make it.This is similar to the pattern of highexpressed emotion (Leff & Vaughn, 1985).

ConsequencesAn invalidating environment does not teachthe child to label private experiences,including emotions, in a manner normativein the larger community.By oversimplifying the ease of solving life’sproblems, it does not teach the child totolerate distress or to form realistic goals.

ConsequencesExtreme emotional displays often becomenecessary to provoke a helpful responsefrom the environment.It fails to teach the child when to trust hisown emotional and cognitive responses asreflections of valid interpretations ofindividual and situational events.

Types of Invalidating FamiliesChaotic FamiliesLittle time or attention is given to thechildren; their needs are disregarded and,therefore, invalidated.“Perfect” FamiliesParents cannot tolerate negative emotionaldisplays from their children. They tend tosimplify the difficulties in solving problems.

Invalidating FamiliesTypical FamiliesThe individuated self in Western culture isdefined by sharp boundaries between selfand others. Mature persons are assumedto be controlled by internal rather thanexternal forces. Self-control is expected,and defined as the ability to control one’sbehavior by using internal cues andresources.

Invalidating FamiliesThe emphasis on individual independenceas normative behavior is unique to, andpervasive in Western culture.It appears that there is a “poorness of fit”between women’s interpersonal style andWestern socialization and cultural valuesfor adult behavior (Linehan, 1993).

Sexual Abuse• Sexual abuse is 2 to 3 times greater forfemales than for males (Finkelhor, 1979).• Of 12 hospitalized patients, 9 (75%)reported a history of incest (Stone, 1981).• Childhood sexual abuse was reported by86% of borderline inpatients (34% in otherpsychiatric patients) (Bryer et al., 1987).• Childhood sexual abuse was reported in67% to 76% of borderline outpatients(26% in other psychiatric patients) (Hermanet al., 1989, Wagner, Linehan & Wasson, 1989)

Sexual Abuse• Sexual abuse might be uniquely associated withBPD (Linehan, 1993).• A similar link has been found between childhoodsexual abuse and suicidal, parasuicidalbehaviors. Up to 55% of these victims go on toattempt suicide.• Sexually abused women engage in moremedically serious parasuicidal behavior.• Individuals with suicide ideation or parasuicidewere 3 times more likely to have abused inchildhood (Bryer et al, 1987).

Sexual Abuse• Abuse may not only be pathogenic forindividuals with vulnerable temperaments,it may “create” emotional vulnerability byaffecting changes in the central nervoussystem.• Chronic stress may have permanentadverse effects on arousal, emotionalsensitivity and other factors oftemperament.

Sexual Abuse• It is a form of extreme invalidation. Thevictim is told that abuse is O.K. but thatthey must not tell anyone else.• If the child says something about theabuse she may be disbelieved or blamedby family members.

Emotional Dysregulation andInvalidating EnvironmentsA slightly vulnerable child, within a slightlyinvalidating family can, over time, evolveinto one in which the individual and thefamily environment are highly sensitive to,vulnerable to, and invalidating of eachother (Linehan, 1993).The child’s response to invalidationreinforces the family’s invalidatingbehavior.

Emotional Dysregulation andInvalidating EnvironmentsCaregivers may expect more or different behaviorsthan the child is capable of emitting. Excessivepunishment and insufficient modeling,instructing, coaching, and reinforcement follow.Needed help is not offered to the child.Unavoidable punishment increases his negativeemotions, leading to an extreme expression ofemotion.This is so aversive for caregivers that they stopattempts at control.

Emotional Dysregulation andInvalidating EnvironmentsCaregivers unwittingly reinforce thefunctional value of extreme expressivebehaviors, and extinguish the functionalvalue of moderate emotional expression.Appeasement after extreme emotionalexpression may create the BPD pattern ofbehavior in adults.

Emotional DysregulationMost borderline behaviors are eitherattempts on the part of the individual toregulate intense affect or outcomes ofemotional dysregulation (Linehan, 1993).

Emotional Dysregulation andImpulsive BehaviorSuicide and other impulsive, dysfunctionalbehaviors are usually maladaptive solutionbehaviors to the problem of overwhelming,uncontrollable, intensely painful negativeaffect.Borderline patients report substantial relieffrom anxiety and intense negative affectafter cutting themselves (Leibenluft, Gardner& Cowdry, 1987)

Emotional Dysregulation andIdentity DisturbanceUnpredictable emotional lability leads tounpredictable behavior and cognitiveinconsistency, preventing the developmentof a stable self-concept or sense ofidentity.The numbness associated with the inhibitionof emotional responses is experienced asemptiness, that contributes to the absenceof a strong sense of identity.

