Cognitive therapy focuses on transforming three types of cognitions—automatic thoughts, underlying assumptions, and maladaptive schema—and on replacing unsuccessful compensatory strategies with effective life skills. For individuals with borderline personality disorder, the schema level of cognition is the most significant, because these patients usually have deeply held and encompassing trauma-related beliefs that they are defective, unlovable, dependent, incompetent, and entitled and that the world is hostile, untrustworthy, and emotionally depriving. These schema are represented by words and images, may be stored in sensory as well as kinesthetic modes, and evoke extremely painful affective responses.
Such schema can produce significant challenges to the treatment process. For example, mistrust schema make it particularly difficult for patients to authentically engage and bond with the therapist. (Because of this, stages of therapy unfold more slowly for these patients, and the 19th rather than an earlier session of therapy is portrayed in this videotape.) Demanding behavior can also threaten the therapeutic alliance. Empathic acknowledgment of these struggles as they occur in the session lays the groundwork for modifying each schema later in treatment.
The compensatory strategies overlearned in childhood to deal with trauma and overwhelming affect are typically rigidly used in current situations in ineffective and self-defeating ways. Examples include clinging, distancing, manipulation, hostility, aggression, avoidance, and demanding behavior. Substance abuse is quite often a problem. More adaptive coping skills, such as self-soothing and boundary setting, must be learned before the patient can relinquish this limited repertoire of compensatory strategies. Physically self-harming activities, however, must be limited, and alternative tension-reducing activities should be instated from the very beginning of treatment. Later in therapy, more sophisticated communication and problem-solving skills are taught, and rehearsal and modeling help patients incorporate these new skills. This skill training is presented as a way of expanding the patient's options so that incompetence schemas are not inadvertently activated and reinforced.
In the middle stage of therapy, a schema is actually restructured by a process of understanding the schema's genesis, beginning with the less traumatic aspects of childhood, and challenging the schema's appropriateness in current situations. Patients learn first to identify the triggers that activate particular schema and the person from their past whose voice is echoed in the schema. The patient then learns to examine the veracity of the schema in light of more recent experiences (i.e., with new coping skills patients begin to have more self-esteem and more harmonious experiences with others). The therapist challenges the patient to discriminate "the then from the now" and to assign more adaptive meaning to today's experiences. Imagery, art, and other nonverbal modes of working are also used to modify schemas. As more severely traumatic memories emerge in treatment, the patient is taught to pace the work and to use the self-soothing skills learned earlier.
As cognitions are transformed and skills are learned, patients experience a diminution of distressing affect. They come to know themselves, to be themselves, and to love themselves, making the somewhat arduous process of therapy rewarding for patients and therapists alike.
Dr. Layden identifies her approach as "cognitive therapy." What does this imply to you? More specifically, what do you expect of her? Will Dr. Layden be active or passive? Will the session be structured or unstructured? Directive or nondirective? Will it focus on the past or on the present? Will the session focus on behaviors, on thoughts, or on feelings? What do you expect to be the relative balance between attention to technique versus the interpersonal interaction?
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