single session treatment of a borderline personality disorder

COGNITIVE AND BEHAVIORAL PRACTICE 3, 183-208, 1996

Single Session Treatment of a Borderline Personality Disorder

Arthur Freeman James Jackson Philadelphia College of Osteopathic Medicine

Introduction

Much has been written about brief or short-term therapy from a variety of theoretical perspectives (Basch, 1992; Bloom, 1992; Budman & Gurman, 1988; Cade & O'Hanlon, 1993; Crits-Cristoph & Barber, 1991; Fisch, Weak- land, & Segal, 1982; Garfield, 1989; Gustafson, 1986; Langley, 1994; Lankton & Erickson, 1994; O'Hanlon & Davis, 1989; Preston, Varzos, & Liebert, 1995; Sifneos, 1987, 1992; Walter &.Peller, 1992; Wells & Gianneti, 1990). Does it work? Does it work better than long-term therapy? Is it the best alternative? Or, is it only a manifestation of the zeitgeist of contemporary times and the managed care treatment model?

These discussions are generally not dispassionate interchanges, but are usually emotionally loaded by the philosophical, financial, theoretical, or conceptual rationale for the short-term therapy. If one does brief or short-term therapy out of a conviction that it is an important option in developing adequate treatment plans, there is less heat. If, however, the therapy is foreshortened because it is forced by the "evil empire" of the managed care companies, there is often great anger.

The short-term debate is exacerbated when the treatment conceptualization includes a diagnosis of personality disorder. Among the diagnostic grouping within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American

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Psychiatric Association, 1994), no diagnosis seems to raise the therapist's emotions as much as that of the borderline personality disorder. For many, the term "borderline" has become an accusation and epithet. It evokes images of non- compliance, unbridled anger, a stormy therapeutic alliance, self-injurious behavior, and dichotomous thinking and actions (Beck, Freeman, & Associates, 1990; Layden, Newman, Freeman, & Morse, 1993; Linehan, 1994). All of the upset, however, fails to note that, as with any diagnosis, the patient can have a mild, moderate, or severe form of that disorder. The mild form of the borderline disorder may be more amenable to treatment than the severe forms of Axis I disorders. The combination of short term therapy and borderline personality disorder is a volatile mix.

The.issue, we believe, is not how many sessions a therapist has to work with a patient, but rather, what one does with the sessions. From our perspective, short-term therapy must be easily available and accessible, structured for the patient, active, directive, cooperative, problem-focused, solution-oriented, and psychoeducational. It is not an issue of time spent, but the goals of the therapy, and the strategies or goals and the consequent interventions used to meet those goals. The mild and moderate forms of a disorder would be treated differently than the more severe manifestation of that disorder. Given a choice, therapy would best be dictated by the needs of the patient, not of the therapist or the payment system. This is not always the case.

The following session attempted to demonstrate what could be done in the shortest possible therapy, a single session with a borderline personality disordered patient.

The context for this session was a workshop led by the first author (AF) on the cognitive behavioral treatment of personality disorders. The workshop organizer invited a patient in his practice to be interviewed as part of that workshop. The patient agreed and was interviewed for 45 minutes in front of a group of practicing therapists. Prior to the interview, the workshop leader met with the patient. Subsequent to the interview, a brief time was used when both the workshop leader and the patient responded to questions from the group. After that, the patient was debriefed by her therapist to assure that there were no problems or issues stemming from the session.

The annotations to the session (interspersed throughout the transcript in italic typeface) will highlight the workshop leader/therapist's development of hypotheses and the treatment conceptualization, as well as the strategies that led to the implementation of that conceptual model through the use of specific therapeutic techniques.

Patient Data

The patient's name, the name of her therapist, and other identifying data have been changed to maintain privacy and confidentiality. While there is a

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vast amount of data available about the patient, it is not included here. In an ideal world, the therapist would have the data and the time to review it all. In the real world, especially in emergent or crisis settings, the data may not be available, or the therapist does not have the time to sift through it all. What is included below is the barest outline, but enough to conceptualize, plan, and enact the single-session therapy.

Debbie, a 43-year-old white woman, is employed as an elementary school teacher. She completed both undergraduate and masters degrees at a state teachers college. She has never been married and lives alone. With no close friends, and few distant friends whom she sees very occasionally on holidays, Debbie's environment is marked by a scarcity of social connections, including those with her teaching colleagues. While relating well to the children she teaches, she experiences interpersonal problems with teacher colleagues, administrators, and with the parents of the children in her class.

For the last 10 years she has had no contact with her f a m i l y - h e r mother and a younger sister. Her father died when she was 3 years old, and her mother remarried when Debbie was 5. She was sexually abused from the ages of 6 to 12 by her stepfather. On several occasions she had told her mother about the abuse, but her mother did not believe her, and nothing was done. The abuse stopped when Debbie was 12.

Debbie has been diagnosed as a borderline personality and has been in therapy with several different therapists over the last 18 years. She has been seeing her present therapist for one and a half years. She has reported both anxiety and depressive symptoms, anger where she verbally "explodes" at people at work, and self-damaging behavior. She had asked that the nature of the self-harm not be shared with the group, and it will be omitted here to honor her request.

Case Conceptualization Based on the discussions with Debbie's therapist, it seemed that the diag-

nosis of borderline personality disorder was appropriate. She met six of the nine criteria for borderline personality listed in DSM-IV. (Only five are required for the diagnosis.) The specific criteria-focused data were gathered from her therapist, Dr. John Smith, and from elucidation by Debbie in a pre-interview meeting with the first author. The criteria met are as follows:

1. Unstable interpersonal relationships: Debbie has difficulty with coworkers that often leads to her avoiding them, and to them excluding her from social functions, and even ignoring her during the work day. The problems take the form of Debbie insulting them, being sarcastic, or angry when others see no reason for her actions.

2. Self-mutilating behavior: Debbie has, for many years, self-mutilated. 3. Affective instability: Debbie reported that she can experience her moods

shifting almost instantly. She can go from calm to anger in what she de-

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scribed as "a flash." She also described having experienced many "moods" in the course of a day.

4. Inappropriate, intense anger: Debbie reported that her anger responses appear to others to "come out of the blue:' The level, content, focus, ex- tent, and duration of the anger often surprises Debbie.

5. Chronic feelings of emptiness: By her own report, Debbie describes herself as "a nothing:' "without value;' "like an empty shell."

6. Dissociative symptoms: When "upset" she has, for many years, used the technique of holding her breath until she becomes what she calls "dizzy" She reports being able to see herself from a distance, sometimes looking down from the ceiling of the room.

Given the above information, she likely had developed schema about the world being a dangerous place: People, especially people in power, were not to be trusted. Because sex was negative, and self-worth was based on sex, Debbie valued herself negatively. Likely self-blaming for what had happened to her, she hoped for support, and was disappointed when she could not find it. Dis- plays of emotion were to be hidden, and she was both helpless and hopeless about changing.