Emotional Dysregulation andInterpersonal ChaosSuccessful relationships require a capacityto self-regulate emotions in approppriateways, to control impulsive behaviors, andto tolerate stimuli that produce pain to acertain degree.

Effective Treatments for BPD• A number of interventions have proven –with varying degrees of empirical backingtobe efficacious for BPD.• These are Dialectical Behavior Therapy(DBT, Linehan), Transference-FocusedPsychotherapy (TFP, Kernberg), SchemaTherapy (Young), Mentalization-BasedTreatment (MBT, Bateman & Fonagy),Cognitive Therapy (Beck, Newman).

Common Features of Effective• Well-structuredTreatments for BPD• They devote considerable effort to theenhancing of compliance• Clearly focused, be it on problem behavior(self-harm) or on interpersonal relationshippatterns• Theoretically highly coherent to boththerapist and patient

Common Features (cont’d)• They are relatively long term• They encourage a powerful attachmentrelationship between therapist and patient,enabling the therapist to take an activerather than passive stance• Well-integrated with other servicesavailable to the patientBateman & Fonagy (2004)

Common Factors(Bateman & Fonagy, 2004)• Warmth, acceptance and a supportiveenvironment contributes to theeffectiveness of all psychotherapies.• But what are the precise aspects ofinterpersonal processes that aretherapeutic for people with BPD?

Common Factors(Bateman & Fonagy, 2004)• All these treatments focus on the capacityfor mentalization, that is, on the implicit orexplicit perception or interpretation of theactions of others or oneself as intentional(i.e., mediated by mental states or mentalprocesses).• The crux of the value of psychotherapywith BPD is the experience of other humanminds having the patient’s mind in mind.

Common Factors (cont’d)• The therapist, in holding on to his view ofthe patient symultaneously fostersmentalizing and secure attachmentexperience.• Feeling recognized creates a secure basefeeling that in turn promotes the patient’sfreedom to explore herself/himself in themind of the therapist.

• An increased sense of security reinforcesa secure internal working model andthrough this, a coherent sense of self.• The patient is increasingly able to allocatemental space to the process of scrutinizingthe feelings and thoughts of others,perhaps bringing about improvement infundamental competence fo the patient’smind interpreting functions.• This, in turn, generates a far more benigninterpersonal environment.

Common Factors (cont’d)• Therapists will need:a) to identify and work with the patient’slimited capacitiesb) to represent internal states inthemselves and in their patientsc) to focus on these internal statesd) to sustain this in the face of constantchallenges by the patient over asignificant period of time

Common Factors (cont’d)Mentalizing techniques will need to be:a) offered in the context of an attachmentrelationshipb) consistently applied over timec) used to reinforce the therapist’scapacity to retain mental closenesswith the patient

Dialectical Dilemmas in theTreatment of BPDA group of three dimensions defined bytheir opposite poles:(1) emotional vulnerability versus selfinvalidation(2) active passivity versus apparentcompetence(3) unrelenting crises versus inhibitedgrieving

The Dialectical Dilemma for theTherapistThe therapist must strive for a dialecticalbalance between validating the essentialwisdom of each patient’s experience(especially her vulnerability and sense ofdesperation) and to teach the patient therequisite capabilities for change to occur(Linehan, 1993).

Overview of TreatmentDBT for BPD consists of two basicinterventions: individual therapy and skillstraining, offered initially for a one-yearperiod, on a once-a-week basis for eachintervention.The treating team also meets once a weekfor consultation/supervision.

A Possible Ancillary Treatment Scenario inDBT(Supervisor)DBTTEAMST(Pharmacotherapist)(Physician)(Supervisor)TP(Inpatient Staff)(VocationalCounselor)(Personal Therapist) (Case Manager) (ResidentialTreatment Counselor)

Structure of DBTStages of disorder, stages of treatmentThe treatment frame is informed both by thebiosocial-transactional theory and by amodel of the stages of the disorder,creating a hierarchy of interventions.The central goal of DBT is creating a lifeworth living, according to the core valuesof the patient.The hierarchy of interventions is determinedby this goal.

Structure of DBTPrimary targetsThe treatment focuses on the behaviors thatinterfere most with the goals of each stage(e.g., cutting).Secondary targetsThese are patient behaviors, environmentalevents or behaviors of others that are “onthe chain” toward the primary target (e.g.,on the chain of the cutting behavior)

PretreatmentStructure of DBTThe patient is informed of the nature of treatment,including:- how it is conducted and evaluated,- the modes of treatment available,- treatment target hierarchy,- assessment procedures,- agreed upon length of treatment (includingfactors that can result in more or less tx),- rules of the treatment setting.

Structure of DBTPretreatmentTherapist and patient evaluate the pros andcons of entering treatment. Clientscomplete daily monitoring sheets, therapistdemonstrates process of treatment. Bothevaluate factors that may interfere withactive participation and commitment.Agreement is usually reached after 2 to 4sessions in an outpatient setting.

