- Email: [email protected]
A cognitive-behavioral analysis of a patient with borderline personality disorder
Response: CBT for Bordeline Personality Disorder L. S. (1996). Structured ClinicalInterviewfor DSM-IVAxis II PersonaL ity Disorders. Washington,DC: American PsychiatricPress. Herman,J. L. (1992). Trauma and recovery.NewYork: Basic Books. Hewlitt, P. L., & Norton, G. R. (1993). The Beck AnxietyInventory:A psychometric analysis.PsychologicalAssessment, 5, 408-412. Miller,W., & Rollnick,S. (1991). Motivationalinterviewing:Preparingpeople to changeaddictive behavior.New York: Guilford Press. Vreven, D. L., Gudanowski,D. M., King, L. A., & King, D. W. (1995). The civilianversion of the MississippiPTSDScale:A psychometric evaluation.Journal of Traumatic Stress, 8, 91-109. Address correspondence to Kenneth A. Chase, Ph.D., Harvard Families mad Addiction Program (116B1), Harvard Medical School Department of Psychiatryat the VAMC,940 Belmont Street (Bldg. 5, C138), Brockton, MA 02301; e-mall:[email protected] Received: August 25, 1999 Accepted: SeptenUSer30, 1999
Response Paper A Cognitive-Behavioral Analysis of a Patient With Borderline Personality Disorder G e r a l d C. D a v i s o n University o f Southern California Comments are made on case material from a patient likely to be diagnosable as borderline personality disorder. The author offers an analysis of the case as one reflecting emotional dysregulation and the complex interpersonal consequences of lack of control over turbulent storms of negative emotionality. A tentative treatment plan is outlined that involves a dialectical cognitive behavioral approach aimed at reducing emotional sensitivity and enabling the patient to cope better with her hitherto uncontrollable and frightening emotional lability and self-destructive behavior. Critical observations are offered on the risks of inferring childhood sexual and physical abuse fiom reports by clients who were treated by therapists whose theoretical or political orientation lead them to assume the presence of abuse in the past histories of people like those with borderline personality disorder.
HE CASE OF KATRINA raises a n u m b e r of interesting questions. My reactions to the material are organized a r o u n d p r e s e n t i n g problems a n d diagnostic impressions, the assessment plan I would follow, my concep-
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Cognitive and Behavioral Practice 7, 497-500, 2000 1077-7229/00/497-50051.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
realization of the case, my tentative t r e a t m e n t plan, a n d finally some concerns regarding the issue of sexual a n d / or physical abuse in the patient's past.
Patient's Presenting Problem and Diagnostic Impressions In D S M t e r m s , I would probably diagnose this patient as Borderline Personality Disorder (BPD). More specifically, a n d consistent with Marsha Linehan's formulation of BPD (Linehan, 1993), I would see her as someone saddled with emotional dysregulation, a problem of extreme autonomic lability a n d an impaired ability to modulate her emotional turmoil. I n a sense, Katrina's behaviors can be seen as maladaptive solutions to dealing with overwhelming negative affect. Associated problems that I see caused by this emotional dysregulation include h e r chaotic interpersonal relationships, suicidal a n d parasuicidal behavior, periods of depression, a n d general impulsiveness. The case report presents the hypothesis that "Katrina's suicide attempts reflect her inability to find alternative strategies toward regulating her intense emotions." I would agree. I am less certain about the hypothesis that "Katrina acts out her overwhelming rage a n d depression by presenting with extreme behaviors in an attempt to behaviorally 'match' her feelings." Why would she do this? More likely to me is that her depression a n d acting out are driven by maladaptive cognitions reinforced by her social e n v i r o n m e n t ; at least I would assess for these possibilities. Also a p p a r e n t in the case material is "splitting," a blackand-white way of viewing the world that is chal-acteristic of patients with BPD. Present as well are what are described as "intrusive memories of abuse" from both h e r father a n d her mother, about which I have more to say below.
Case Formulation L i n e h a n a n d others hypothesize that a series of n o n validating experiences in c h i l d h o o d a n d adolescence can c o n t r i b u t e to the d e v e l o p m e n t of BPD, most likely in an individual with a biological diathesis of some kind. I believe we see some e l e m e n t of n o n v a l i d a t i o n in the case material. For example, we are told that Katrina a n d her b r o t h e r were very u n h a p p y as children, b u t that these feelings were concealed by their parents by dressing t h e m in n e a t a n d pretty clothes a n d teaching them to be pleasant a n d u p b e a t in front of others "no matter what." But whether such experiences occurred in Katrina's past is less i m p o r t a n t than h e r c u r r e n t low self-esteem a n d sensitivity to rejection a n d disapproval. In addition to her extreme emotional lability, Katrina manifests a tendency to see the world, including herself, in dichotomous terms ("splitting," as just mentioned), Thus, a therapist either walks on the water or deserves to be
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Davison drowned. A spouse is either worthy o f adoration or of the most severe condemnation. Life is perfect or life is hopeless. Katrina behaves in ways that alienate, even frighten, those close to her. H e r standards for others are as unrealistically high as h e r standards for herself, a n d this contributes to a sense o f hopelessness a n d helplessness and, consistent with Seligman (1974) a n d Beck (1967), a generally depressed, periodically suicidal frame of mind.