As therapist (AF), my goal was to use the available time to demonstrate how a short-term cognitive behavioral therapy (CBT) model can be used with a borderline patient. The intent was not to cure, but rather to treat. My goals included the following:

1. identify a problem area 2. reduce that area to a small enough piece for the single-session therapy 3. develop a conceptualization of the patient's problems 4. decide which parts of the conceptualization could be worked on in the

single session 5. decide what specific techniques would be useful 6. implement the technical therapy 7. evaluate the success of the interventions 8. make mid-course changes, as needed 9. get frequent feedback from the patient

10. leave time for appropriate closure and debriefing after the session

Of specific note is the use of the Socratic questioning throughout the session. To enhance the rapport in this brief time, many of the questions are closed- ended questions that elicit an affirmative response. This assists in overcoming the negative set many patients have about therapy.

There were several questions and issues that had to be kept in mind. These included:

Issue #1. Did Debbie have the potential for verbal or physical violence? I wanted to avoid this. It would not have been helpful to Debbie, and it might have been seen by her as a failure and/or an embarrassment, and would, if


physical, cause damage to me. Given her history, the therapist's response, and my own estimation, there was little chance of this.

Issue #2. Were Debbie's social skills adequate and appropriate for her ap- pearance in front of a group? The goal was to demonstrate a particular set of interventions, not to put Debbie on display as an example of a diagnostic category. Again, based on her history, Debbie had social skills, but often had trouble using them. I could try to use her social skills by avoiding putting any stress on Debbie.

Issue #3. Were Debbie's intelligence and verbal ability adequate for the task? History and interview confirmed no problem in this area. Further, her intelligence and verbal ability were potential strengths to be used in the interview.

Issue//4. What would be the effect of the audience on Debbie? Debbie's re- action to me and to the audience would be crucial. While she had agreed to participate after several discussions with her therapist, it was not clear what effect the audience would have. Would she use it as an opportunity to try to embarrass and humiliate me (an authority figure and a male)? Would she use it as an opportunity to get all of the audience feeling sorry for her as a way of justifying her anger and upset?

Were there ways to minimize the effect of the audience? Ideally, the setting for this would be a consultation room with video capability. This way, the audience could see and hear the session without being present in the room. How- ever, as in life, the ideal is not always available. The second choice was to have Debbie sit in front of the audience with her back to the group, which would allow the therapist to face the audience and to keep his session notes on an overhead projector. In this way, both the audience and Debbie could see the session notes actually being written.

In terms of lighting and sound, the room was dimmed, with lights on the stage, and, aside from some coughing, there were few sounds from the audience. O n several occasions Debbie's responses evoked supportive laughter from the group.

Issue//5. What was Debbie's frustration tolerance level? This would be the key to the single session and to the treatment as a whole. It would be essential to establish Debbie's flexibility and strength of boundaries. I f her boundaries were crossed, she would likely (and reasonably) retreat. IfDebbie's boundaries or safety zone were not expanded, there would be minimal growth (Freeman & Leaf, 1989).

If Debbie perceived a threat, she would withdraw. The best way to establish her boundaries (or how far and fast she could be pushed) would be to test the boundaries gingerly and gently. The therapist had to be prepared to immediately back off and, if needed, apologize quickly for the intrusion.

Schema about intrusion, boundary violations, lack of remorse by the offender, lack of support, and victimization were all part of her life and had to be considered throughout the session.


Overall, my concerns focused on the possible lability of the patient, possible motivational or compliance problems, and her ability to maintain control. Having been satisfied in an extensive discussion with her therapist, and also with the patient, prior to the interview, I was assured that there would not likely be any major problems.

Session Transcript

Therapist: Hi, Debbie. I really appreciate your willingness to do this. We'll talk for about forty minutes, is that all right?

Patient: Yes. T: How are you feeling about doing this? P: I'll be fine in about forty minutes. T: About forty minutes. It feels okay now, but you'll feel better later? P: Yeah. T: Again, I'd like to thank you for doing this. l think that it's interesting that

you volunteered to do this because it says something about a level of courage. It takes an awful lot of courage to come into a room of strangers, to talk to a stranger about some very personal things. Given that we're going to talk for about forty minutes, are there particular things that you would like to try to address in the time we have?

In addition to establishing rapport, the therapist was testing hypotheses regarding her view of self. I f she is offered a positive statement, how does she deal with it? Since it is likely dissonant with her negative self-view, it will probably evoke a "Yes-But," or it may be ignored as if she did not hear it at all. P: What seems to keep me stuck is how bad I feel about myself. T: That 's pretty general. Can you be more specific? What does that mean?

What is the patient's idiosyncratic meaning for her often-used terms such as "road"or "anger"? The therapist can never assume idiosyncratic meanings. P: I 'm not mad at the appropriate people, I take everything out on myself,

even if it's not my fault. T: So, if someone does something, you'll take responsibility for it? P: I tend to take a lot and then it starts oozing out in inappropriate ways. T: Can you give me an example, Debbie, of how this would show itself. Give

me a typical example. P: If a situation occurs at work and it might have happened for the fifth time

that week, I would blow up at whatever person is in front of me, it had nothing to do with that person, it was something underneath and they just happened to get in the way.

T: Okay, so things have been happening, the anger builds up, builds up, and then there's a trigger and then you explode?

P: Right. This summary of the chain of events does two things. First, it indicates to the patient that

the therapist is listening, and, second, establishes a basis for further clarification.

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T: The other person is saying what to themselves? P: "Where did that come from?" T: Where did that come from.

This reflective statement also encourages perspective-taking by asking Debbie what she guesses the other person might be thinking. P: A n d then I feel so guilty about laying somebody out, but it's too much to

deal with. T: Do you feel guilty because you got angry or do you feel guilty that you

got angry to such a high degree? Guilty is too broad a concept. It is important to delineate her meaning, but also the nature

of the '~uilt" problem and any second-order problems attached to it. P: The degree. T: The degree? Is gett ing angry okay. P: No. Periodically, yes, it's good, I mean I know that I 'm angry, but it's not

okay for any long time. T: W h y not, why isn't anger okay? P: I haven't had much experience seeing appropr ia te anger and I 'm afraid that

that was exactly like what I grew up with. This is a very broad invitation to explore issues of childhood experience, early learning,

parental interactions and reactions, and a general theme of the past. Given the parameter of the setting and the single-session format, this will be left aside. The basic schema regarding anger will have to be addressed as "here-and-now" issues. T: Okay, so one th ing we might be able to focus on in the t ime we have is

this issue of appropr ia te anger or inappropr ia te anger, jus t kind of looking at that.