Structure of DBTIndividual TherapyStage 1The main difficulty is behavioral dyscontrol.The goal for the patient is to achievebehavioral control across all relevantcontexts.This involves three domains:- Life-threatening behaviors- Therapy-interfering behaviors- Severe quality-of-life interfering behaviors

Stage 1Life-threatening behaviorsSuicidal and parasuicidal behaviors,aggression, violence, child abuse andneglect.Therapy-interfering behaviorsAbsence from sessions, noncollaborativebehaviors, interfering with the treatment ofother patients, behaviors that can burn thetherapist/team out or decrease motivationto-treat.

Stage 1Severe quality-of-life-interfering behaviorsSevere drug abuse, a severe eatingdisorder, being homeless or in jail, or anyout-of-control behavior that limits anacceptable quality of life.

Stage 1• This stage involves teaching selfmanagementskills, strengthening themand generalizing them to the naturalenvironment.• It also involves changing environments tomake them safer or more compatible withskillful living.

Stage 2The main difficulty is emotional misery,thought to be related to deficits inemotional experiencing (BPD patients areemotion-phobic). The prototype problem inStage 2 is Posttraumatic Stress Disorder.The client must learn to experienceemotions effectively (without escalating orblunting them).

Stage 2• Treatment strategies in this stage mayoriginate a return to problematic behaviorsaddressed in Stage 1. If so, stage 1strategies are applied again untilstabilization is achieved.• Effective experiencing of emotionsdemands a validating environment. Atherapist may provide this during exposuretreatment for PTSD.

Stage 3• The main difficulty in this stage is lifeproblems. The target is to amelioratemajor life problems.• The focus flows from problem solving(change) to problem management(accepting problems in a way thatminimizes associated difficulties).• Topics normally revolve around education,employment and relationships.

Stage 4• The target in this stage is to enhance thecapacity for sustained contentment andjoy; dealing with the “incompleteness” ofhuman experience.• When basic problems have been solved,human beings must still struggle withmeaning, isolation, intimacy.

Therapist Characteristics in DBTOriented toChangeUnwaveringCenterednessBenevolentDemandingNurturingCompassionateFlexibilityOriented toAcceptance

Dialectical Behavior Patterns:Balanced Lifestyle1. Skill enhancement vs. self-acceptance2. Problem solving vs. problem acceptance3. Affect regulation vs. affect tolerance.4. Self-efficacy vs. help seeking5. Independence vs. dependence6. Transparency vs. privacy.7. Trust vs. suspicion.

Dialectical Behavior Patterns:Balanced Lifestyle8. Emotional control vs. emotionaltolerance.9. Controlling/changing vs. observing.10.Attending/watching vs. participating11. Needing from others vs. giving to others12. Self-focusing vs. other-focusing13. Contemplation/meditation vs. action

Treatment Strategies in DBTSTYLISTICCHANGEIrreverentReciprocalACCEPTANCEProblem SolvingValidationConsultation tothe patientEnvironmentalInterventionCASE MANAGEMENTTerapist Supervision/Consultation

• Mindfulness skillsSkills TrainingGroup Therapy• Emotion regulation skills• Distress tolerance skills• Interpersonal effectiveness skills

Mindfulness Skills• Training in attention control• Awareness of self and others• Reducing emotional reactivity• Provides a foundation for self-validation,reducing feelings of emptiness and selfand cognitive dysregulation

Emotion Regulation Skills• Ability to identify and label emotions• Reduction of vulnerability to negativeemotion• Reduction of suffering associated withnegative emotion• Ability to change negative emotion,reducing emotional lability, and problemsassociated with anger and other negativeemotions.

Distress Tolerance Skills• Counterbalance of impulsivity• Learning how to inhibit dysfunctionalactions (substance abuse, parasuicide)• Learning to tolerate intense emotional painand urges to engage in problematicresponses (not to exacerbate misery orsuffering)

Interpersonal Effectiveness Skills• Learning how to achieve interpersonalgoals.• Manage relationships effectively• Maintain self-respect in interpersonalsituations.• Learning the –difficult- balance betweensituational objectives with relationshipobjectives while maintaining self-respect.