Assessment
Plan
My assessment would n o t likely include the tests described in the case material, most particularly the projectives. W h a t is r e p o r t e d from t h e m seems to m e no differe n t from what was already known a b o u t the patient, a n d represents, to my mind, time a n d expense n o t well spent. I find it interesting a n d a tad disconcerting that the case material contrasts h e r s e e m i n g to be motivated a n d cooperative d u r i n g the four intake sessions with h e r reluctance to c o m p l e t e the various assessment measures. Perhaps Katrina has the kind of skepticism a b o u t some o f the tests given to h e r that I do, so h e r diffculties c o m p l e t i n g t h e m may n o t have p a t h o g n o m o n i c significance (unless it be j u d g e d that I a m d e f e n d i n g on b e h a l f o f the patient!). Rather than rely on psychological tests of d u b i o u s validity a n d utility, I would p r o b a b l y use clinical interviews a n d p e r h a p s some situation-specific questionnaires like the Dysfunctional Attitudes Scale (Weissman & Beck, 1978) o r the F e a r o f Negative Evaluation Scale (Watson & Friend, 1969). In sessions with b o t h the p a t i e n t a n d h e r h u s b a n d , I would c o n d u c t a functional analysis o f the clinical complexities o f h e r case; that is, I would conceptualize h e r p r o b l e m a c c o r d i n g to the familiar cognitivebehavioral SORC m o d e l (Kanfer & Saslow, 1969), to wit: S:
W h a t are the situational d e t e r m i n a n t s o f h e r maladaptive cognitions, emotions, a n d behaviors? O: W h a t internal factors, from cognitions to biological variables, have to be i n c l u d e d for a useful u n d e r s t a n d i n g of the patient? R: W h a t overt responses o r behaviors does the p a t i e n t e n g a g e in? C: W h a t are the consequences o r payoff for h e r behaving o r t h i n k i n g o r feeling in a particular way? T h e h o p e is that a careful functional analysis (cognitive behavioral assessment) o f Katrina would yield inform a t i o n that would allow a construction o f h e r psychological distress that would in turn imply a t r e a t m e n t p l a n possessing some m e a s u r e o f empirical support.
Initial T r e a t m e n t Plan My overall treatment plan would probably be modeled after Linehan's dialectical behavior therapy (DBT; Line-
han, 1993). I would first o f all establish a relationship m a r k e d by acceptance o f the p a t i e n t that is a t h o r o u g h going validation o f h e r fears, concerns, a n d destructive impulses. I would assume that she is d o i n g the best that she can at any given m o m e n t . This could take a n u m b e r of sessions a n d would be a leitmotif t h r o u g h o u t treatment. T h e challenge, at the same time, is to p e r s u a d e the patient to refrain from self-harming behaviors. Necessary also is teaching the p a t i e n t b e t t e r control over h e r emotions, p e r h a p s by training in d e e p muscle relaxation. This dialectical feature of DBT has always b e e n for me the most d i f f i c u l t - - b a l a n c i n g the validation that seems to be particularly necessary for a b o r d e r l i n e p a t i e n t against the n e e d to r e d u c e the f r e q u e n c y / i n t e n s i t y of destructive behaviors a n d increase the f r e q u e n c y o f behaviors that will improve the clinical situation. Given the exquisite sensitivity that Katrina is likely to exhibit to any signs from the therapist that she is n o t behaving as well as she could, it seems of the utmost i m p o r t a n c e to work towards a synthesis o f acceptance a n d change. In contrast to what a Rogerian would hold, I would n o t assume that a c c e p t a n c e without specific change efforts would improve the clinical picture in Katrina or, for that matter, in most patients, regardless o f their clinical diagnosis. L i n e h a n has asserted m a n y times that DBT is essentially cognitive behavior therapy within a dialectical context. I agree with this conceptualization. T h e core c h a n g e aspects o f DBT are social skills training a n d o t h e r cognitive behavioral procedures. T h e r e is m u c h to work on with Katrina. She seems to use alcohol in an effort to control h e r stress. BPDs are said to abuse drugs often. She also is said to have h a d periods o f a n o r e x i a a n d bulimia. T h e latter has b e e n linked to the k i n d o f d i c h o t o m o u s thinking that is a core feature o f BPD, in this case s o m e t h i n g like "It is absolutely essential that my physical a p p e a r a n c e m e a s u r e u p to the ideals I see a r o u n d m e in this society, a n d so I must be very careful a b o u t weight gain a n d t h e r e f o r e have to get rid o f any f o o d I eat" (Fairburn, 1985). H e r taking two psychoactive drugs would require my working with a physician, hopefully a psychiatrist knowle d g e a b l e a b o u t the risks a n d the benefits of medications. T h e side-effects o f the SSRI Effexor, for example, include increases of 10 to 15 mm. in b o t h systolic a n d diastolic b l o o d pressure, (hypo)mania, seizures, headaches, dizziness, insomnia, anxiety, a n d anorexia. O n e has to consider w h e t h e r this p a t i e n t can afford these possibe burdens o n top o f what she is already trying to c o p e with. I n d e e d , one wonders how m u c h o f the symptom picture is a result o f the drugs she is on. T h e "stated beliefs r e g a r d i n g self, others, a n d the world" that are i n c l u d e d in the case material certainly describe a p e r s o n with a very low o p i n i o n o f herself a n d with little h o p e that things will ever get better. Reflected
Response: CBT for Bordeline Personality Disorder also is the d i c h o t o m o u s t h i n k i n g that is p a r t o f the "dialectical failure" that L i n e h a n describes for patients with BPD. A general cognitive goal is to teach the p a t i e n t a b o u t dialectics as a way to move h e r away from blackwhite thinking. O f course, A a r o n Beck has a central place for this k i n d o f cognitive distortion in his widely known a n d practiced cognitive therapy (Beck, 1976). I would see Beck's a p p r o a c h as applicable with this patient, b u t I would b l e n d it with A l b e r t Ellis's (1962) focus o n unrealistic b e l i e f s - - i m p e r a t i v e thinking o r d e m a n d s for perfection a n d approval from everyone, a n d d e m a n d s that the world be as the p a t i e n t wants it to be. I would also take a p r o b l e m - s o M n g a p p r o a c h with Katrina, focusing especially on e n c o u r a g i n g h e r to construe h e r seemingly impossible p r e d i c a m e n t in terms o f difficult p r o b l e m a t i c situations that are amenable