P: Right. T: Anyth ing else you might want to look at in the t ime we have, and then we

can see what would be reasonable for the l imited t ime that we have? P: I think anger pre t ty much covers everything that I do.

This sets out an early problem list that would ideally be broad enough to fill the available time, and Jbcused enough to allow use of the time. T: So anger is really something with a big capital 'N"?

P: Yeah. T: A n d it's with you pre t ty much all the time? P: I feel like I 'm jus t boi l ing mad and I take it out on myself and I 'm t rying

to find other ways . . . T: Are you boi l ing m a d right now? P: No, I 'm scared to death r ight now. T: Is that an alternative, ei ther you're angry or you're scared? P: Yeah. T: So we have two possibilities, you can be angry or scared. Is scared a way

of not deal ing with your anger? Is this one method of coping? I f it is, then it can be used us the start of a list of coping

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strategies. For many patients, the predominant idea is that they have r~ coping strategies and are driven by the winds (chance or fate. By identifying any strategies, we can introduce the idea that control is already part of their repertoire, and the therapeutic goal is to enhance and build that list. P: Well, I think I become angry when I'm really scared because I don't know

how to deal with being afraid, but at least anger leaves me someplace, I feel paralyzed by the fear.

T: So being scared, you're stuck? This is another summary statement that elicits a positive response. She knows the therapist

is listening. P: Yeah. T: Anger gives you what? P: I don't want anybody to see me when I'm mad. I end up cleaning the house. T: Lot's of cleaning? P: Yeah. T: So anger gets you moving, anger gets you mobilized, so it's a good part

of anger, you get your house clean . . . very clean. P: Yeah.

This is the beginning of a cost-benefit analysis. The idea of this type of analysis will be introduced here and expanded over the session. Just what is the function and value of anger in her life? T: But the anger's also upsetting, is that what you're saying? P: Because it's unpredictable and it oozes out and I don't always see it until

it's pointed out. T: When you say it's unpredic table . . , i f . . . let me use an extreme example,

let's suppose someone from the audience comes up to you and kicks you in the ankle, would that make you angry?

By constructing and introducing an extreme example, the therapist can see how Debbie re- sponds to a scenario that is "here-and-now"rather than situations that are outside of the therapy situation. P: Yes. T: Would you express your anger? P: Probably in an instant. T: So if someone comes up and kicks you in the ankle, you'd say, "You know

you have a helluva nerve doing that, who do you think you are, you shouldn't do that?" You'd get pretty angry?

P: I probably wouldn't be that wordy. T: Is that right? Would that be appropriate anger? P: Off the top of my head, yes. T: So if someone comes up to you and kicks you in the ankle and you got angry

at them, would you feel guilty afterwards for being angry? P: Yeah. T: Why? What would get you from being angry at what they did to you and

then feeling bad about being angry? Can you describe the process?

TREATMENT OF A BORDERLINE PERSONALITY DISORDER 191

How does Debbie process the event? By asking her to explicate and describe the process in detail, possibly the thought-feeling-action connection can be elicited. P: It would be because of my response, its like I would have to have a reason

why I did that, obviously I did something to them. It's because I 'm the kind of person that I am that they did that. This is what I deserved, and on and on and on.

T: So if you were a better person, a nicer person, a sweeter person, a gentler person, they wouldn't have kicked you in the ankle?

P: That's right. There is an obvious segue in this example, the likelihood of Debbie's response being similar

to her response as a child where she was abused and hurt. It was then that she likely developed the idea that if she were a better person, the abuse would not have occurred. As before, this avenue is too much of a jump for the context or this brief contact. This is a rich avenue for further and future therapy work.

On the other hand, it may be an area that has been covered much over years and has been discussed with this and every other therapist, and is of little value at this point. T: H m m . . . P: I would be more angry that if you knew that about him why you wouldn't

try to defend me. T: So you'd then get angry at me? P: And then I'd be angry at you. T: So that the anger is with you all the time? P: Pretty much. T: There are two ways to look at anger in my view, one is that people carry

around with them a kind of basket filled with anger and they keep pulling from the basket and spreading the anger around the world, but if that were t rue then at some point the basket might be empty and you say, Whew, I finally got rid of that last piece of anger. What you're describing though is kind of a well that keeps being replenished from underneath so that you always have this anger that keeps being there. Is that right?

P: Yeah. T: Is that an accurate view on my part? P: Yeah. T: Have you thought about, either yourself or with John,* what generates the

anger, what keeps filling the well? P: Alot oftimesit's situational, ifsomethinghappens andthere'slike, someone

could have spoken up for me or in some ways defended me and didn't. [Patient's voice breaks and she gets teary.]

Here is the data to support the hypothesis of the anger, the lack of control, and the early abuse. This lead is very compelling, but I have decided that it would not be in the patient's best interest to explore it in this context. T: Let me just stop, you're getting real upset right now. Can you tell me if

* References to '~lohn" refer to Dr. J o h n Smith, Debbie's therapist.


you're comfortable in this setting, what is getting you upset r ight now? John, if you have a box of tissues, can I have them please? As you start ta lking about "why haven't I been defended; ' the tears come. What ' s going on right now that 's generat ing those tears coming?

By immediately focusing on the emotional response, we can access the disturbing cognitions (automatic thoughts). Once again, the focus has the effect of bringing the therapy work into the here-and-now. P: Tha t so many things happened and that there was no one there for me . . . . T: So what really gets upset t ing is the idea that "I should have been defended

or helped or suppor ted" P: Yes. T: But I wonder. Maybe the upset t ing par t is not that. W h a t it sounds like

is, "I should have been defended or helped or suppor ted andyou weren't." This addresses the patient's rules about how others should have acted. Her rules or expecta-

tions are, of course, entirely reasonable. We can probab ly all say "You know I should have been helped," "my teacher

should have been nicer" "my parents should have been kinder" "l shouldn' t have been hur t " You know we can all th ink of that. But the th ing that seems to be most upset t ing for you is more this last piece, you needed to be supported, to be helped, to be defended andyou weren't. A n d when you have that idea, I should have been defended and I wasn't, how does that make you feel?

The connection between the thoughts and feelings is important here. I have chosen not to explore the broad or specific parts of the abase. It would be too revealing in the context of being in front of an audience. The operative piece for her is, in my view, not the idea that being hurt is the issue, but rather that she was not defended. This is also my clue as to how to use the single session. I think that her issue is not being defended either externally or internally. Does she defend herself against her negative cognitions. I think not. P: Well I wasn't. A n d I have . . . it's like I jus t lost it. T: Well, does that make you happy? P: No. T: Does it make you sad? P: It's jus t the way it was. T: Does it make you angry? P: It's jus t the way it was. T: That ' s true, but as you look back on it, does it make you angry? P: I suppose.

