Cognitively Speaking….

Therapy. It’s useful. It’s useful to most people, not just those with characterological problems (a.k.a. personality disorders). There are so many different kinds of therapy and therapeutic techniques that it can be dizzying to decide which is best for you. Fortunately most people don’t have to worry about making this decision. If you’re stressed out from work, having issues with a spouse, not sleeping, fighting drug or alcohol abuse… there are a multitude of programs and therapies specifically designed and tailored for each of these. Especially Cognitive Behavioral Therapy which focuses on treating people that display all those Axis-I disorders that a good majority of the population experience from time to time.
That said, Cognitive Behavioral Therapy likely isn’t enough for someone with Borderline Personality Disorder. In fact, I’m not sure any singular type is as effective as a combination of therapies since not only are we an Axis-II disorder but an incredible majority of us also display comorbid Axis-I issues and disorders as well. It only makes sense to me that if you have a multitude of manias it would make sense that you should use a multitude of techniques to tackle the entire spectrum.  
The very nature of personality disorders means that the way we perceive the world, how we interact with the world, how we experience emotion and our very selves is quite different than your average Joe. By extension, how we are capable of utilizing, dealing with, and incorporating therapeutic technique is also going to be different. That’s not to say that we don’t want to work through things, obviously this may not be the case, but since our base functioning is different, we need to approach these problems from a different point of view.
Quite often traditional CBT makes basic assumptions of its patients that don’t apply to the “normal” state of someone with BPD. Normal is relative right? When ‘normal’ is incapable of feeling these things in the same way, these basic assumptions flounder and fail. Different strokes for different folks and all. So where might basic CBT therapeutic assumptions cause issue for the personality disordered?
Assumption 1: Patients will comply with the treatment protocol.
            Now this doesn’t translate as a desire to be difficult. The first time I went into therapy it was not from a desire to move beyond my borderline, but from a place of needing support to deal with an abusive significant other. I was more interested in obtaining consolation and recognition of my suffering than in understanding and fixing the problems that lead me to be in that situation in the first place. Hell, at the time I wasn’t even certain of the exact problems that fixed me into that black hole of emotional destruction. (I do realize it is unfair to black holes to compare them to my Evil-Ex). But because I didn’t understand the detrimental thought processes that kept me from leaving I couldn’t internalize the techniques that my therapist was giving me to help me cope. My point is, often for PD patients therapy is complicated and it’s not so straight forward for us to take on CBT techniques. With wildly fluxuating mood swings we might one day recognize that we have severe problems that we would give anything to be rid of, while the next we may rail against the idea that what is wrong with us is in need of fixing. It’s not easy to admit that there’s something fundamentally flawed with your make-up. It hurts and it’s hard to see that something you can’t control should hold such sway over your world beyond your ability. You were born this way, that means you’re supposed to be this way, right? What’s wrong with that? Ultimately we were given what we were given and it is our responsibility to manage ourselves. Life rarely turns out the way you expect it would. For anyone.     
Assumption 2: With brief training, patients can access their cognitions and emotions and report them to the therapist.
Cue the broken record. Someone with a Borderline Personality Disorder does not experience emotions the way a normal person does, by definition. Sometimes the buildup of emotion is so frustrating and such a jumble of so many different things that it’s impossible to distinguish individual thoughts or feelings. Or patients may block disturbing thoughts and images in a cognitive or affective avoidance of disturbing memories and negative feelings. When you learn that by avoiding negative stimuli you reduce your susceptibility to pain, it becomes ingrained into your habits and lifestyle. Breaking an instinctive pattern that you’ve developed as a maladaptive coping strategy isn’t easy. To first face those things that hurt you in order to finally move past them takes courage and time to reach that place of strength. Or you have someone like me that is dissociative on top of my other issues. Where something should inspire intense emotions all I can describe is…. A blank. A void of feeling like speeding to the pinnacle of Mount Everest with emotions ramping up higher and faster only to divert into a dark cave before you hit the top and, stop. How do you navigate the void?  
Assumption 3:   Patients can change their problematic cognitions and behaviors through such practices as empirical analysis, logical discourse, experimentation, gradual steps, and repetition.
The problem here is that our problems are rarely so straight forward. Our issues have issues.  “Because characterological patients usually lack psychological flexibility, they are much less responsive to CB techniques and frequently do not make meaningful changes in a short period of time. Rather, they are psychologically rigid. Rigidity is a hallmark of personality disorders. These patients tend toward hopelessness about changing. Their characterological problems are ego-syntonic: Their self-destructive patterns seem to be so much a part of who they are that they cannot imagine altering them. Their problems are central to their sense of identity, and to give them up can seem like a form of death – a death of a part of the self.” Do you know what it’s like to want to be rid of something, to despise it so much, and fear the losing of it in the same breath? Or to feel in your bones that something is so, despite all evidence to the contrary? I do.
Assumption 4: Patients can engage in a collaborative relationship with the therapist within a few sessions.
            I’ve been in therapy 8 months and I’m just now, in the past few weeks, beginning to bond with my therapist in a way that I can internalize. Oh I trust her, cognitively. I believe she wants to help me and has my best interest in mind. Throughout my life my interpersonal relationships with people have been marked by distrust and an expectation that they will implode. I don’t do it on purpose, it’s just happened so often that it’s natural for me to hold back. I don’t even have to try. When you’re so accustomed to having a hard time relating to others, it’s a natural extension that you would have a hard time relating to a therapist who is a relative stranger (at first).  From this point of view it makes sense that not only should a person’s personal problems be at the focus of therapy, but also a focus on developing the therapeutic bond between patient and therapist should come into play.   
Assumption 5: The patient is presumed to have problems that are readily discernible as targets of treatment.
Fill my emptiness please. What? You don’t have a prescription for that? No definitive list of reasons why this may be? It’s hard to treat a problem when you don’t have a clear idea of what the problem even is. Vague senses are difficult to discern for anyone, especially someone who has trouble connecting with how they feel in the first place.
So does that mean there is no hope? No, of course not. It just means that we need an expanded approach. Where we begin, where we go, what we seek and where we search for it will be in different places. Having our own individual reasons, subconscious or otherwise, for therapy means that we will have our own individual starting points. Sometimes it just takes a different approach to find the mark. Where one technique may fail, another may succeed. There are always more options. Don’t give up.
Being individual makes us human. Being human means we all have our own journeys.

3 comments on “Cognitively Speaking….

  1. Until I read this post I didn't understand why CBT on its own didn't work for me. However adding some DBT really made the difference. Thank you for such an enlightening post Haven!

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