Basic Treatment Strategies1. Dialectical Strategies2. Core Strategies3. Stylistic Strategies4. Case Management Strategies

Dialectical StrategiesTwo levels of therapeutic behavior:• Alert to the therapeutic interaction• Teach and model dialectical behaviorpatterns out of the therapeutic interaction

Specific Dialectical Strategies• Entering the paradoxPatient’s own behavior, the therapeuticprocess and reality in general.• Using metaphors, parables and stories• The Devil’s Advocate Technique• Extends the seriousness or implicationsof patient’s comunication

Specific Dialectical Strategies II5. Activating “Wise Mind”6. Making lemonade out of lemons7. Allowing natural change in therapy8. Dialectical Assessment: examiningboth the individual and the broadersocial context

Core Strategies1. Problem-solving strategies2. Validation strategies

Defining Validation• The therapist communicates to thepatient that her responses makesense and are understandable withinher current life context or situation• Validating the patient’s history is notthe same as validating her currentbehavior• Three steps: Active Observing,Reflection, Direct Validation

Emotional Validation Strategies1. Providing opportunities for emotionalexpression2. Teaching emotion observation and labelingskills3. Reading emotions: timing and offering multiplechoiceemotion questions4. Communicate the validity of emotion

Behavioral Validation Strategies1. Teaching behavior observation and labelingskills2. Identifying the “Should”3. Countering the “Should”4. Accepting the “Should”5. Moving to the dissapointment

Cognitive Validation Strategies1. Eliciting and reflecting thoughts andassumptions2. Discriminating facts from interpretations3. Finding the “Kernel of Truth”4. Acknowledging “Wise Mind”5. Respecting differing values

Cheerleading Strategies1. Assuming the best2. Providing encouragement3. Focusing on the patient’s capabilities(a) communicating that the patient has whatit takes to succeed,(b) expressing belief in the therapeuticrelationship,(c) validating the patient’s emotions,behaviors, thinking

Cheerleading Strategies1. Contradicting/modulating externalcriticism2. Providing praise and reassurance3. Being realistic, but dealing directly withfears of insincerity4. Staying near

Levels of Problem Solving1. The entire DBT program can be seen as ageneral application of problem solving2. Figuring out which strategies andprocedures should be applied to thisspecific patient, at this moment, for thisproblem3. Addresses specific problems: reviewingdiary cards, responding to questions aboutsuicide ideation or parasuicide

Behavioral analysis strategies1. Defining the problem behavior (describing the problemspecifically): frequency, duration, intensity andtopography2. Chain analysis :a. Select one instance of problem to analyze;b. Attend to small units of behavior in terms of emotions, bodilysensations, thoughts and images, overt behaviors andenvironmental factors.3. Generate hypotheses about variables influencing orcontrolling the behaviors in question: use the previousanalysis to guide the current one

Insight (Interpretation) Strategies5. Highlighting the patient’s behavior: thetherapist gives the patient feedback aboutsome aspect. In the case of negativebehaviors, try to balance highlighting of apatient’s strengths with a focus onproblematic responses6. Observing and describing recurrent patterns(thoughts, affective responses, behavioralsequences): look for those relationships thatwill throw light on causal patterns

Insight (Interpretation) Strategies1. Commenting on implications of behavior: “if - then”rules or relationships of which the patient may not beaware. Be particularly careful about suggesting thatconsequences are painful or socially unacceptable2. Assessing difficulties in accepting or rejectinghypotheses: recurrent pattern or implication that is notrecognized by the patient; the pattern or implicationmay be recognized, but the patient may have difficultyeither acknowledging it to the therapist or accepting itsreality

Didactic strategies1. Providing information about thedevelopment, maintenance, andchange of behavior in general2. Giving reading materials aboutbehavior, treatments, BPD3. Giving information to family members

Solution Analysis Strategies1. Identifying goals, needs and desires: help toredefine wishes to engage in parasuicidalbehavior as expressions of desire to decreasepain and improve quality of life; redefine lackof desire to change or inability to generategoals as an expression of hopelessness andpowerlessness2. Generating solutions: brainstorm; specificcoping strategies to shortcircuit impulsive,self-damaging behaviors

Solution Analysis Strategies1. Evaluating solutions: focus on consequences, shortandlong-term; discuss problem solution criteria;identify factors that might interfere with problemsolutions2. Choosing a solution or implementing it: specific DBTprocedures (case management, skills trainingstrategies, exposure strategies, cognitive modificationstrategies, contingency management strategies)3. Troubleshooting the solution: review the patient’s waysin which attempts to solve problem can go wrong

Orienting strategies1. Providing role induction: therapistorients patient to DBT and to her rolein therapy2. Rehearsing new expectations:therapist rehearses with patientexactly what she is to do in trying torespond to the problem

Commitment Strategies1. Selling commitment: evaluating the pros andcons2. Playing the Devil’s Advocate3. “Foot-in-the-door/Door-in-the-face” techniques4. Connecting present commitments to priorcommitments5. Highlighting freedom to choose and absenceof alternatives6. Using principles of shaping7. Generating hope: cheerleading8. Agreeing on homework