She is either reluctant or unable to connect the thoughts or the emotions. She is also unable or unwilling to labd the emotions. I use a true~false format to help her to identify and labd her emotions. T: I don't want to put words in your mouth. P: I jus t th ink that people are enti t led to the basics. T: You're right, I th ink we can take a vote and most of us would agree with

that. M a y b e some people wouldn't , but most of us would agree you're en- t i t led to the basics and those basics include what?


Having endorsed her idea of being entitled to basics, whatever that means, I seek the meaning for Debbie. P: To be safe, to be protected, to be helped to survive. T: Right , and that wasn't your experience? P: No. T: But that was a while ago, wasn't it? You still carry it in your head? P: Like it was yesterday. T: Like it was yesterday. But physically it wasn't yesterday, was it? P: No. T: But in your head it could have been this morning? P: Right . T: W h a t goes on here [I point to my head] for you that keeps you upset all

this t ime? The thought-feeling connection is very important. This is basic in the C B T model. She

has been in C B T with an experienced C B T therapist, so there is no need to offer a formal description of the therapy. 73 emphasize the therapy, I chose to demonstrate throughout the session the connections between thoughts, feelings, and behavior. P: The noise in my head that 's very loud and critical, I can't do anything right. T: The noise in your head, what does that noise sound like? P: Sometimes it's a loud critical voice and sometimes there are so many of

them that it's like having an a i rp lane that flies over your head, one after another.

T: W h e n you hear the critical voices, what do the critical voices say to you? P: Tha t I 'm really bad, I'll never amoun t to anything, this is a joke, I 'm k idding

myself if I th ink that things are going to be any better. This is likely only a small sample of the internal negative dialogue. The initial hypothesis

of difftculty in accepting positives is clearer here. How can she see things as positive when there are all of these negative voices. Having Debbie verbalize positive affrmations would not be useful inasmuch as she would not believe them, no matter how often they were repeated. A goal of therapy would be to work from the other end. 73 quiet the negative voices and allow some room

for the positive seems a better bet. T: As you hear the voice say those things, how does that make you feel? P: Like I don't s tand a chance. T: You don't s tand a chance? P: No. T: I f any one of us had a bunch of people following us saying, "You'll never

amoun t to anything, you're worthless, you're a waste," what effect do you th ink it would have on any one of us?

P: After a while, you'll begin to belieye it. Here was an attempt at normalizing her experience.

T: Right , have you ever tr ied to argue with those voices? P: I must have at some point. T: You must have . . .

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P: I 'm sure . . . T: How about in the last six months, have you tried to argue with those voices

recently? My choice is to choose a proximal point. Six months is long ago, but still recent. 7b focus

on the more likely time frame of the last forty years would be far too upsetting. This introduces the therapeutic notion of countering the automatic thoughts. P: I argue with John instead. T: You argue with John instead, well maybe we can do it for free here. P: Okay. T: Okay, there are some advantages, for example, tell me again what those

voices say, I want to write them down. What are some typical things those voices say?

Having elicited some of the negative cognitions, I have decided to help her try to challenge them. This focus is far more reasonable than trying to modify the obvious schema. P: That you're no good, you don't deserve goo d things. T: Wait a minute, slow down, "you're no good," "you don't deserve good things"

I want to write them down. What else? [At this point the thoughts are being listed on the overhead.]

The thoughts run through her head like a runaway train. By directly slowing her down and writing each one on my overhead, I want to highlight each and every thought. P: You'll never amount to anything. T: "You'll never amount to anything" P: That I 'm kidding myself if I believe that things could be better. T: "You're kidding yourself to think that things ever will be better."

I f we took anybody in this room and we attached a tape recorder to their waist and there was a constant tape that ran "you're no good, you don't deserve good things, you'll never amount to anything, you're kidding yourself to think you deserve any better" what effect do you think it would have, say, on John? John's a pretty strong guy, I've known him for a long time. What effect do you think it would have on John?

Before challenging the negative thoughts, I want Debbie to see that having the thoughts is normal, reasonable, and expected, for anyone in the room. Given her life experience, it should not be a surprise to Debbie that there are many negative self-referential thoughts. The problem

for Debbie is that she does not question the thoughts. P: After a while it weighs you down. T: Yeah, after a while you start saying, Yeah, it's true. P: Uh huh. T: Is that what you're saying now, Yeah, it's true? P: Uh huh. T: You're agreeing with it. P: Uh huh. T: What do you think would happen, Debbie, if you challenged those voices

• . . those ideas. What effect do you think it would have on you?


P: Hopefully it would change. T: Okay, hopefully it would change? What would be your guess if you could

answer these voices back, if you could, what would happen to the voices? What 's your prediction?

P: I'd . . . it would get louder and then go away. T: You think it may" get louder and shout you down? P: Initially. T: Initially? I'd agree with that, I think initially the voices will get louder, but

then they'd probably . . . ideally, go away. When you hear these voices is there a particular person or voice attached

to it? Here is the family-of-origin connection. It is not one that I want to emphasize, at this point.

Whatever the answer, I will not delve more deeply. This is for the ongoing therapy. The ex- ploration would be more of a distraction in this context. It is a great lead that will be allowed to pass.

P: Sometimes it's my own, sometimes it's my stepfather's, sometimes it's my grandmother's.

T: So there's specific people that you can hear saying these things? P: Uh huh. T: Let me just explore something with you in terms of this, because what you're

saying is by believing these things you then say, "I should have been defended and not have heard these things and I wasn't and that makes me really sad and angry"

P: Uh huh. T: Is it true that you're no good?

Can she examine the evidence for goodness or badness? P: I've had a good day now. T: So you have a good day. What would be a good day? P: I don't really know, it's kind o f . . . like I guess . . . I haven't had one in

a very long time that I don't remember what it's like. T: But if you were to have one of these infrequent good days you wouldn't easily

say you're no good, you would say what, maybe you're not so bad? P: No, it would probably have more to do with the environment, with the sun

being out and going for a walk. Debbie externalizes her good days. She has no control. This is a basic schematic element.

Rather than confronting and disputing the schema, I'll try to collect data to have her challenge

the absolutistic nature of this idea. T: Okay. Do you believe you don't deserve good things? P: Most of the time. T: So you only deserve bad things? P: Yeah, basically.

I will take an extreme position. Will Debbie take a more moderate one? I am not sure. I'll try an extreme metaphor. T: Do you go and buy torn clothing?


P: I hate shopping. T: That 's not what I asked. P: No!! [She is very emphatic.] T: Do you pull clothes out of the trash can? P: No!! [More emphasis.]

