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APA Psychotherapy Training Videos are intended solely for educational purposes for mental health professionals. Viewers are expected to treat confidential material found herein according to strict professional guidelines. Unauthorized viewing is prohibited.
In Cognitive Therapy for Borderline Personality Disorder, Dr. Mary Anne Layden demonstrates her approach to working with clients with this diagnosis. This therapy focuses on helping the client to substitute the unsuccessful compensatory strategies associated with this disorder with effective life skills. Therapy with clients with borderline personality disorder can be difficult, as the disorder generally involves deep mistrust of other people. In this session, Dr. Layden works with a 40-year-old woman who reveals some potentially suicidal and homicidal thoughts. Through role-playing, Dr. Layden helps her client to learn skills for expressing her anger appropriately. This video features a client portrayed by an actor on the basis of actual case material. Precipitating Events The client, Magda, entered outpatient therapy with Dr. Layden after spending 10 days in the psychiatric unit of a local hospital, a result of a serious suicidal attempt (i.e., an overdose of barbiturates). The hospital psychiatrist recommended individual outpatient treatment when Magda was released from the hospital approximately 20 weeks before the session to be viewed (Session 19). As the eldest of three daughters, Magda was often maligned by her father, a Romanian-born attorney who immigrated to the United States as a young man. Raised in a family that was disparaging of women, he was an angry, hypercritical man by virtue of his own upbringing. Magda's father's attitudes and behavior toward his wife and three daughters exemplified this disparaging attitude. He constantly belittled them for their lack of intelligence and their "sloppy" appearance. Other than high-status male attorneys, physicians, and bankers, he held most people in low esteem and was highly vocal about it. According to Magda, her mother was passive, compliant, and avoidant. She would not challenge her husband's hostility directed toward her or her daughters. Magda's mother acted more as a sister to Magda; they watched old movies together on television and daydreamed about soap opera stars, activities they kept secret from Magda's father. However, when Magda's mother was depressed, particularly when Magda was a young child, she would withdraw emotionally and was unresponsive to her children's bids for emotional engagement. As Magda became an adolescent, her father focused his negative comments on her developing body. Although she was of average weight when she started therapy, at age 15 she was about 10 pounds overweight. Her father would call her a "pig" and ran a constant negative commentary about other aspects of her appearance. Her family life engendered in Magda schemas of herself as defective, unlovable, incompetent, and powerless and of the world as hostile and untrustworthy. She internalized her mother's avoidant behaviors and her father's demeaning voice. She was constantly bombarding herself with critical judgments. Like her father, she also mistrusted most people, and she was particularly distrustful of anyone who reminded her of her father. Magda had few coping strategies and tended to compensate with avoidance and, when schemas of incompetence were triggered, with outbursts of rage. Self-destructive fantasies and impulses occurred frequently. When angry, she would often drink alcohol and drive. At other times, she would give into urges to cut her forearms with a razor blade. She often had an impulse to buy a gun. Magda had particular difficulty at work, where she was expected to be at the service of others administratively. She was consistently late and often called in sick so that she could stay at home and read in bed. She felt entitled to this because she believed that her supervisors, particularly the men, expected more of her than they did from other employees. She also used this belief to justify taking long lunches and to otherwise abuse the system. She responded to reprimands, even those diplomatically delivered, with stony silence or with outrage. She found it impossible to consider that she was in the wrong and had no idea how to rectify the situation in the rare instances when she could admit to herself that she was at fault. Magda married at age 22, a month after she met her husband, and the marriage was disastrous from the start. Her husband, who had showered her with gifts and praise when they met, became narcissistically demanding once they wed. He insisted that she dress in certain ways when they were in public and constantly voiced his fears that she would become obese. Like her father, he eventually called her abusive names. When she discovered that he was having an affair with one of his colleagues, she insisted that he move out of their home. Later, she left long telephone messages for him, begging him to return, but he did not answer her phone calls. Magda then became involved with a married man at work, who was withholding and narcissistic. When he was unavailable, she would pick up men in bars, stimulated by the inherent danger and by feelings that she was getting even with her lover. Eventually, her paramour ended their relationship, and Magda found herself extremely depressed. It was at this point that she took the overdose of pills. She began her least self-destructive relationship with another patient whom she met while she was hospitalized. John was too fragile to hold a job or go to school, but he was not abusive to her. In fact, he seemed to worship her. They primarily had a telephone and letter relationship after she was released from the hospital. She entertained extensive fantasies of helping John "become whole" and then living together happily ever after. Questions