to a solution. This general p r o b l e m orientation, c o n s i d e r e d b u t the first stage of social problem-solving therapy by D'Zurilla a n d Goldfried (1971), may itself be helpful to a person like Katrina, who is easily o v e r w h e l m e d by perceived catastrophes. I have for some time related this p r o b l e m orie n t a t i o n to R o b e r t Pirsig's classic Zen and the Art of Motorcycle Maintenance (1974), in which he uses the m e t a p h o r o f fixing a n d m a i n t a i n i n g his motorcycle (a c o m p l e x p r o b l e m ) to convey the i d e a that o n e is well advised to a d o p t a certain attitude toward life's inevitable challenges, a stance that expects life to serve u p p r o b l e m s - - t h a t we n e e d n o t be paralyzed by them; rather, that we can view t h e m as p r o b l e m s a m e n a b l e to solution. Would I design t h e r a p y as c o n j o i n t o r individual? I d o n ' t believe the research literature is a sufficient guide. But if the couples t h e r a p y she has b e e n in for several m o n t h s has b e e n at all u s e f u l - - a n d in the case of this k i n d o f patient, "useful" can m e a n little m o r e than h e r n o t killing herself or otherwise acting in self-destructive a n d socially aversive w a y s - - t h e n I would be inclined to k e e p the h u s b a n d involved in h e r treatment. In fact, I would think that it would be necessary to teach h i m how to deal with his wife's thin-skinned n a t u r e a n d to provide the k i n d o f s u p p o r t a n d a c c e p t a n c e that the therapist tries to provide in those few hours each week that he o r she is in direct contact with an outpatient. T h e fact that Katrina has c o m p l a i n e d that h e r h u s b a n d has r a p e d a n d physically a b u s e d h e r also supports the n o t i o n that h e should be involved in the therapy.
A C o m m e n t o n t h e Patient's History of Sexual/Physical Abuse T h e issue o f the patient's recollections o f sexual a n d physical abuse by h e r father must b e e x a m i n e d . F r o m the case material I see the very real possibility that the patients's m e m o r i e s are n o t veridical, to wit: " . . . it was only in r e c e n t years that Katrina b e g a n to infer that she must
have been [emphasis a d d e d ] sexually a b u s e d by [her father] because o f 'impulsive a n d d a n g e r o u s behaviors' she e n g a g e d in." T h e r e p o r t goes on to say that h e r various clinical r e c o r d s contain inconsistencies in the time a n d n a t u r e of the alleged abuse incidents. O n e is struck by the s t a t e m e n t that h e r father's abuse o f h e r c o n t i n u e d until a m o n t h into h e r marriage, which means that he has allegedly b e e n abusing h e r for p e r h a p s 20 years, f r o m c h i l d h o o d until a d u l t h o o d , i n c l u d i n g d u r i n g a time when she was living with a n o t h e r adult. While this p a t t e r n a n d extensiveness o f abuse are n o t impossible, I believe they are very rare. Whose i n f e r e n c e is it that she was a b u s e d as a child? Is it possible that o n e o r m o r e o f h e r previous therapists l e d h e r to believe that she h a d b e e n abused, based on t h e i r own theoretical or political beliefs in c h i l d h o o d abuse as a key etiological factor in a range o f a d u l t m e n t a l disorders, especially BPD? Did a previous therapist assume that s o m e o n e with a p a t t e r n characteristic o f BPD must have b e e n sexually a b u s e d as a child? This is n o t a comfortable question to pose, b u t I believe it is i m p o r t a n t to do so, especially when the alleged o f f e n d e r is still alive, as is the case with Katrina. We have all r e a d a b o u t the lawsuits, the c o u r t trials, a n d the b r o k e n lives occasioned by the alleged uncovering o f r e p r e s s e d m e m o r i e s o f child abuse (Lazo, 1995). T h e p r o b l e m , o f course, is m a k i n g an accurate appraisal o f a given situation: Did o r d i d n o t abuse occur in Katrina's c h i l d h o o d ? W h e n inferences are m a d e on the basis o f theory and, perhaps, also personal, politically driven biases, we, as clinical scientists a n d practitioners, have reason to worry. T h e way this case is written up, I a m worried. Take n o t e o f the observation that the patient's father h a d recently b e c o m e a "distinguished c o m m u n i t y leader." Does this m a k e his alleged status as a child molester o f his own d a u g h t e r m o r e o r less likely? Are we to assume, ~t la psychoanalytic theory, that the father has tried to c o m p e n s a t e for o r expiate his guilt a b o u t having m o l e s t e d his d a u g h t e r by throwing himself into selfless c o m m u n i t y activities? This is a very slippery slope. T h a t Katrina's psychological state w o r s e n e d when she b e g a n "intensive o u t p a t i e n t therapy that focused o n exp l o r i n g issues related to abuse" does n o t necessarily m e a n that these m e m o r i e s are veridical. I should t h i n k that anyonewho comes to believe that h e r father sexually m o l e s t e d a n d b e a t h e r a n d who is e n c o u r a g e d by h e r therapist to talk a b o u t these (putative) past events would b e c o m e psychologically u n h i n g e d . Note, I am not saying that Katrina was definitely n o t sexually or physically abused as a child. I am suggesting only that the presence o f this finding in h e r clinical records b e dealt with cautiously a n d with scientific skepticism. F u r t h e r m o r e , we know that a characteristic o f posttraumatic stress d i s o r d e r is intrusive a n d f r e q u e n t m e m o -
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Kohlenberg & Tsai ries o f t h e p a s t t r a u m a t i z i n g e v e n t s ( A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , 1994). So s o m e t i m e s p e o p l e cannot forget t h e i r t r a u m a s . C o u p l e d w i t h w h a t we k n o w a b o u t t h e constructive n a t u r e o f h u m a n m e m o r y - - we d o n o t r e c o r d o u r m e m o r i e s t h e way a c a m e r a takes a p i c t u r e ( B r a n s f o r d & J o h n s o n , 1973) - - t h e r e is r e a s o n to b e wary o f acc o r d i n g validity to all r e p o r t s b y p a t i e n t s o f h a v i n g b e e n s e x u a l l y a b u s e d . Social scientists as well as t h e legal syst e m s h a r e a h e a v y r e s p o n s i b i l i t y in d e c i d i n g w h e t h e r a g i v e n r e c o v e r e d m e m o r y o f a b u s e is a r e f l e c t i o n o f a n act u a l ( a n d c r i m i n a l ) e v e n t . E r r i n g i n e i t h e r d i r e c t i o n creates a n i n j u s t i c e f o r e i t h e r t h e a c c u s e d o r t h e accuser.