Debbie seems to be getting annoyed. I will try to gently push. T: Why not? Those are pretty bad things. P: Because I 'm probably not tall enough to get in it, I don't know . . . . T: Do you pull clothes out of the trash? P: No!! T: Do you sneak out to the Salvation Army dumpster at night? P: No!! T: Why not, because if you don't deserve good things, so why not go out and

get bad and torn things? P: Because I have enough to wear. T: Is that the only reason? P: I never thought about it. T: Think about it. P: I don't want to think about it!! T: Why you don't deserve nice clothes, clean clothes? P: It's not a big deal.

Debbie's annoyance with this line of therapy is clear and emphatic. 73 continue in this vein is to risk harming whatever therapeutic alliance we have developed. I'll back off and come at the problem another way. My goal was to ask Debbie to operationalize her meaning of being uruteserving of good things. My hope was to use it to help her examine evidence for her belief. I'll go back to safer ground. T: Okay, if you could quiet these voices, there's a chance that you might feel bet-

ter, all right. Do you ever try to argue with the voices, to challenge these ideas? P: Yeah. T: And the result of that? P: The noise gets louder and I begin to hurt myself. T: I 'm not clear, if you try to answer the voices the noise gets louder and then

you hurt yourself. P: It's part of a chain of events, its just so loud, it wins. T: And when it wins, its reward is that you hurt yourself?. P: Yes, I know it doesn't make sense, but . . . T: Help me understand it, Debbie, I 'm trying to understand the sequence.

The voice says, for example, "Debbie, you're no good," and you say, "Yes I am" then the voice says "Forget it, no you're not," and you say "Okay, you're right, no I 'm not" and then you do what, you hurt yourself?.

P: I start getting more and more agitated and it pretty much plays into the noise, but, yeah you're right, ! say, "This is the truth, you are a worthless piece of crap."


T: . . . and, and what, you're a worthless piece of crap and . . . . P: Yeah. T: I f the result is that you hur t yourself then you then say you're a worthless

piece of t r a p and you want to do something to prove it? P: No, I jus t know it jus t happens. T: W h a t jus t happens, you hur t ing yourself?.

The "it" externalizes the problem. "It happens without M Y doing anything." P: Yeah, sometimes the pressure feels so big it's like sometimes it eases . . . T: Hur t ing yourself?. P: Yeah. T: Have you ever kind of t r ied to tough it out and let the noise bui ld and bui ld

and not hur t yourself?. P: I have a contract. T: A n d what happens then? P: First I t ry to deal with it. And then, and if it hasn't gone away, I'll call John

or Dr. White. [N.B.: Dr. Whi te is a colleague of John 's and works in the same practice. They will cover for each other's pat ients as needed.]

T: Okay, and what happens then? P: Usual ly in talking 5 minutes on the phone it's enough to work it through

and it might not be total ly gone, but at least its bet ter and I don't have to hur t myself.

This is great news. Debbie can be, and is, able to take control-- at this point, with the therapist. The ultimate treatment goal is for her to internalize it. (Linehan, 1994). T: It's not up here? [Therapis t points to his head.] P: Right . T: Okay, why when you talk about it does it then release some of that pressure?

What ' s most helpful? P: W h e n I 'm exper iencing a lot of pain I tend to hold my brea th and sort of

black out. I have to go to someplace else that eases the pain so what I 'm working on is t ry ing to b r ing it out so that it won't stay stuck inside.

T: A n d then you don't dissociate?

P: I do, but I can come down from being up in the ceiling and I can hear the voices and be able to work it through.

Another great lead for therapy work, but one that I will choose to not take, given this context. T: Okay, what do you think would happen, Debbie, if you could answer these

voices back as soon as you hear them? W h a t do you think the result of that would be?

Would direct disputation work? I want to try it out. P: The way to go is that I could talk back to the voices, I could be louder and

make myself heard. T: A n d what do you think would be the result of that? P: Tha t I could feel better. T: A n d what would be the result of that?


P: That I wouldn't have to hurt myself anymore. T: And what would be the result of that? P: I wouldn't see John anymore. T: And what would be the result of that? P: I would be very sad. T: That you wouldn't see him? P: Yeah, even though it would hurt sometimes . . . .

The downward arrow technique has Debbie looking at each successive level of belief(Freeman, Pretzer, Fleming, & Simon, 1990). T: Sometimes. If you're able to not hurt yourself, if you're able to feel better

about yourself, if you can answer all of these negative voices, then you wouldn't need therapy and you would lose John as a support.

P: By that time I wouldn't need it. T: You're not so sure about that? P: Well definitely no, I've really taken a long time to be able to talk with him. T: Yeah, one of the things that I said to you when we just started talking, Debbie,

is the fact that you're just doing what you're doing with me shows a great deal of courage. Can you see it that way, do you see yourself as courageous? What do you think when I say to you I think that you're courageous and that most people in this room would not have the strength to do what you're doing?

I want to come back to the initial hypothesis. What will she do with the positive statement. It is not meant to simply pat her on the back. I truly believe that very few of the 100 or so people in the audience would have the courage to do what she is doing. She keeps dismissing the positive to avoid the voices and hurting herself. Avoidance has become one of Debbie's major coping tools. P: It's not a big deal. T: It's not a big deal? P: No. T: So if you do something really positive, really in effect very powerful, you

dismiss it how? P: I don't know, it's that I 'm doing this and just keep on doing it. T: So it doesn't require any strength or courage on your part? What do you

think they're [pointing to the audience] thinking, do you think they con- sider it courageous?

P: I don't know. T: Maybe we can check later.

I have planted a seed. There is no reason to follow that lead now. I'll come back to it later. P: It's a very negative thing right now and I'd beat myself up, because it's just

too much. T: So if everyone here comes up and says, Debbie, boy you did a great job? P: I wouldn't know what to say. T: You could just say, Thank you . . .

T R E A T M E N T OF A BORDERLINE PERSONALITY DISORDER 199

P: Well, I know that . . . T: Inside what would you say?

P: It's not a b ig deal. T: So you kind of dismiss the positive? P: U h huh. T: A n d emphasize what you don't do or what you see as a negative? H m m m .

Would you be willing to try a little exper iment with me? I'll tell you what it is, don't agree to it unti l I tell you what it is.

P: Okay. T: W h a t i f . . . you've gone to school, have you ever been in a debate at school? P: No. T: Never in a debate?

P: No. T: Have you ever seen a debate? P: Yeah. T: What ' s your unders tand ing of a debate? P: You do your best to be the most convincing. T: Right . W h a t if you and I were to have a debate, I would like to be this

really negative voice and what I want you to do is debate with me. I want to see if you can quiet me down. Would you be willing to try that?

The session is about half gone. I have made a clinical decision. By externalizing the negative voices I think that several points can be made. First, I can demonstrate the technique to the audience. Second, we can see exactly how Debb# copes with the negative voices. Third, Debbie can see just how she copes. Finally, we can use the data from the experience to try to help her to respond in a more adaptive fashion. P: Yeah. T: Okay, so I 'm going to be the negative voice and you're going to debate with

me. You're going to try to quiet me. Got it?