Process Notes on Initial Sessions Sessions 1–18: Magda began therapy with Dr. Layden immediately after her discharge from the hospital. Dr. Layden used the first sessions to structure small successes in getting her living situation better organized. Magda had returned home to stacks of unpaid bills and a completely disorganized apartment, and she felt overwhelmed. Trust in the therapy was built in part when Magda was able to meet these jointly derived and manageable goals (e.g., obtaining a file box one week, organizing her financial files the next). These successes provided tangible proof to Magda that Dr. Layden would not expect too much of her yet was also interested in her becoming more effective in the world. Together, Dr. Layden and Magda would celebrate her successes or, when Magda was not successful, figure out what had gotten in the way and how to handle those contingencies next time. Dr. Layden helped Magda avoid black-and-white thinking by teaching her not to discount the outcome when she was partially successful. Trust was also built by predictable behavior on the part of Dr. Layden (e.g., always being on time for appointments; being clear about cancellation policies). When Magda would test these limits, Dr. Layden would nonpunitively maintain the therapeutic framework. Once her living situation was better organized, a majority of time in sessions was spent on Magda's employment situation. Cognitive–behavioral techniques aimed at getting her to work, and to work on time, included writing about the advantages of going to work rather than staying home (she kept a "therapy notebook"). Magda would also write of the advantages of not responding in anger when her supervisor corrected her work. In her therapy notebook, Magda kept track of what she was working on in therapy and her many small successes in better managing her life. When Magda was able to get to work on days she had a strong impulse to stay at home, she would record in her therapy notebook at the end of the day whether she felt better than if she had stayed home. She and Dr. Layden planned rewards for successes such as these. One major reward was reading in bed after she came home from work. Her therapy notebook also contained exercises and homework assignments that were geared toward current life challenges. For example, when focusing on her role as an employee, coping statements were written during the session that were later copied on Post-it notes placed strategically around the house or at her desk at work. Examples of these coping statements included
Magda sometimes used a printed form to help analyze an unexpected situation that was causing her a problem between sessions. On this form, she would describe the situation, the automatic thoughts she had about it, the assumptions that seemed to underlie those thoughts, any images or nonverbal sensations related to the situation, any emotions that she could label, and any life skills she and Dr. Layden had worked on that might be useful in managing the situation. Toward the end of this time, Dr. Layden began working on less concrete skills with Magda, such as communication skills. Magda had no idea how to be assertive without being abusive or how to interact verbally from a position of equality rather than from a position of one-upsmanship. Dr. Layden helped her to begin looking at how her "father's voice" inside of her would prompt her to behave like him in current situations. She would also help Magda compare "the then with the now" to determine whether her schema fit the present situation. Magda had never learned how to rectify interpersonal situations in which she had behaved inappropriately. Therefore, when Magda had acted objectionably, Dr. Layden would explain why and how to apologize so that Magda could do so without feeling overly shamed or feeling as if she were groveling. Dr. Layden encouraged Magda to keep her relationship with John on a friendship level until she got to know more about herself and what she needed from dating relationships. Identifying needs in relationships (rather than impulsively acting them out) was a new skill to learn as well. Throughout the sessions, any problems that arose between Magda and Dr. Layden were subjected to this same kind of problem solving. Dr. Layden modeled taking responsibility for one's part in a problem (e.g., admitting that perhaps she had not been too clear on a particular point), without having to give up one's entire position on an issue. When Magda was able to restrain her abusive comments when she was enraged during a session, Dr. Layden let her know how much more effective her less dramatic statements had been. Session 19: To be viewed Questions
Stimulus Questions About the Session Dr. Layden opens the session by stating that she and Magda are going to talk first about what they want to work on and make progress toward in the session. She asks Magda, "Have you thought a little bit about the agenda for this week?"
About 8 1/2 minutes into the session, Magda complains that her hands "feel like wood." Dr. Layden suggests that Magda slow her breathing and rub her hands together, while Dr. Layden models these behaviors herself.
About 11 minutes into the session, Dr. Layden characterizes Magda's desire to call her coworker names and hit him as understandable efforts to cope and protect herself. Dr. Layden does not blame the patient or label her aggressive impulses as inappropriate or as an overreaction.
About 19 minutes into the session, Magda hesitantly reveals her impulse to purchase a gun and her actual behavior of buying whiskey and driving while drinking.
About 21 minutes into the session, Dr. Layden asks Magda to describe in sensory detail the image, sound, smell, and feeling of her father's belittling voice as she experienced it as a young child. Several minutes after, Dr. Layden asks Magda to shift to "just the opposite of that voice." In response, Magda images her riding instructor.
About 30 minutes into the session, Dr. Layden and Magda role-play the "strong riding instructor" (Sandra) apologizing to Magda's coworker (Gary) for calling him names and "flying off the handle." Magda subsequently practices telling Gary herself that she is sorry for her angry outburst.
At the end of the session, Dr. Layden gives Magda a homework assignment to obtain a piece of her horse bridle to carry with her daily to remind her that she can be big, powerful, good, and competent.
Throughout the session, Dr. Layden takes copious notes on a clipboard.
General Questions
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