References American Psychiatric Association. (1994). Diagnosticand statistical manual of mental disorders (4th ed.). Washington, DC: Author. Bransford, J. D., & Johnson, M. K. (1973). Considerations of some problems of comprehension. In W. G. Chase (Ed.), Visual information processing. NewYork: Academic Press. Beck, A. T. (1967). Depression:Clinical, experimentaland theoreticalaspects. New York: Harper & Row. Beck, A. T. (1976). Cognitive therapyand the emotionaldisorders.New York: International Universities Press. D'Zurilla, T.J., & Goldfried, M. R. (1971). Problem-solving and behavior modification. Journal of Abnormal Psychology, 78, 107-126. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Fairburn, C. G. (1985). Cognitive-behavioral treatment for bulimia. In D. M. Garner & E E. Garfinkel (Eds.), Handbook ofpsychotherapyfor anorexia nervosa and bulimia. New York: Guilford Press. Kanfer, E H., & Saslow, G. (1969). Behavioral diagnosis. In C. M. Franks (Ed.), Behavior therapy: Appraisal and status. New York: McGraw-Hill. Lazo,J. (1995). True or false: Expert testimony on repressed memory. Loyola of Los Angeles Law Review, 28, 1345-1413. Linehan, M. M. (1993). Cognitivebehavioraltreatmentof borderlinepersonality disorder: The dialectics of effective treatment. New York: Guilford Press. Pirsig, R. M. (1974). Zen and the art of motorcyclemazntenance:An inquiry into values. New York: Morrow. Seligman, M. E. R (1974). Depression and learned helplessness. In R.J. Friedman & M. M. Katz (Eds.), The psvchology of depression: Contemporary theory and research.Washington, DC: Winston-Wiley. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and ClinicalPsychology,33, 448-457. Weissman, A. N., & Beck, A. T. (1978). Developmentand validation of the Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the annual meeting of the American Educational Research Association, Toronto. Address correspondence to Gerald C. Davison, Ph.D., Department of Psychology, University of Southern California, Los Angeles, CA 900891061; e-mail: [email protected]
Received: August 25, 1999 Accepted: September30, 1999
Response Paper Radical Behavioral Help for Katrina RobertJ. Kohlenberg, University o f W a s h i n g t o n M a v i s T s a i , I n d e p e n d e n t Practice, Seattle, W a s h i n g t o n
Our treatment plan for Katrina is guided by the principles of functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991), an approach derived from radical behaviorism. The fundamental assumption is that we and our clients act the way we do because of the contingencies of reinforcement we have experienced in past relationships. It then follows that clinical improvements, which are acts of the client, also involve contingencies of reinforcement that occur in the relationship between the client and therapist. Thus, our treatment of Katrina emphasizes the use of the client-therapist interaction as an in-vivo learning opportunity. It is for this reason that FAP views a caring, genuine, sensitive, and emotional client-therapist relationship as the most important element in the change process. We describe a FAP case conceptualization form designed to help the therapist achieve a curative therapeutic relationship. Our case conceptualization of Katrina includes an account of how Katrina's history resulted in her current daily life problems, identification of Katrina's cognitive phenomena that might be related to her current problems, and most importantly the prediction of how Katrina's clinically relevant behavior dailv life problems, dysfunctional thinking, and improvements~might occur during the session within the therapist-client relationship.
UR COMMENTS a b o u t this case a r e f r o m t h e p e r s p e c tive o f p r a c t i c i n g r a d i c a l b e h a v i o r a l c l i n i c i a n s . T h e t h e o r y t h a t g u i d e s o u r c l i n i c a l w o r k is d e c e p t i v e l y simple. It is t h a t we a n d o u r c l i e n t s act t h e way we d o b e c a u s e o f t h e c o n t i n g e n c i e s o f r e i n f o r c e m e n t we e x p e r i e n c e d i n p a s t r e l a t i o n s h i p s . B i o l o g i c a l v a r i a b l e s s u c h as g e n e t i c p r e d i s p o s i t i o n s a r e also i n f l u e n t i a l , b u t s i n c e t h e s e g i v e n s c a n n o t h e c h a n g e d , o u r e m p h a s i s i n t r e a t m e n t is o n c o n tingencies of reinforcement. These contingencies are c u r r e n t a n d a r e always h a p p e n i n g d u r i n g t h e give a n d take o f t r e a t m e n t - - w h e n e v e r we i n t e r a c t w i t h o u r clients. B a s e d o n this t h e o r y , c l i n i c a l i m p r o v e m e n t s , h e a l i n g , o r p s y c h o t h e r a p e u t i c c h a n g e , all o f w h i c h a r e acts o f t h e clie n t , also i n v o l v e contingencies o f r e i n f o r c e m e n t t h a t o c c u r in t h e r e l a t i o n s h i p b e t w e e n t h e c l i e n t a n d t h e r a p i s t . T h e t r e a t m e n t b a s e d o n t h e s e p r i n c i p l e s is c a l l e d f u n c t i o n a l a n a l y t i c p s y c h o t h e r a p y (FAP; K o h l e n b e r g & Tsai, 1991), a n d s t e m s f r o m t h e f u n c t i o n a l analysis d e s c r i b e d b y B. E S k i n n e r . I n c o n t r a s t to p o p u l a r m i s c o n c e p t i o n s a b o u t
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Response Paper A Cognitive-Behavioral Analysis of a Patient With Borderline Personality Disorder G e r a l d C. D a v i s o n University o f Southern California Comments are made on case material from a patient likely to be diagnosable as borderline personality disorder. The author offers an analysis of the case as one reflecting emotional dysregulation and the complex interpersonal consequences of lack of control over turbulent storms of negative emotionality. A tentative treatment plan is outlined that involves a dialectical cognitive behavioral approach aimed at reducing emotional sensitivity and enabling the patient to cope better with her hitherto uncontrollable and frightening emotional lability and self-destructive behavior. Critical observations are offered on the risks of inferring childhood sexual and physical abuse fiom reports by clients who were treated by therapists whose theoretical or political orientation lead them to assume the presence of abuse in the past histories of people like those with borderline personality disorder.
