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.

Have a seat on my couch: Therapy

Today I was originally going to talk about Hospitalization, but frankly, the idea bores me at the moment so let’s look at something else.
Have you ever noticed that every therapist’s office has a couch? It’s almost cliché in a comforting kind of way. Hell, even my background has a couch/comfy chair. Subconscious foreshadowing? Intuition? Perhaps. So kick back. Pull up a cushion. Relax. And let’s talk about therapy.  
There are a ton of different types and methodologies when it comes to therapy. Maybe, eventually, I’ll be able to discover what they all are in order to talk about them, but for now I want to take a look at the ones I know the most about which are also applicable to Borderline Personality Disorder: Cognitive Behavioral Therapy (CBT), Schema Therapy, and Dialectical Behavior Therapy (DBT).
What are each of these?
Cognitive behavioral therapy (CBT) is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present. The particular therapeutic techniques vary within the different approaches of CBT according to the particular kind of problem issues, but commonly may include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation, mindfulness and distraction techniques are also commonly included.
Dialectical behavior therapy (DBT) is a system of therapy originally developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder (BPD). DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT may be the first therapy that has been experimentally demonstrated to be generally effective in treating BPD.
All DBT can be said to involve two components:
An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority. Second in priority are behaviors which while not directly harmful to self or others, interfere with the course of treatment. These behaviors are known as therapy-interfering behaviors. Third in priority are quality of life issues and working towards improving one’s life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
A group component in which the group ordinarily meets once weekly for two to two-and-a-half hours and learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.
Schema Therapy was developed by Dr. Jeffrey E. Young for use in treatment of personality disorders. Schema Therapy is intended for use when patients fail to respond or improve after having been through other therapies. Schema therapy is a combination of many different therapy techniques, including Cognitive Behavioral Therapy, object relations, psychoanalysis, mindfulness, Dialectical behavior therapy, interpersonal relation skills, discussion one-on-one, group discussion, and constructivism. Schema Therapy also borrows extensively from a range of theoretical concepts and methods from Transactional Analysis (I’m not even sure what this is).
As opposed to some of the more widely known and popular therapy methods, Schema therapy is most often used and considered a specialty form of therapy in the treatment of personality disorders, most commonly borderline personality disorder. Schema Therapy is based on a theory that childhood and adolescent traumas are the most likely causes of Borderline Personality Disorder and other similar personality disorders. The approach of Schema therapy emphasizes patients, psychiatrists, and therapists building bonds of trust with each other.
Each one of these topics is HUGE. All containing vast amounts of ideas, techniques, theories…. Given my compulsive nature we may be exploring therapy for quite a while. I promise you this. If you’re at all interested in the deeper aspects of the psyche these are absolutely fascinating.
My therapist uses a combination of all 3 of these therapies but she specializes in Schema Therapy. I own a copy of the Practioner’s Guide and I’m going to be getting into a great deal of it, but hopefully in a way that is more accessible and easy to relate to.  If I start to sound like a text book, please feel free to poke me.