P: Yeah. T: Okay, in fact, one of the things we can do here that we can't otherwise do,

I'd like to stack the deck. Do you mind if I do that? In your favor, of course. Can we do that? All right, John, I 'd like to invite you to jo in us. I would like you to sit next to Debbie and if she starts having t rouble I would like you to help her out. Okay? Would that be all r ight with you?

P: Yeah. T: Okay. [To John] So you don't have to say a word until she gets into trouble.

[To Debbie] You in t rouble yet? P: No. T: No? Okay. So this is you and me. P: Okay. T: But if you need help, we've got the enforcer [point ing to John]. Okay? All

right. You know, you're really no good, you're really a worthless person. P: You're right.


That was fast. She immediately agrees with the negative voice. T: Wait a minute, wait a minute. What kind of a debate is that?

[John says something to her. She moves back into role.] P: Why would you say that? T: Oh, no reason, I just think it. P: Of course you need a reason. T: No, I just think you're a worthless person, you're just, you're a bad person. P: Nobody's listening. T: Except you. You're no good and you don't deserve anything good happening

to you. P: That 's not true. T: It is true. [Stopping.] What 's happening? P: All I hear are negative voices, it's like I 'm lying to you. T: That 's right. So we have a problem with this debate because you hear the

negative idea and the voice inside you says "True, you're right." I f you could say the things that would quiet me, that might be a beginning and you don't have to believe it. At first you have to practice saying it. You okay? What I'd like to do is switch roles. Okay?

P: Uh huh. T: I would like for you to be the negative voice and I want to see i f I can model

for you a way of responding. Okay? Can you be the negative voice that beats you up?

P: No problem. Certainly she has no problem being the negative voice. I want to model a strong and adaptive

voice that is not afraid of the negative voice, but is assertive and reasonable. A voice too un- reasonable will be rejected by Debbie, and a voice too positive will be rejected as "cheerleading." I have to model some level of adaptive response. T: No problem? Do it. P: You really aren't worth a piece of crap. T: Says who? P: Says me. T: Who the hell are you to tell me that I 'm no good? P: I know it all. T: I think you know very little, you have no right to make judgments on anyone. P: It's not just anyone, I 'm talking to you. T: Oh, it's me and you have no right to make judgments about me. I 'm not

worthless and I don't have to listen to this garbage from you. If you weren't so damn stupid you wouldn't even say something like that. Just who in the hell do you think you are talking to me like that? I 'm sick and tired of hearing it.

[Debbie sits back in her seat, shakes her head, and smiles.] Where's that negative voice, Debbie? Where is it?

P: You're being a pain in the butt.


T: I may be a pa in in the butt , but I 'm t ired of feeling bad, I 'm t i red of hur t ing myself, I 'm t i red of b l aming myself for everything, and it's your fault and I want to hear no more of it. Where ' s the negative voice?

P: I don't hear it. T: Wait, let's back up. Where did the negative voice go? P: I jus t feel like I 'm sinking. T: You're sinking right now? The negative voice is sinking, or you're sinking? P: I 'm sinking. T: Why? W h y are you sinking? P: Because I can't keep up with you . . . .

She interprets this as a failure, and feels like she is sinking. She may believe that I have overwhelmed her and "won." Maybe I have. I'll back off. T: Okay, what do you say to yourself that 's mak ing you sink? P: I 'm jus t gonna be loud, I feel fine now when I 'm loud. T: Does it feel bet ter or worse when that negative voice is quiet? P: Better. T: W h e n I was really doing a job on that negative voice you were smiling. Why?

I wanted to do two things here. First to understand why Debbie was smiling, and second to give her some breathing space. P: Well, you're quite powerful. T: Yeah. Why were you smiling? P: Cause it was kind of funny. T: It's funny? You weren't laughing, you were smiling. P: Well I guess I never stood up to myself in that way. T: A n d you were smil ing because of what? P: Because of how you were saying it. T: Are those things you could say? P: Today? Yeah. On ly one th ing . . . T: I have a hunch, let me share my hunch with you, Debbie. W h a t I . . . my

experience over the years has been that very often people car ry voices that they give great power to. Tha t the voices are kind of l i k e - - D i d you ever see the film The Wizard of Oz? The par t where they are in the Wizard's castle and want to talk to the wizard, and they see this fearsome image on a screen saying, "I'm the great and powerful O z " R e m e m b e r that scene?

P: U h huh. I decide to use a metaphor that has great power. I f the image has no meaning for Debbie

it would not be worth explaining. I would try to 3~nd another image. T: W h a t was he? Was he a great wizard? Wha t was he? P: A sorry old man. T: Us ing all kinds of tricks to make himself look bigger and sound bigger. I

wonder . . . and I 'd jus t like to present that for your considerat ion . . . is it possible that this negative voice is like the W i z a r d of Oz? Because if we could shut that voice up so easily that it's a lot of bluster and a lot of

202 FREEMAN e JACKSON

noise and lot of smoke, but it's not as powerful as it makes out to be. Is that possible?

At this point I am addressing her beliefs that people in power are indeed as powerful as they make themselves out to be. I am fully aware that the image of the "pathetic old man" may well be the stepfather who was viewed as very powerful. Again, given the context and the limit of our contact, I will plant the seed for her therapist to harvest. P: It feels like it. T: Right now it feels like it? Okay. So what I'd like to do, if that's true, I 'm

going to be the negative voice again and I'd like you to really be tough. No messing around, and John's there to help you. I want you- - don't just be gentle -- I want you to really quiet me cause I 'm not doing you any good. I 'm not your friend. I make you feel bad, you get angry, you hurt yourself. Okay?

Having offered the metaphor that the voice may not be that powerful after all, we need to try the debate again. Can she be helped to feel powerful?

"You know, Debbie, you're no good. You're worthless." P: That 's not true. T: "Yeah it is. Yeah it's true. You're no good, you'll never amount to anything."

Come on, that's it. P: [John offers a response. Debbie gulps and then repeats it.] Who the hell

are you? T: I 'm the negative voice, I've been here a long time. And don't you talk to

me that way. P: Okay. [audience laughs.] T: Oh boy! In that one time when you said what John did, how did you feel? P: It was great.

I wanted Debbie to identify what she was feeling at that moment, and to offer her feedback about her response. T: Again, I wish you could see yourself, if we had a mirror to see you weren't

smiling, you were grinning, you gulped once and then said, "Who do you think you are anyway?" But it felt good?

P: Uh huh. T: Let's do it again.