HE CASE OF KATRINA raises a n u m b e r of interesting questions. My reactions to the material are organized a r o u n d p r e s e n t i n g problems a n d diagnostic impressions, the assessment plan I would follow, my concep-
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Cognitive and Behavioral Practice 7, 497-500, 2000 1077-7229/00/497-50051.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
realization of the case, my tentative t r e a t m e n t plan, a n d finally some concerns regarding the issue of sexual a n d / or physical abuse in the patient's past.
Patient's Presenting Problem and Diagnostic Impressions In D S M t e r m s , I would probably diagnose this patient as Borderline Personality Disorder (BPD). More specifically, a n d consistent with Marsha Linehan's formulation of BPD (Linehan, 1993), I would see her as someone saddled with emotional dysregulation, a problem of extreme autonomic lability a n d an impaired ability to modulate her emotional turmoil. I n a sense, Katrina's behaviors can be seen as maladaptive solutions to dealing with overwhelming negative affect. Associated problems that I see caused by this emotional dysregulation include h e r chaotic interpersonal relationships, suicidal a n d parasuicidal behavior, periods of depression, a n d general impulsiveness. The case report presents the hypothesis that "Katrina's suicide attempts reflect her inability to find alternative strategies toward regulating her intense emotions." I would agree. I am less certain about the hypothesis that "Katrina acts out her overwhelming rage a n d depression by presenting with extreme behaviors in an attempt to behaviorally 'match' her feelings." Why would she do this? More likely to me is that her depression a n d acting out are driven by maladaptive cognitions reinforced by her social e n v i r o n m e n t ; at least I would assess for these possibilities. Also a p p a r e n t in the case material is "splitting," a blackand-white way of viewing the world that is chal-acteristic of patients with BPD. Present as well are what are described as "intrusive memories of abuse" from both h e r father a n d her mother, about which I have more to say below.
Case Formulation L i n e h a n a n d others hypothesize that a series of n o n validating experiences in c h i l d h o o d a n d adolescence can c o n t r i b u t e to the d e v e l o p m e n t of BPD, most likely in an individual with a biological diathesis of some kind. I believe we see some e l e m e n t of n o n v a l i d a t i o n in the case material. For example, we are told that Katrina a n d her b r o t h e r were very u n h a p p y as children, b u t that these feelings were concealed by their parents by dressing t h e m in n e a t a n d pretty clothes a n d teaching them to be pleasant a n d u p b e a t in front of others "no matter what." But whether such experiences occurred in Katrina's past is less i m p o r t a n t than h e r c u r r e n t low self-esteem a n d sensitivity to rejection a n d disapproval. In addition to her extreme emotional lability, Katrina manifests a tendency to see the world, including herself, in dichotomous terms ("splitting," as just mentioned), Thus, a therapist either walks on the water or deserves to be
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Davison drowned. A spouse is either worthy o f adoration or of the most severe condemnation. Life is perfect or life is hopeless. Katrina behaves in ways that alienate, even frighten, those close to her. H e r standards for others are as unrealistically high as h e r standards for herself, a n d this contributes to a sense o f hopelessness a n d helplessness and, consistent with Seligman (1974) a n d Beck (1967), a generally depressed, periodically suicidal frame of mind.
Assessment
Plan
My assessment would n o t likely include the tests described in the case material, most particularly the projectives. W h a t is r e p o r t e d from t h e m seems to m e no differe n t from what was already known a b o u t the patient, a n d represents, to my mind, time a n d expense n o t well spent. I find it interesting a n d a tad disconcerting that the case material contrasts h e r s e e m i n g to be motivated a n d cooperative d u r i n g the four intake sessions with h e r reluctance to c o m p l e t e the various assessment measures. Perhaps Katrina has the kind of skepticism a b o u t some o f the tests given to h e r that I do, so h e r diffculties c o m p l e t i n g t h e m may n o t have p a t h o g n o m o n i c significance (unless it be j u d g e d that I a m d e f e n d i n g on b e h a l f o f the patient!). Rather than rely on psychological tests of d u b i o u s validity a n d utility, I would p r o b a b l y use clinical interviews a n d p e r h a p s some situation-specific questionnaires like the Dysfunctional Attitudes Scale (Weissman & Beck, 1978) o r the F e a r o f Negative Evaluation Scale (Watson & Friend, 1969). In sessions with b o t h the p a t i e n t a n d h e r h u s b a n d , I would c o n d u c t a functional analysis o f the clinical complexities o f h e r case; that is, I would conceptualize h e r p r o b l e m a c c o r d i n g to the familiar cognitivebehavioral SORC m o d e l (Kanfer & Saslow, 1969), to wit: S:
W h a t are the situational d e t e r m i n a n t s o f h e r maladaptive cognitions, emotions, a n d behaviors? O: W h a t internal factors, from cognitions to biological variables, have to be i n c l u d e d for a useful u n d e r s t a n d i n g of the patient? R: W h a t overt responses o r behaviors does the p a t i e n t e n g a g e in? C: W h a t are the consequences o r payoff for h e r behaving o r t h i n k i n g o r feeling in a particular way? T h e h o p e is that a careful functional analysis (cognitive behavioral assessment) o f Katrina would yield inform a t i o n that would allow a construction o f h e r psychological distress that would in turn imply a t r e a t m e n t p l a n possessing some m e a s u r e o f empirical support.
