Cognitive Therapy

Layden, Newman, Freeman, and Morse (1993) presented the first extended guide to conducting CT for BPD. Treatment is multifaceted, but focuses on helping patients to identify early maladaptive schemas, core unconditional beliefs about the self and the world, and the behavior patterns seen as driven by those schemas, and to work on changing the schemas. Layden et al. suggest that of 15 early maladaptive schemas (EMSs) identified by Young (1990), those most commonly present in BPD are unlovability, incompetence, mistrust, abandonment, emotional deprivation, lack of individuation, and dependency, and that these schemas often conflict with one another, such as dependency and mistrust. In our own experience, many patients with BPD also score high on most of Young's other EMSs, such as fear of losing control, vulnerability to harm, unrelenting standards, guilt/punishment, and social undesirability. They propose that it is important for the clinician to also know the Ericksonian stage of development when the schema was acquired, which largely determines which schemas are most affected; through which perceptual channels; and at what Piagetian level of cognitive processing, which determines the types of cognitive distortions manifested.

In addition to use of all standard CT strategies in treating BPD, special emphasis is given to establishing and maintaining a good therapeutic relationship, crisis intervention strategies, and schema-focused interventions. The most problematic schemas are identified by noting the presenting problem, the types of crises that occur, developmental history, and common automatic thoughts. Schema-focused interventions include completion of worksheets on evidence that contradicts or reframes old core beliefs, use of imagery of trauma from the patient's childhood, and introduction of the adult self to modify the outcome, in addition to other uses of imagery and sensations, and behavioral tests. Layden et al. (1993), Young (1990), and other CT authors (e.g., Beck et al., 1990) discuss stages of treatment; others who treat BPD, from behavioral to psychodynamic experts, appear to agree on similar stage notions. Arntz (1994) suggests that treatment for the patient with BPD involves the following five stages:

1. Construction of a working relationship, which requires therapist patience; avoidance of intimacy, confrontation, or lack of clarity; allowing the patient some control; observing one's own limits; and admitting errors.

2. Symptom management, through functional analysis and patient practice of alternative behaviors.

3. Correction of thinking errors, such as dichotomous thinking, personalizing, and catastrophizing.

4. Trauma processing and schema change through graduated exposure, cognitive restructuring, and psychodrama.

5. Termination, which needs to be particularly well planned and gradual, and to involve booster sessions.

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