Contingency Procedures• Rationale for contingency procedures• The distinction between managingcontingencies and observing limits• The therapeutic relationship ascontingency

Contingency Management Procedures• Reinforcing target-relevant adaptivebehaviors• Extinguishing target-relevant maladaptivebehaviors• Using aversive consequences … with care

Observing – Limits Procedures1. Monitoring limits2. Being honest about limits3. Temporarily extending limits whenneeded4. Being consistently firm5. Combining soothing, validating, andproblem solving with observing limits

Skills Acquisition Procedures1. Instructions in skill to be learned: therapistspecifies necessary behaviors and theirpatterning in concrete terms, breaksinstructions down into easy-to-follow steps,begins with simple tasks, providesexamples and gives handouts2. Modeling skilled behavior: role-play,therapist uses skilled behavior in interactingwith patient, thinks out loud (self-talk), tellsstories illustrating skilled behaviors

Skills Strengthening Procedures1. Behavioral rehearsal: role-play,therapist guides patient in sessionpractice, imaginal (covert) practice andin vivo practice2. Reinforcement of new skills3. Feedback and coaching

Skills Generalization Procedures1. Generalization programming: variety ofskilled responses to each situation;therapeutic relationship2. Between-session consultation: apply skillsin vivo; therapist assist patient in applyingskills to problem situations via phone calls3. Providing session tapes for review: to listento in-between sessions

Skills Generalization Procedures4. In vivo behavioral rehearsal assignments:therapist gives specific tasks to practice withskills training therapists and skills trainingtherapists gives task to practice with individualtherapist (in standard DBT)• Environmental change: therapist helps patientto create an environment that reinforces skilledbehaviors

Exposure-Based Procedures1. Providing nonreinforced exposure tocues that elicit problematic emotions2. Blocking action tendencies associatedwith problem emotions: escape/avoid,hide or withdraw, repair or self-punish,hostile and aggressive responses

Exposure-Based Procedures3. Blocking expressive tendenciesassociated with problem emotions:therapist helps patient express converseemotions to those he/she is feeling(therapist differentiates “masking” fromexpressing a different emotion).4. Enhancing a sense of control overaversive events

Cognitive Modification Procedures1. Contingency clarification procedures:1. Highlight current contingencies2. Communicating future contingencies in therapy2. Cognitive restructuring procedures:1. Teaching cognitive self-observation2. Identifying and confronting maladaptive cognitive contentand style3. Generating alternative, adaptive cognitive content andstyle4. Developing guidelines for when to trust and when tosuspect interpretations

Schema-Focused CognitiveTherapy of Borderline PersonalityDisorderBased on the developments of J.Young and C.F. Newman at theUniversity of Pennsylvania

Borderline Personality Disorder:Diagnostic criteria.DSM-IV (APA, 1994)• Frantic efforts to avoid…abandonment.• Pattern of unstable and intense interpersonalrelationships…(idealization and devaluation)• Identity disturbance…• Impulsivity in at least two areas that arepotentially self-damaging (do not include selfmutilating).• Recurrent suicidal behavior, gestures, orthreats, or self-mutilating behavior.

BPD Diagnostic Criteria (continued)• Affective instability…marked reactivity…• Chronic feelings of emptiness.• Inappropriate, intense anger.• Transient, stress-related paranoid ordissociative symptoms.

Early Maladaptive Schemas(Adapted from J. Young, 1999)• Abandonment.• Mistrust and abuse.• Defectiveness/ “Badness”/ Social exclusion.• Failure / Incompetence.• Vulnerability to harm.

Early Maladaptive Schemas(Continued)• Dependence.• Subjugation / Lack of individuation.• Emotional deprivation.• Unrelenting standards.• Entitlement / Insufficient limits.

Schema Processes• Schema activation (When the patient’s “buttonsget pushed.” When they “make mountains out ofmolehills.”)• Schema maintenance (The “self-fulfillingprophecy.” When patients keep bringing abouttheir own worst nightmares.)• Schema avoidance (“Out of sight, out of mind,out of touch.” When patients structure their livesso as never to be able to test or disprove theirmost destructive beliefs.)

Schema Processes(Continued)• Schema compensation (“The lady doth protesttoo much”. When patients try to solve anextreme problem by going to the oppositeextreme, thus causing a new problem withoutever solving the old problem.)• Schema antagonism and vacillation (Cognitiveand emotional “gridlock.” “Damned if you do,and damned if you don’t.” When patients holdmutually exclusive schemas simultaneously, orin sequence, thus leading to “roller-coastering.”

Key Elements for Case Formulation• Historical / Developmental– Family history of mental disorder, substanceabuse, suicide.– Family structure, landmarks, secrets.– Quality of patient’s relationships to parents orcaregivers.– History of emotional, physical, sexual abuse.– Quality of peer relationships before adulthood.