Initial T r e a t m e n t Plan My overall treatment plan would probably be modeled after Linehan's dialectical behavior therapy (DBT; Line-
han, 1993). I would first o f all establish a relationship m a r k e d by acceptance o f the p a t i e n t that is a t h o r o u g h going validation o f h e r fears, concerns, a n d destructive impulses. I would assume that she is d o i n g the best that she can at any given m o m e n t . This could take a n u m b e r of sessions a n d would be a leitmotif t h r o u g h o u t treatment. T h e challenge, at the same time, is to p e r s u a d e the patient to refrain from self-harming behaviors. Necessary also is teaching the p a t i e n t b e t t e r control over h e r emotions, p e r h a p s by training in d e e p muscle relaxation. This dialectical feature of DBT has always b e e n for me the most d i f f i c u l t - - b a l a n c i n g the validation that seems to be particularly necessary for a b o r d e r l i n e p a t i e n t against the n e e d to r e d u c e the f r e q u e n c y / i n t e n s i t y of destructive behaviors a n d increase the f r e q u e n c y o f behaviors that will improve the clinical situation. Given the exquisite sensitivity that Katrina is likely to exhibit to any signs from the therapist that she is n o t behaving as well as she could, it seems of the utmost i m p o r t a n c e to work towards a synthesis o f acceptance a n d change. In contrast to what a Rogerian would hold, I would n o t assume that a c c e p t a n c e without specific change efforts would improve the clinical picture in Katrina or, for that matter, in most patients, regardless o f their clinical diagnosis. L i n e h a n has asserted m a n y times that DBT is essentially cognitive behavior therapy within a dialectical context. I agree with this conceptualization. T h e core c h a n g e aspects o f DBT are social skills training a n d o t h e r cognitive behavioral procedures. T h e r e is m u c h to work on with Katrina. She seems to use alcohol in an effort to control h e r stress. BPDs are said to abuse drugs often. She also is said to have h a d periods o f a n o r e x i a a n d bulimia. T h e latter has b e e n linked to the k i n d o f d i c h o t o m o u s thinking that is a core feature o f BPD, in this case s o m e t h i n g like "It is absolutely essential that my physical a p p e a r a n c e m e a s u r e u p to the ideals I see a r o u n d m e in this society, a n d so I must be very careful a b o u t weight gain a n d t h e r e f o r e have to get rid o f any f o o d I eat" (Fairburn, 1985). H e r taking two psychoactive drugs would require my working with a physician, hopefully a psychiatrist knowle d g e a b l e a b o u t the risks a n d the benefits of medications. T h e side-effects o f the SSRI Effexor, for example, include increases of 10 to 15 mm. in b o t h systolic a n d diastolic b l o o d pressure, (hypo)mania, seizures, headaches, dizziness, insomnia, anxiety, a n d anorexia. O n e has to consider w h e t h e r this p a t i e n t can afford these possibe burdens o n top o f what she is already trying to c o p e with. I n d e e d , one wonders how m u c h o f the symptom picture is a result o f the drugs she is on. T h e "stated beliefs r e g a r d i n g self, others, a n d the world" that are i n c l u d e d in the case material certainly describe a p e r s o n with a very low o p i n i o n o f herself a n d with little h o p e that things will ever get better. Reflected
Response: CBT for Bordeline Personality Disorder also is the d i c h o t o m o u s t h i n k i n g that is p a r t o f the "dialectical failure" that L i n e h a n describes for patients with BPD. A general cognitive goal is to teach the p a t i e n t a b o u t dialectics as a way to move h e r away from blackwhite thinking. O f course, A a r o n Beck has a central place for this k i n d o f cognitive distortion in his widely known a n d practiced cognitive therapy (Beck, 1976). I would see Beck's a p p r o a c h as applicable with this patient, b u t I would b l e n d it with A l b e r t Ellis's (1962) focus o n unrealistic b e l i e f s - - i m p e r a t i v e thinking o r d e m a n d s for perfection a n d approval from everyone, a n d d e m a n d s that the world be as the p a t i e n t wants it to be. I would also take a p r o b l e m - s o M n g a p p r o a c h with Katrina, focusing especially on e n c o u r a g i n g h e r to construe h e r seemingly impossible p r e d i c a m e n t in terms o f difficult p r o b l e m a t i c situations that are amenable to a solution. This general p r o b l e m orientation, c o n s i d e r e d b u t the first stage of social problem-solving therapy by D'Zurilla a n d Goldfried (1971), may itself be helpful to a person like Katrina, who is easily o v e r w h e l m e d by perceived catastrophes. I have for some time related this p r o b l e m orie n t a t i o n to R o b e r t Pirsig's classic Zen and the Art of Motorcycle Maintenance (1974), in which he uses the m e t a p h o r o f fixing a n d m a i n t a i n i n g his motorcycle (a c o m p l e x p r o b l e m ) to convey the i d e a that o n e is well advised to a d o p t a certain attitude toward life's inevitable challenges, a stance that expects life to serve u p p r o b l e m s - - t h a t we n e e d n o t be paralyzed by them; rather, that we can view t h e m as p r o b l e m s a m e n a b l e to solution. Would I design t h e r a p y as c o n j o i n t o r individual? I d o n ' t believe the research literature is a sufficient guide. But if the couples t h e r a p y she has b e e n in for several m o n t h s has b e e n at all u s e f u l - - a n d in the case of this k i n d o f patient, "useful" can m e a n little m o r e than h e r n o t killing herself or otherwise acting in self-destructive a n d socially aversive w a y s - - t h e n I would be inclined to k e e p the h u s b a n d involved in h e r treatment. In fact, I would think that it would be necessary to teach h i m how to deal with his wife's thin-skinned n a t u r e a n d to provide the k i n d o f s u p p o r t a n d a c c e p t a n c e that the therapist tries to provide in those few hours each week that he o r she is in direct contact with an outpatient. T h e fact that Katrina has c o m p l a i n e d that h e r h u s b a n d has r a p e d a n d physically a b u s e d h e r also supports the n o t i o n that h e should be involved in the therapy.