"You're a worthless individual, you don't deserve anything good to happen to you"

P: That 's not true. T: "It's been true for years, Debbie, lets just face i t - -you ' re a worthless piece

of crap." P: Who the hell are you? T: "I am just your voice, I've been with you a long time; that gives me great

longevity and seniority and I know you're worthless." P: Things can change.


T: Oh, yeah, yeah, sure, the oceans can all dry up. You know you're worthless and you'll be that way forever.

P: [John whispers to her.] You're just like the character in the Wizard of Oz. T: "You know you're just kidding yourself if you think that things will ever

get better. You'll always be . . . you know . . . no good, worthless, a loser, a piece of crap"

P: You don't know that. T: "Well, I 'm inside your head, I know everything. I 'm the smartest thing going" P: Who says so? You don't know everything. T: "Well, I know, I may not know everything but I know you're no good." P: You're a disturbed pathetic old man. [Debbie starts giggling.] T: Let me stop. You look, you've gone from smiling, to grinning, to being almost

giggly. Why? The here-and-now focus invites her response.

P: I guess it's all the things he's [pointing to John] saying about you. T: He's not saying it. You're saying it. I 'm running out of things to say. P: It's the same stuff, you'll run out of them. T: Exactly. B u t . . . "yeah says you." How does it feel for you right here, right

now, to say those things? P: It's like you're talking about somebody else. T: So if you practice and then they get to be yours. How does it make you

feel when you start getting giddy and start giggling? What are you feeling? Here we can focus on the need for practice via homework.

P: A lot lighter. T: Lighter? Does it make you want to go out and hurt yourself?. P: No, not at the moment . T: So when you're able to answer that voice back, to be really tough, do you

feel guilty for quieting that voice down? P: Not yet. T: But you might. P: Uh huh. T: Okay. And that's something else that you're going to work on with John.

Right here, right now, you've gone from smiling to grinning, to giggly, just answering this negative voice back. Debbie, what's been going on inside your head?

P: Well I haven't been thinking about the voice. T: Okay. Having someone nearby is real helpful. P: Yeah. T: Okay. Well let me recommend something that might be a good exercise,

some good homework for you. Was this little exercise painful? P: In the beginning, I was afraid I wouldn't have the right answer. T: And then . . . P: I would fail.


T: And then what happened?

P: I get really nervous in front of all these people. T: That 's right, but what happened instead of that? P: I 'm still here, I didn't move. T: Are you embarrassed in front of all these people? P: Not yet. T: Not yet? Okay, let me suggest something that can maybe be helpful. Do

you have a cassette recorder at home? P: Yes. T: Okay. I would like to recommend something, and again this is something

I'll recommend for John and you to work on. I don't think your negative voice is that terribly clever. Okay? I don't think it's terribly smart. I think it's kind of a Johnny One Note. It has just the same things over, you're no good, you know, same kind of crap over and over again. First thing that I'd like to recommend is that you write those thoughts down. Try to identify all of the thoughts, those negative thoughts that this really insistent negative voice annoys you with. Then what I'd recommend you do is to record them on a tape recorder in the following way: You're no good, You're a worthless piece of c r a p - and give yourself about ten seconds between each negative statement -You'll never amount to anything in your life-- 10 seconds--You're just a piece of crap, no one even caresabout you. And then, I 'd like to recommend . . . . Do you understand what I 'm asking so far, to work with John, cause John's a good helper on this, you just saw what he d id - - to come up with responses that you can write down.

So what I'd like for you to do is that you're going to go home and you're going to put on your cassette recorder and a voice is going to say "You're no good." And you're going to practice, "You know you're full of shit, I don't have to take that from you, you're a worthless jerk, you're a stupid, stupid voice, I don't have to agree with you any longer"

"Nothing's going to ever work out for you" Well, that's not true, something is working out right now, I 'm shutting you up. Write those down and practice them a couple of times a week. So you're going to become your own negative voice on the tape and John's going to help you respond. Does that make sense?

P: Yup. T: What do you hear me asking you to do?

I want to be sure that Debbie and I are talking about the same thing. By having her repeat the homework, I can monitor and change, if necessary. P: Change the way it is. T: Is this something you think you'd be able to manage to do? P: Yeah. T: You can practice it in the office and then you can work on it at home. John,


is that something you'd be willing to work with Debbie on? [John agrees.] Okay. I f you could quiet that negative voice, what would the result be?

P: I wouldn' t need to hur t myself. T: Would that be good or bad? P: Good. T: Okay. We're runn ing close on our time. Let me ask you, as our t ime is al-

most up, what are you going to take home from today's session? W h a t have you learned?

I wanted Debbie to review the session work for herself, for me, and also to have the audience hear what she was taking home. P: W h a t I did. T: Wi th what? P: Change. T: Yeah and . . . P: Quie t ing the voice. T: Yeah, what else? P: Tha t I have a way now of t ry ing to use the mechanisms I have . . . . T: Okay. H o w . . . W h a t word do I want? How likely do you th ink it is you'll

be able to do this? P: Well, I want to be realistic because you suggested and it seemed like a pre t ty

good idea, it's not like its gonna change right away like today. T: You're right. You know maybe it wouldn't change your behavior at all. Maybe

it won't change things one bit. How are you going to find out. P: I 'd have to t ry it. T: Okay. Sounds like a good idea. In closing, Debbie, how do you feel about

what we've done in the last 45 minutes? P: I 'm more relaxed than in the beginning. T: More relaxed than in the beginning? P: U h huh. T: Did I say anyth ing that upset you or hur t you? P: No.

T: Did I say anything that you found obnoxious or difficult to deal with? P: No. T: Okay. What ' s your overall impress ion of the 45 minutes we spent? P: I was on the hot seat. T: You certainly were. Okay. How do you th ink you did on the Hot Seat? P: Well, I 'm still talking. T: You survived? P: Yeah. T: O n a scale of zero to one hundred , where zero equals total failure, one hun-

dred equals really positive. How do you th ink you did today? P: Sixty. T: Better than half. You know I 'm going to ask them [the audience] the same


question, they're listening to us of course, and I 'm going to see what their view is. Once again, if what you said is accurate, that you underestimate your value, so you're giving yourself a sixty which is still pretty good, would you be interested in hearing what they think? Or would you rather not hear it?

P: Okay. T: Okay, we're going to stop and what we're going to do, they're going to have

a chance to ask me questions. Would you like to stay, and maybe they'll have some questions for you, and if you feel comfortable maybe you can answer them.

P: Okay.

At this point the session ended. Debbie stayed for a brief question session and then left. She was debriefed by her therapist at that time and reported feeling quite positive. She told her therapist that she hoped I didn't take her statements about being a pathetic old man personally. He assured her that I did not.