Case formulation (continued)• Historical / Developmental (cont.)– Role of religion in the patient’s upbringing.– Academic and employment history.– Significant romantic relationships and patternsthereof.– History of patient’s use of alcohol and otherdrugs.– Patient’s medical and legal histories.

Case Formulation (cont.)• Current Life Situation– Typical daily activities.– Patient’s personal strengths.– Patient’s current mood state.– Patient’s current level of suicidality.– Patient’s beliefs about self, others, and future.– Environmental factors that maintaindysfunctional patterns and schemas.

Clinical Strategies and Techniques(Overview)• Establishing, nurturing, and learning fromthe therapeutic relationship.• Crisis-intervention and limit-settingstrategies.• Standard cognitive therapy self-monitoringand self-help skills.• Schema-focused conceptualization andintervention.

The Therapeutic Relationship(Part 1)• Acknowledge that therapy is difficult, requireswork, and is not supposed to be comfortable.• At the same time, strive to create a safe haven(free of abuse, rejection, and condemnation).• Remain calm and cool, even if the patient is not.• Remember important information about thepatients from session to session.• Give much attention for wellness.• Neither avoid nor push uncomfortable issues.

The Therapeutic Relationship(Part 2)• Ask for feedback. Be willing to answer questionswithin reasonable boundaries.• Be careful giving personal compliments. Rather,give patients positive feedback for their work intherapy.• Use your own reactions as cues toconceptualize.• Do not make important clinical decisions as aresult of feeling coerced or threatened. Feel freeto defer a response, and to consult on thematter.

Dealing with Crises and Limit-Setting• Elevated suicide risk is always the top-priorityagenda item for discussion in a session.• Generate “safe” alternatives to self-harmingbehaviors (e.g., the “ice cube” method).• Ask guided discovery questions (i.e. do not rushin with extreme interventions).• Remain calm, non-defensive, and empathic.• Make distinctions between “normative life crises”and “schema activation crises.”

Dealing with Crises and Limit-Setting(continued)• Teach the patients to use problem-solving skillsinstead of feeling hopeless, helpless, and angry.• Teach patients the concept of “damage control.”• Remember that you are not responsible forsolving all of the patients’ problems for them,even if they think you are.• Conceptualize the ways in which the patient’sschemas and behaviors interfere with theprocess of therapy itself, and suggest newapproaches.

Setting Limits (continued)• Set ground rules early in treatment (regardingphone contacts, missed appointments, behaviorin session, etc.)• Discuss the responsibilities of both the therapistand the patient in treatment.• Explain what is and is not proper in a therapeuticrelationship, especially if the patient hasmisconceptions.

Setting Limits (continued)• Be quick to set limits, but not to endtreatment.• Sessions can be ended on the spot if thepatient is impaired and/or if the therapistfeels threatened with harm.• Additional clinicians can be brought in.

Setting Limits (continued)• Therapeutic Phone Contacts– Should be used primarily for clinicalemergencies, not simply for the patients’ fullarray of concerns.– Should not be used routinely in lieu of face-tofacetherapy sessions.

Setting Limits (continued)– Establish “rules of engagement” (e.g.,therapist will terminate call if patient isabusive, or will phone for an ambulanceif the patient has taken self-harmingactions).– Patients can “earn” phone time viahomework (e.g., indicating assignmentsto be completed before next call).

Setting Limits (continued)• Therapist Self-Care– Consult and document, document and consult!– Be a good role-model of self-respect for your BPDpatients. Showing self-respect often involvesasserting yourself with patients.– Do not try to be a “patient pleaser.” Be fair-mindedand competent, but do not feel obliged to do as yourpatient commands.– Form professional support groups with colleagues (donot get trapped in shame and secrecy).

Standard Techniques• Anxiety Reduction– Graded exposures to feared situations.– Breathing modulation.– Relaxation (use caution – some BPD patients feelexcessively vulnerable during an induction).• Problem-Solving– Define the problem non-schematically.– Generate possible solutions without acting on themimpulsively.– Try the best choice, and monitor the results.

Standard Techniques (continued)• Communication and Listening Skills– Patient listens to self on tape.– Teach the turning of accusations into requests.– Learn to reflect before responding to others.– Patients urged to abstain from the use of profanity.• Rational Re-evaluation Skills– Combat all-or-none thinking, tunnel vision, jumping toconclusions, overgeneralizing, and disqualifying thepositive.– Learn to ask positive, literal questions of oneself.

Standard Techniques (continued)• Continua ratings (to counter all-or-nonethinking).• Activity schedules– Increase “mastery” activities.– Learn “self-soothing,” instead of self-harming.– “Create more, consume less.”– Plan activities proactively, and monitor theresults.