A C o m m e n t o n t h e Patient's History of Sexual/Physical Abuse T h e issue o f the patient's recollections o f sexual a n d physical abuse by h e r father must b e e x a m i n e d . F r o m the case material I see the very real possibility that the patients's m e m o r i e s are n o t veridical, to wit: " . . . it was only in r e c e n t years that Katrina b e g a n to infer that she must
have been [emphasis a d d e d ] sexually a b u s e d by [her father] because o f 'impulsive a n d d a n g e r o u s behaviors' she e n g a g e d in." T h e r e p o r t goes on to say that h e r various clinical r e c o r d s contain inconsistencies in the time a n d n a t u r e of the alleged abuse incidents. O n e is struck by the s t a t e m e n t that h e r father's abuse o f h e r c o n t i n u e d until a m o n t h into h e r marriage, which means that he has allegedly b e e n abusing h e r for p e r h a p s 20 years, f r o m c h i l d h o o d until a d u l t h o o d , i n c l u d i n g d u r i n g a time when she was living with a n o t h e r adult. While this p a t t e r n a n d extensiveness o f abuse are n o t impossible, I believe they are very rare. Whose i n f e r e n c e is it that she was a b u s e d as a child? Is it possible that o n e o r m o r e o f h e r previous therapists l e d h e r to believe that she h a d b e e n abused, based on t h e i r own theoretical or political beliefs in c h i l d h o o d abuse as a key etiological factor in a range o f a d u l t m e n t a l disorders, especially BPD? Did a previous therapist assume that s o m e o n e with a p a t t e r n characteristic o f BPD must have b e e n sexually a b u s e d as a child? This is n o t a comfortable question to pose, b u t I believe it is i m p o r t a n t to do so, especially when the alleged o f f e n d e r is still alive, as is the case with Katrina. We have all r e a d a b o u t the lawsuits, the c o u r t trials, a n d the b r o k e n lives occasioned by the alleged uncovering o f r e p r e s s e d m e m o r i e s o f child abuse (Lazo, 1995). T h e p r o b l e m , o f course, is m a k i n g an accurate appraisal o f a given situation: Did o r d i d n o t abuse occur in Katrina's c h i l d h o o d ? W h e n inferences are m a d e on the basis o f theory and, perhaps, also personal, politically driven biases, we, as clinical scientists a n d practitioners, have reason to worry. T h e way this case is written up, I a m worried. Take n o t e o f the observation that the patient's father h a d recently b e c o m e a "distinguished c o m m u n i t y leader." Does this m a k e his alleged status as a child molester o f his own d a u g h t e r m o r e o r less likely? Are we to assume, ~t la psychoanalytic theory, that the father has tried to c o m p e n s a t e for o r expiate his guilt a b o u t having m o l e s t e d his d a u g h t e r by throwing himself into selfless c o m m u n i t y activities? This is a very slippery slope. T h a t Katrina's psychological state w o r s e n e d when she b e g a n "intensive o u t p a t i e n t therapy that focused o n exp l o r i n g issues related to abuse" does n o t necessarily m e a n that these m e m o r i e s are veridical. I should t h i n k that anyonewho comes to believe that h e r father sexually m o l e s t e d a n d b e a t h e r a n d who is e n c o u r a g e d by h e r therapist to talk a b o u t these (putative) past events would b e c o m e psychologically u n h i n g e d . Note, I am not saying that Katrina was definitely n o t sexually or physically abused as a child. I am suggesting only that the presence o f this finding in h e r clinical records b e dealt with cautiously a n d with scientific skepticism. F u r t h e r m o r e , we know that a characteristic o f posttraumatic stress d i s o r d e r is intrusive a n d f r e q u e n t m e m o -
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Kohlenberg & Tsai ries o f t h e p a s t t r a u m a t i z i n g e v e n t s ( A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , 1994). So s o m e t i m e s p e o p l e cannot forget t h e i r t r a u m a s . C o u p l e d w i t h w h a t we k n o w a b o u t t h e constructive n a t u r e o f h u m a n m e m o r y - - we d o n o t r e c o r d o u r m e m o r i e s t h e way a c a m e r a takes a p i c t u r e ( B r a n s f o r d & J o h n s o n , 1973) - - t h e r e is r e a s o n to b e wary o f acc o r d i n g validity to all r e p o r t s b y p a t i e n t s o f h a v i n g b e e n s e x u a l l y a b u s e d . Social scientists as well as t h e legal syst e m s h a r e a h e a v y r e s p o n s i b i l i t y in d e c i d i n g w h e t h e r a g i v e n r e c o v e r e d m e m o r y o f a b u s e is a r e f l e c t i o n o f a n act u a l ( a n d c r i m i n a l ) e v e n t . E r r i n g i n e i t h e r d i r e c t i o n creates a n i n j u s t i c e f o r e i t h e r t h e a c c u s e d o r t h e accuser.