Discuss ion

Debbie's schema provides the instructions that guide the direction and quality of her daily life (Young, 1990). The products are largely conscious and accessible to consciousness. Her dysfunctional feelings and conduct are largely due to the function of certain schemas that tend to produce consistently biased judgments and a concomitant consistent tendency to make cognitive errors in certain types of situations. What is clear in this interview is that the schematic errors, not unconsciousness or defensiveness per se, are the source of her difficulties. Given the long-term nature of Debbie's characterological problems, her general difficulty in relating to others, and her emotional lability, the diagnosis of borderline seems appropriate. It is interesting to note that in some ways Debbie differs from the typical, stereotyped Axis II patient who is referred through family pressure or legal remand, who generally avoids psychotherapy, presenting with poor motivation and a seeming reluctance or inability to change. Debbie, on the other hand, comes to therapy and works hard. Also, she did not seek out therapy because of an Axis II disorder. She came, as is typical, with Axis I complaints of depression and anxiety. The reported problems may be separate and apart from the Axis II patterns or derived and fueled by her Axis II personality disorder.

Debbie sees the difficulties that she encounters in dealing with other people or tasks as often outside of her self or her control. She does, however, see her role in the interactions. Her problem is how to take and maintain control. An- other difference between Debbie and many Axis II patients is that she has an idea of why she is the way she is, how she got that way, what she would like to do, and how to do it. The problem is more how to build tolerance for the

T R E A T M E N T OF A BORDERLINE PERSONALITY DISORDER 207

ongoing frustration and to increase her threshold for the frustrations that lead to emotional outbursts.

The degree to which Debbie's schemas are on the continuum from active to inactive, as well as the degree to which they are on the continuum from un- changeable to changeable, is an essential dimension in conceptualizing her problems (Beck, Freeman, & Associates, 1990; Freeman et al., 1990). Her active schemas relating to trust and dependence are central (Young, 1990), and govern her integration of information from her environment. Debbie's inactive schemas exist outside of awareness and become active when under stress, serving to govern behavior. Of course, when the anxiogenic situation is no longer present, the inactive schemas recede to their previous state of dormancy. It was important, therefore, that the stress of the interview be kept low, and that the therapist back away from any confrontation.

Debbie's cognitive distortions served as signposts that suggested schema. The goal of the therapy session was to help her to identify some of the different rules that she lives by and to work on schematic modification (Freeman et al., 1990). This involved asking her to make some changes to her basic manner of responding to her internal world.

Summary

Debbie, a patient in ongoing therapy, volunteered to assist in a workshop by participating in an interview. The goals of the session were to identify some small, discrete problem that could he worked on in the limited time available, and to demonstrate how a short-term treatment can be used.

The issues considered revolved around Debbie's schema. Her early abuse set several schemas that have directed Debbie's life. The goals of the therapy would be to help modify those rules. The single session was a microcosm of a longer-term therapy. Overall, from the reports of the patient and her therapist, on follow-up, she was able to do the homework with the therapist's as- sistance and found that it was helpful in countering the negative thoughts. This led to a lifting of the concomitant depression and a diminution in the self-injurious behavior.

Many sessions would be needed to reinforce and strengthen the exercise started in this session. Overall, I would see this session as both a successful treatment session and a demonstration of how identifying discrete, proximal goals can benefit patients with long-standing Axis II problems. The hypotheses and questions led to data gathering and hypothesis testing. Throughout the session, it was essential to be aware of the likely schemas so that some could be used in the session, while others were clearly avoided. By developing a conceptualization or model of the problem(s), a set of interventions could be mobilized within the session and as homework between sessions. By working toward a coping model of treatment rather than attempting to cure long-standing problems, brief cognitive behavioral interventions can be successful.


References

Basch, M. E (1992). Practicing psychotherapy: A Casebook. New York: Basic Books. Beck, A. T., Freeman, A., & Associates (1990). Cognitive therapy of personality disorders. New York: Guil-

ford Press. Bloom, B. L. (1992). Planned short-term psychotherapy. Boston: Allyn and Bacon. Budman, S. H., & Gurman, A. S. (1988). Theory and practice of brief therapy. New York: Guilford Press. Budman, S. M., Hoyt, M. F., & Friedman, S. (Eds.). (1992). Thefirst session in brief therapy. New

York: Guilford Press. Cade, B., & O'Hanlon, W. H. (1993). A brief guide to brief therapy. New York: W. W. Norton. Crits-Cristoph, R, & Barber, J. R (Eds.). (1991). Handbook of short-term dynamicpsyvhotherapy. New York:

Basic Books. Fisch, R., Weakland, J. H., & Segal, L. (1982). The tactics of change: Doing therapy briefly. San Fransisco:

Jossey. Freeman, A., & Leaf, R. (1989). Cognitive therapy of personality disorders. In A. Freeman, K. M.

Simon, L. Beutler, and H. Arkowitz (Eds.), Comprehensive handbook of cognitive therapy. New York: Plenum Press.

Freeman, A., Pretzer, J., Fleming, B., & Simon, K. M. (1990). Clinical applications of cognitive therapy. New York: Plenum Press.

Garfield, S. L. (1989). The practice of brief therapy. New York: Pergamon Press. Gustafson, J. E (1986). The complex secret of brief psychotherapy. New York: W. W. Norton. Langley, M. H. (1994). Self-manugem~nt therapy for borderline personality disorder. New York: Springer

Publishing. Lankton, S. R., & Erickson, K. K. (Eds.). (1994), The essence of a single-session success. New York:

Brunner/Mazel. Layden, M. A., Newman, C. F., Freeman, A., & Morse, S. B. (1993). Cognitive therapy of borderline

personality disorder. Boston: Allyn and Bacon. Linehan, M. M. (1994). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. O'Hanlon, W. H., & Davis, M. W. (1989). In search of solutions: A new direction in psychotherapy. New

York: W. W. Norton. Preston, J., Varzos, N., & Liebert, D. (1995). Every session counts." Making the most of your brief therapy.

San Luis Obispo, CA: Impact Publishers. Sifneos, P. E. (1987). Short-term dynamic psychotherapy (2nd ed.). New York: Plenum Press, Sifneos, R E. (1992). Short-term anxiety-provoking psychotherapy. New York: Basic Books. Walter, J. L., & Peller, J. E. (1992). Becoming solution-focused in brief therapy. New York: Brunner/Mazel. Wells, R. A., & Gianneti, V.J. (Eds.). (1990). Handbook of the brief therapies. New York: Plenum Press. Young, J. E. (1990). Schema-focused cognitive therapy for borderline personality disor&z. Sarasota, FL: Pro-

fessional Resource Exchange.

To maintain the authenticity and flow of the session, the grammatical errors or dysfluencies of therapist and patient were left unedited with few emendations.

RECEIVED: August 5, 1996 ACCEPTED: August 12, 1996

single session treatment of a borderline personality disorder

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