Case Report: Restitution 101
Sidney R. Ornduff
University of Tennessee Health Science Center
The Case Report is a forum for distinguished
clinicians representing a range
of theoretical orientations to share diagnostic
formulations and treatment
recommendations of the same psychotherapy
patient. The present case is that
of Ms. S, a young woman with features of
borderline personality disorder,
mood disturbance, and posttraumatic stress
disorder who was self-referred
for individual outpatient psychotherapy.
Treatment was precipitated by the
sudden onset of vivid, snapshot-like memories
of early childhood sexual
abuse. Material from the initial weeks of
therapy is presented, followed by a
discussion of points of convergence and
divergence from the expert therapists.
Finally, a few closing comments are offered by
the case contributor.
“Restitution: (n.) the act of restoring to the
rightful owner something that has been
taken away, lost, or surrendered”—American
Heritage Dictionary
“I am dealing with a lot of things,” said Ms. S, a
biracial woman in her
early 20s, as she began her first therapy
session. Self-referred and with no
previous history of psychotherapy, the patient
was well prepared for our
first meeting. When asked about her
motivation for seeking treatment, she
readily identified three seemingly disparate
areas of concern that she
wished to explore: (a) her recent recall of two
incidents of sexual abuse that
occurred during her early childhood and
involved her father; (b) her
self-reported history of poor interpersonal
relationships; and (c) pervasive
feelings of confusion, most notably involving
personal identity, sexual
preference, and career choice. Moreover, she
described long-standing feelings
of sadness, loneliness, self-doubt, self-hatred,
dread, and overwhelming
worry; intrusive negative thoughts;
hypervigilance; and distrust of
herself and others as additional areas of
concern.
At intake, the patient described symptoms of
depression, including
Correspondence concerning this article should
be addressed to Sidney R. Ornduff,
Department of Psychiatry, School of Medicine,
University of Tennessee Health Science
Center, 135 North Pauline, Memphis, TN 38105.
E-mail: sornduff@utmem.edu
Journal of Psychotherapy Integration Copyright
2005 by the Educational Publishing Foundation
2005, Vol. 15, No. 1, 69–73 1053-
0479/05/$12.00 DOI: 10.1037/1053-
0479.15.1.69
69
sadness, anhedonia, initial insomnia and
nightmares, difficulty with concentration,
and feelings of guilt and worthlessness. These
symptoms were
not present most of the day but came and
went. At no time did Ms. S
present suicidal ideation or exhibit parasuicidal
behavior.
The information presented in this article was
obtained primarily during
Ms. S’s initial therapy session, but additional
material gleaned from the five
subsequent sessions of her 1st month of
treatment is also included to
provide a more thorough case history of this
articulate, motivated young
woman.
At intake, Ms. S presented as an attractive,
athletic-looking college
senior majoring in the behavioral sciences. She
shared an apartment with
two roommates whom she knew only casually,
held two part-time jobs, and
attended summer school full time. After
graduation she planned to pursue
employment or postbaccalaureate education in
public service.
When specifically asked about the timing of her
entry into psychotherapy,
Ms. S referred to a comment made by her
gynecologist during a recent
routine examination. According to Ms. S, her
physician mentioned signs of
visible damage to Ms. S’s genitals suggestive
of some type of early injury.
The physician questioned Ms. S about possible
childhood trauma, which
she flatly denied. Shortly thereafter, however,
she began to see brief but
vivid, snapshotlike images of herself being
sexually abused as a very young
child. She initially referred to these phenomena
as “flashbacks.” Over time,
these troubling recollections occurred with
increased frequency and intensity,
always without warning. Ms. S was particularly
bothered by her lack of
control over these intrusive images, the
distress they generated, and fears
that new, different images would emerge.
These images and thoughts were
distracting and began to interfere with her
performance at school and her
part-time jobs. At this same time, she began to
experience nightmares and
a variety of somatic symptoms (e.g.,
abdominal pain, headache, vaginismus,
insomnia). She identified this constellation of
occurrences as her primary
impetus for pursuing psychotherapy.