References American Psychiatric Association. (1994). Diagnosticand statistical manual of mental disorders (4th ed.). Washington, DC: Author. Bransford, J. D., & Johnson, M. K. (1973). Considerations of some problems of comprehension. In W. G. Chase (Ed.), Visual information processing. NewYork: Academic Press. Beck, A. T. (1967). Depression:Clinical, experimentaland theoreticalaspects. New York: Harper & Row. Beck, A. T. (1976). Cognitive therapyand the emotionaldisorders.New York: International Universities Press. D'Zurilla, T.J., & Goldfried, M. R. (1971). Problem-solving and behavior modification. Journal of Abnormal Psychology, 78, 107-126. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Fairburn, C. G. (1985). Cognitive-behavioral treatment for bulimia. In D. M. Garner & E E. Garfinkel (Eds.), Handbook ofpsychotherapyfor anorexia nervosa and bulimia. New York: Guilford Press. Kanfer, E H., & Saslow, G. (1969). Behavioral diagnosis. In C. M. Franks (Ed.), Behavior therapy: Appraisal and status. New York: McGraw-Hill. Lazo,J. (1995). True or false: Expert testimony on repressed memory. Loyola of Los Angeles Law Review, 28, 1345-1413. Linehan, M. M. (1993). Cognitivebehavioraltreatmentof borderlinepersonality disorder: The dialectics of effective treatment. New York: Guilford Press. Pirsig, R. M. (1974). Zen and the art of motorcyclemazntenance:An inquiry into values. New York: Morrow. Seligman, M. E. R (1974). Depression and learned helplessness. In R.J. Friedman & M. M. Katz (Eds.), The psvchology of depression: Contemporary theory and research.Washington, DC: Winston-Wiley. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and ClinicalPsychology,33, 448-457. Weissman, A. N., & Beck, A. T. (1978). Developmentand validation of the Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the annual meeting of the American Educational Research Association, Toronto. Address correspondence to Gerald C. Davison, Ph.D., Department of Psychology, University of Southern California, Los Angeles, CA 900891061; e-mail: [email protected]
Received: August 25, 1999 Accepted: September30, 1999
Response Paper Radical Behavioral Help for Katrina RobertJ. Kohlenberg, University o f W a s h i n g t o n M a v i s T s a i , I n d e p e n d e n t Practice, Seattle, W a s h i n g t o n
Our treatment plan for Katrina is guided by the principles of functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991), an approach derived from radical behaviorism. The fundamental assumption is that we and our clients act the way we do because of the contingencies of reinforcement we have experienced in past relationships. It then follows that clinical improvements, which are acts of the client, also involve contingencies of reinforcement that occur in the relationship between the client and therapist. Thus, our treatment of Katrina emphasizes the use of the client-therapist interaction as an in-vivo learning opportunity. It is for this reason that FAP views a caring, genuine, sensitive, and emotional client-therapist relationship as the most important element in the change process. We describe a FAP case conceptualization form designed to help the therapist achieve a curative therapeutic relationship. Our case conceptualization of Katrina includes an account of how Katrina's history resulted in her current daily life problems, identification of Katrina's cognitive phenomena that might be related to her current problems, and most importantly the prediction of how Katrina's clinically relevant behavior dailv life problems, dysfunctional thinking, and improvements~might occur during the session within the therapist-client relationship.
UR COMMENTS a b o u t this case a r e f r o m t h e p e r s p e c tive o f p r a c t i c i n g r a d i c a l b e h a v i o r a l c l i n i c i a n s . T h e t h e o r y t h a t g u i d e s o u r c l i n i c a l w o r k is d e c e p t i v e l y simple. It is t h a t we a n d o u r c l i e n t s act t h e way we d o b e c a u s e o f t h e c o n t i n g e n c i e s o f r e i n f o r c e m e n t we e x p e r i e n c e d i n p a s t r e l a t i o n s h i p s . B i o l o g i c a l v a r i a b l e s s u c h as g e n e t i c p r e d i s p o s i t i o n s a r e also i n f l u e n t i a l , b u t s i n c e t h e s e g i v e n s c a n n o t h e c h a n g e d , o u r e m p h a s i s i n t r e a t m e n t is o n c o n tingencies of reinforcement. These contingencies are c u r r e n t a n d a r e always h a p p e n i n g d u r i n g t h e give a n d take o f t r e a t m e n t - - w h e n e v e r we i n t e r a c t w i t h o u r clients. B a s e d o n this t h e o r y , c l i n i c a l i m p r o v e m e n t s , h e a l i n g , o r p s y c h o t h e r a p e u t i c c h a n g e , all o f w h i c h a r e acts o f t h e clie n t , also i n v o l v e contingencies o f r e i n f o r c e m e n t t h a t o c c u r in t h e r e l a t i o n s h i p b e t w e e n t h e c l i e n t a n d t h e r a p i s t . T h e t r e a t m e n t b a s e d o n t h e s e p r i n c i p l e s is c a l l e d f u n c t i o n a l a n a l y t i c p s y c h o t h e r a p y (FAP; K o h l e n b e r g & Tsai, 1991), a n d s t e m s f r o m t h e f u n c t i o n a l analysis d e s c r i b e d b y B. E S k i n n e r . I n c o n t r a s t to p o p u l a r m i s c o n c e p t i o n s a b o u t
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Cognitive and Behavioral Practice 7, 500-505, 2000 1077-7229/00/500-50551.00/0 Copyright © 2000 by Association for A d v a n c e m e n t of Behavior Therapy. All rights of reproduction in any form reserved.