I Hate You—Don't Leave Me (25 page)

In the initial stages of treatment DBT focuses on a hierarchical system of targets, confronting first the most serious, and then later the easiest, behaviors to change. The highest priority addressed immediately is the threat of suicide and self-injuring behaviors. The second-highest target is to eliminate behaviors that interfere with therapy, such as missed appointments or not completing homework assignments. The third priority is to address behaviors that interfere with a healthy quality of life, such as disruptive compulsions, promiscuity, or criminal conduct; among these, easier changes are targeted first. Fourth, the focus is on increasing behavioral skills.

The structured program consists of four main components:

Another manual-based variation of CBT is STEPPS, developed at the University of Iowa. Like DBT, STEPPS focuses on the borderline's inability to modulate emotions and impulses. The unique modifications of STEPPS were partly built on a wish to develop a less costly program. STEPPS is a group therapy paradigm, without individual sessions. It is also designed to be shorter—consisting of twenty two-hour weekly groups (compared to the typical one-year commitment expected in DBT). This program also emphasizes the importance of involving the borderline's social systems in treatment. Educational training sessions “can include family members, significant others, health care professionals, or anyone they regularly interact with, and with whom they are willing to share information about their disorder.”
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STEPPS embodies three primary components:

A second phase of STEPPS is STAIRWAYS (Setting goals; Trusting; Anger management; Impulsivity control; Relationship behavior; Writing a script; Assertiveness training; Your journey; Schemas revisited). This is a twice-monthly one-year extension of skills-training “seminars,” which reinforce the STEPPS model. Unlike DBT, which is designed to be self-contained and discourages other therapy contributions, STEPPS is designed to complement other therapy involvement.

SFT combines elements of cognitive, Gestalt, and psychodynamic theories. Developed by Jeffrey Young, PhD, a student of Aaron Beck's, SFT conceptualizes maladaptive behavior arising from
schemas.
In this model, a
schema
is defined as a worldview developed over time in a biologically vulnerable child who encounters instability, overindulgence, neglect, or abuse. Schemas are the child's attempts to cope with these failures in parenting. Such coping mechanisms become maladaptive in adulthood. The concept of
schemas
derives from psychodynamic theories. SFT attempts to challenge these distorted responses and teach new ways of coping through a process denoted as
re-parenting.
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Multiple schemas can be grouped into five primary
schema modes
, with which borderline patients identify and which correlate with borderline symptoms:

Specific treatment strategies are appropriate for each mode. For example, the therapist emphasizes nurturing and caring for the Abandoned and Abused Child mode. Expressing emotions is encouraged for the Detached Protector mode. “Re-parenting” attempts to supply unmet childhood needs. Therapists are more open than in traditional therapies, often sharing gifts, phone numbers, and other personal information, projecting themselves as “real,” “honest,” and “caring.” Conveying warmth, praise, and empathy are important therapist features. Patients are encouraged to read about schema and BPD. Gestalt techniques, such as role-playing, acting out dialogue between modes, and visualization techniques (visualizing and role-playing stressful scenarios) are employed. Assertiveness training and other cognitive-behavioral methods are utilized. A possible danger in SFT is the boundary confrontation in “re-parenting.” Therapists must be extremely vigilant regarding the risk of transference and countertransference regression (see chapter 7).

Psychodynamic approaches typically employ discussion of the past and present, with the goal of discovering patterns that may forge a more productive future. This form of therapy is usually more intensive—with sessions conducted several times a week—than the cognitive-behavioral approach. The therapist should implement a structured, consistent format with clear goals, yet be flexible enough to adapt to changing needs.

Mentalization
, a term elaborated by Peter Fonagy, PhD, describes how people understand themselves, others, and their environment. Using mentalization, an individual understands why she and others interact the way they do, which in turn leads to the ability to empathize with another's feelings.
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The term overlaps with the concept of
psychological mindedness
(understanding the connection between feelings and behaviors) and
mindfulness
(a goal in DBT; see above). Fonagy theorizes that when the normal development of mentalization beginning in early childhood is disrupted, adult pathology develops, particularly BPD. This conceptualization is based on psychodynamic theories of a healthy attachment to a parenting figure (see chapter 3). When the child is unable to bond appropriately with a parent, he has difficulty understanding the parent's or his own feelings. He has no healthy context on which to base emotions or behaviors. Object constancy cannot be sustained. The child develops abandonment fears or detaches from others. This developmental failure may arise either from the child's temperament (biological or genetic limitations) or from the parent's pathology, which may consist of physical or emotional abuse or abandonment, or inappropriate smothering of independence, or from both.