Standard Techniques (continued)• Behavioral experiments (to test beliefs, and tobuild new skills in everyday life, where it mattersmost).• Homework– Supports the patient’s non-dependence ontherapist.– Provides valuable practice of self-help skills.

Major Targets for StandardInterventions• Excessive Expectations of Others– Help patients to articulate and modify theirexpectations of themselves, others, andtherapy.– Teach the principles of interpersonalreciprocity.– Examine the patients’ history of feeling deniedtheir “just due” from others.– Examine the patients’ history of being overindulgedby others.

Major Targets for StandardInterventions (cont.)• Empathy Training– Ask the patients about what other people intheir lives may be feeling or thinking.– Give tactful feedback about how you feel inresponse to the patient’s behaviors.– Study the pros and cons of caring about howothers feel, and recognizing such feelings.– Look at the drawbacks of assuming howothers feel, or what others want.

Major Targets for StandardInterventions (cont.)• Self-Correction Skills– Teach self-monitoring skills, and assign suchtasks for homework as soon as possible.– Examine the patient’s past for clues abouthow not to repeat painful mistakes.– Appeal to the patient’s “creativity” to discovernew ways to solve old problems.– Use frustration as a “cue” to try somethingdifferent, not the same thing even more!

Major Targets for StandardInterventions (cont.)• Interpersonal Limits and Boundaries– Be a good role model for your patients.– Emphasize the importance of personal spaceand privacy for the patients and for others.– Examine the patients’ history of having theirpersonal boundaries violated, and what thisteaches them about how to steer clear ofunhealthy attachments.

Major Targets for StandardInterventions (continued).• Extreme Opinions of Self and Others– Encourage patients not to use labels (e.g.,“loser”)– Examine and modify the “saint-demon”dichotomy.– Learn to accept imperfections in self andothers.– In evaluating self and others, look at theevidence, not just an immediate impression.

Modulation of Emotionality• The therapist serves as a role model byacting gracefully and calmly.• Help the patient to speak at a normalpace, with moderate volume, and whilemaking appropriate eye contact.• Teach patients to notice and to documenttheir thoughts and behaviors thataccompany their most extreme feelings.

Modulation of Emotionality (cont.)• Instruct patients to rate the levels of theiremotions on a scale, or a continuum, sothat they do not view their emotions as “allor none.”• Teach patients to breath slowly, steadily,and in the manner of a gentle wave; thiswill help moderate excessive sympatheticnervous system activity.

Modulation of Emotionality (cont.)• Validate the patient’s emotionalexperiences, while still testing theschemas and thoughts that are behindthese emotions.• Teach patients how to resist actingimpulsively on their emotions.• Help the patients to generate and utilizepleasant imagery.• Evoke specific, pleasant memories.

When Patients Avoid Treatment• Dealing with Patients Who Cannot or WillNot Discuss Issues in Session– Express respect for the patient’s boundaries(i.e., do not force the discussion).– Gently explain your clinical rational for tryingto discuss the issue in question.– Carefully ask the patients for their reasons forbeing averse to talking about the topic.

When Patients Avoid Treatment• Dealing with Patients Who Cannot or WillNot Discuss Issues in Session (cont.)– Try to ask non-threatening questions.– Engage the patient in an exploration of thepros and cons of discussing difficult topics intherapy.– Ask for permission to return to the topic at alater time or date, if necessary.

Problems with Homework• Homework assignments may activate theBPD patients’ incompetence and/ordependence schemas, and thus they willfeel overwhelmed and incapable.• Homework assignments may activate theBPD patients’ subjugation schema, andthus they may resent being “controlled” bythe therapist.

Problems with Homework (cont.)• Homework may activate the BPD patients’emotional deprivation schema, in that they mayview self-help exercises as a poor substitute forthe care, concern, and attention of the therapist.• Homework may activate the BPD patients’entitlement schema (“I shouldn’t have to dothis”).• Homework may activate the BPD patients’schema of badness or defectiveness, and theymay expect the therapist to judge or reject them.

Schema-Focused Techniques• Teach patients to identify schemas and theirprocesses (e.g., “My abandonment schema wasjust activated!”). Create and test alternatives.• Utilize role-plays to re-enact, practice, or planimportant interpersonal interactions, includingthose that represent hope.• Imagery reconstruction (for empowerment).• Use sensory experiences that evoke schemas,or that produce feelings against schemas.

Schema-Focused Techniques• Identification of Schemas– Patients are taught that if they experienceextreme emotions, or dissociativesymptoms, they are to hypothesize theschema that has been activated.– Patients are taught to explain theirschema-activation to loved ones who mayotherwise be frightened or angered by theBPD patient’s behavior.– Patients are instructed to apply a numberof self-help skills to reduce the effects ofthe schema activation.