MBT is based on the supposition that beliefs, motives, emotions, desires, reasons, and needs must first be understood in order to function optimally with others. Confirming data on the effectiveness of this method has been documented by Bateman and Fonagy, primarily within a daily partial hospital setting in England.
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In this design, patients attend the hospital during the day, five days a week for eighteen months. Treatment includes psychoanalytically oriented group therapy three times a week, individual psychotherapy, expressive therapy consisting of art, music, and psychodrama programs, and medications as needed. Daily staff meetings are held and consultations are available. Therapists, employing a manual-based system, focus on the patient's current state of mind, identify distortions in perception, and collaboratively attempt to generate alternative perspectives about himself and others. While much of the behavioral techniques recalls DBT, some of the psychodynamic structure of MBT overlaps with Transference-Focused Psychotherapy (TFP).

TFP is a manual-based program that Otto Kernberg, MD, and colleagues at Cornell have developed from more traditional psychoanalytic roots.
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The therapist focuses initially on developing a contract of understanding of the roles and limitations in the therapy. Like DBT, early concerns revolve around suicide danger, interruption of therapy, dishonesty, and so on. Like other treatment approaches, TFP acknowledges the role of biological and genetic vulnerability colliding with early psychological frustrations. A primary defense mechanism seen in borderline patients is
identity diffusion
, which refers to a distorted and unstable sense of self and, consequently, others.
Identity diffusion
suggests a perception of oneself and others as if they were fuzzy, ghostlike distortions in a fun-house mirror, barely perceptible and insubstantial to the touch. Another feature of BPD is persistent
splitting
, dividing perceptions into extreme and opposite dyads of black or white, right or wrong, resulting in the belief that oneself, another, or a situation is all-good or all-bad. Accepting that a good person could disappoint is difficult to comprehend; thus, the formerly good person mutates into an all-bad person. (The professional reader will note that distortions in MBT's mentalization would include the concepts of
identity diffusion
and
splitting
; the difficulty with dyadic extremes recalls the dialectical paradoxes theorized in DBT.)

TFP theorizes that identity diffusion and splitting are early, primary elements in normal development. However, in BPD, normal, developing integration of opposite feelings and perceptions is disrupted by frustrating caregiving. The borderline is stuck at an immature level of functioning. Feelings of emptiness, severe emotional swings, anger, and chaotic relationships result from this black-and-white thinking. Therapy consists of twice-weekly individual sessions, in which the relationship with the therapist is examined. This here-and-now transference experience (see chapter 7) allows the patient to experience in the moment the splitting that is so prevalent in his life experience. The therapist's office becomes a kind of laboratory, in which the patient can examine his feelings in a safe, protected environment, and then extend his understanding to the outside world. The combination of intellectual understanding and the emotional experience in working with the therapist can lead to the healthy integration of identity and perceptions of others.

A vignette may help demonstrate how therapists utilizing these various approaches might handle the same situation in therapy:

A DBT therapist might focus on Judy's anger and physical outburst. He might empathize with her frustration, accept her impulsive gesture, and then work with her to vent her frustration without becoming violent. He might also discuss ways to deal with her frustration with her father.

The SFT therapist might first try to correct Judy's misperception of him and reassure her that he is not angry at her and is totally on her side.

In MBT, the doctor may try to get Judy to relate what she is feeling and thinking at this moment. He may also attempt to direct her to thinking (mentalizing) about what she supposed her father was reacting to during their conversation.

The TFP therapist may explore how Judy is comparing him to her father. He might focus on her severely changing feelings about him at that moment in therapy.

A number of other therapy approaches, less studied, have also been described. Robert Gregory and his group at the State University of New York in Syracuse have developed a manual-based protocol, Dynamic Deconstructive Psychotherapy (DDP), specifically directed toward borderline patients who are more challenging or have complicating disorders such as substance abuse.
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Weekly individual, psychodynamically oriented sessions are directed toward activating impaired cognitive perceptions and helping the patient develop a more coherent, consistent sense of self and others.

Alliance-Based Therapy (ABT) developed at Austen Riggs Center in Stockbridge, Massachusetts, is a psychodynamic approach that focuses specifically on suicidal and self-destructive behaviors.
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Much like TFP, the emphasis is on the therapeutic relationship and how it impacts the borderline's self-harming actions.

Intensive Short-Term Dynamic Psychotherapy (ISTDP), designed for the treatment of patients with borderline and other personality disorders, has been elaborated by a Canadian group.
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Weekly individual sessions concentrate on unconscious emotions that are responsible for defenses and the connections between these feelings and past traumas. Treatment is generally expected to continue for a period of around six months.