Schema-Focused Techniques• Creating Alternatives to the Schemas (1)– Design behavioral experiments that requirethe patient to act in ways that are inconsistentwith the schema.– Discover and write down experiences fromthe patient’s life that are inconsistent with theschema.– Identify and pursue goals that are inconsistentwith the schema.

Schema-Focused Techniques• Creating Alternatives to the Schemas (2)– Identify situations in which the schema isactivated. Think of new ways to perceive thesituation that are inconsistent with theschema.– Change from “all-or-none” thinking style thatis characteristic of the schema and discussthe degree to which the patient believes orfeels something.

Schema-Focused Techniques• Role-play situations that typically evokeschemas– Helps patients to learn interpersonal skills.– Enables the patient and therapist to “reenact”significant interpersonal interactionsfrom the BPD patient’s life.– Helps the patient to arrive at a betterunderstanding of the reactions of otherpeople.– Brings “hot cognitions” into the therapysession for evaluation and change.

Schema-Focused Techniques• Role-Play Methods (Part 1)– The therapist takes the role of the patient.• Models new responses for the patient tocopy.• Demonstrates comprehension andempathy about the patient.– The patient takes his or her own role.• To act “as if” he or she does not havethe schema.• To practice interpersonal skills with norisk of rejection or negative judgmentfrom the therapist.

Schema-Focused Techniques• Role-Play Methods (Part 2)– The patient reads from a script that thetherapist prepares (“healthy,” confidentdialogue).– The patients write their own script and recitefrom it (information to fight against theschemas).– Therapist gives feedback to the patient.– Therapist addresses patient’s “hot cognitions.”

Schema-Focused Techniques• Use multiple sensory experiences– Imagery (for example, of “safe” places, or of ahappier future).– Tactile experiences (for example, acomfortable blanket, a warm bath).– Pleasant sounds (for example, soothingmusic, “nature sounds”).– Taste and smell (for example, comfortingfoods, fragrances).

Schema-Focused Techniques• Imagery Reconstruction (Part 1)– For the purpose of changing the way that theBPD patient cognitively and emotionallyprocesses the memory of painful memories.– Also for the purpose of empowering the BPDpatient.– This technique does not attempt to “recoverlost memories.”

Schema-Focused Techniques• Imagery Reconstruction (Part 2)– Identify the schema (for example, mistrust,unlovability, abandonment, etc.)– Construct a hypothesis about the etiology.• Review importantdevelopmental/historical events.• Identify painful and traumatic memories.• Establish their relationship to currentdifficulties.• Establish their relationship to theschema.

Schema-Focused Techniques• Imagery Reconstruction (Part 3)– Choose a specific, traumatic memory.– The patient describes the memory in detail.– The patient explores his or her thoughts andfeelings in the memory.– Therapist helps the patient to think of newways to view the memory, so as to reduceshame, blame, stigma, and schemaactivation.

Schema-Focused Techniques• Imagery Reconstruction (Part 4)– Relaxation induction.• Pleasant, “safe” images.• Count backward from 10 to 1, slowly.• Slow, wavelike breathing.– Guide the patient to remember the traumaticmemory, but in a very relaxed state, with eyesclosed.– Prepare to “experience” the memory again.

Schema-Focused Techniques• Imagery Reconstruction (Part 5)– Goals:• Conceptualize the traumatic memory with lessshame, blame, and stigma.• Modify the schema associated with the trauma.– Methods:• Patients describes the images and events of thememory with great detail, assisted by thetherapist’s questions and encouragement.

Schema-Focused Techniques• Imagery Reconstruction (Part 6)– In the image/memory:• What is the child (patient) thinking and feeling?• How does the child make sense of what ishappening?• What are the negative consequences for thepatient, as a child (in the memory) and as an adultin the present?• What does the child believe about others and self?

Schema-Focused Techniques• Imagery Reconstruction (Part 7)– In the image/memory:• What effect does the traumatic event have on thepatient’s ability to feel loved, safe, competent, andhealthy?• What are the schemas that correspond with thisimage/memory?• What are the rational responses that can be usedagainst these schemas?

Schema-Focused Techniques• Imagery Reconstruction (Part 8)– In the new, guided, image.• Introduce a “hero” who will help the child.• The “hero” can be anyone the child trusts andloves.• The “hero” can be…– The patient’s healthy self.– The abuser’s healthy counterpart.– A deceased loved one.– Anyone who represents care and nurturing.

Schema-Focused Techniques• Imagery Reconstruction (Part 9)– As a result of the new, guided imagery:• What does the patient now believe about thetraumatic memory?• What rational responses can the patient now giveagainst the schema?• What has the patient learned about others and theself?• How much does the patient believe the newrational responses?