Ms. S is the elder in a sibship of two; her
brother, B, is 1 year her junior.
Her parents separated when she was a toddler
and then divorced. She
described a close bond with her brother and
reported weekly telephone
contact with her mother. Despite the
appearance of closeness, Ms. S’s
description of her relationship with her mother
revealed intense ambivalence.
She portrayed her mother as infantilizing,
overinvolved, and critical;
nonetheless, she continued to seek guidance
and support from her mother,
despite the patient’s usual disappointment in
her mother’s response. Ms. S
related fears of engendering disapproval and
rejection if she became more
independent and less reliant on her mother.
Conversely, she worried that
her mother could manage without her, the
proof of which lay in the fact
that her mother raised Ms. S and her brother as
a single parent, with the
70 Ornduff
help of no one. Ms. S was both proud of and
intimidated by this domineering,
capable woman.
Since her parents’ divorce, Ms. S had had only
intermittent contact
with her father, whom she described as
“unreliable, crazy, and capable of
anything.” While growing up, she recalled
spending time with her father in
the summer when her mother sent Ms. S and
her brother to his out-of-state
home for visitation. These memories were
painful for Ms. S, who characterized
these visits as frightening and abusive. Her last
reported encounter
with her father was at the time of her high
school graduation, when she was
17 years old. Recollection of this reunion was
similarly disturbing; Ms. S
reported that on the morning of her
graduation, her father got into bed and
fondled her “as if he belonged there.” The
patient reported that, since then,
she had been intensely preoccupied by the
possibility of other such occurrences
between herself and her father. Her concerns
had intensified over
the past 4 months, since the time of the
aforementioned gynecologic
examination. Her increased distress led her to
contact her father by telephone
some 9 weeks earlier, at which time she
confronted him about his
abuse of her as a child. Ms. S reported that,
during this conversation, her
father “called me a liar and instilled doubt in
me.” At intake, Ms. S
expressed extreme insecurities stemming from
the abuse, including a selfpunishing
sense that she had somehow brought about
and deserved the
maltreatment and the notion that others could
tell she was a victim just by
looking at her.
Regarding her childhood sexual abuse, Ms. S
was particularly disturbed
by an event that occurred, she believed, when
she was approximately
3 years of age and involved her father
penetrating her vagina with
his penis. She recalled this incident with
dramatic detail and summarized
her account of the incident with the haunting
admission that “he violently
raped me.” In addition to strong feelings of
disgust and shame toward both
herself and her father, she reported feeling
betrayed by and lied to by her
mother. She questioned the timing of certain
developmental milestones
(per her mother, Ms. S was “self-sufficient” at
an early age; i.e., she was
toilet trained and could bathe herself by 2
years of age) and the break-up
of her parents’ marriage (when Ms. S was 3
years old) and began to doubt
her mother’s insistence that her mother had no
knowledge of what had
been going on between the patient and her
father. These doubts were
amplified as Ms. S began recalling more details
of the abusive incidents that
occurred when she was a toddler. For example,
she reported an instance in
which she saw her mother’s legs in the
bedroom doorway while she was
lying on a bed with her father standing over
her, his limp penis exposed. As
she began to consolidate these and other
images of her abuse, Ms. S’s
ambivalence toward her mother intensified.
Her mother became a target of
anger and contempt; however, Ms. S was
fearful that she would say or do
Special Section: Restitution 101 71
something that would rupture her relationship
with her mother “like I did
with my father.”
Ms. S stated that she had no friends, a
situation for which she blamed
herself. She had an instrumental view of
relationships in which interpersonal
transactions were based on contingencies of
reward and punishment.
For example, in describing her relationship with
her mother, she stated, “I
knew she loved me if she bought me
something, and she did not buy
much.” This view pervaded all of her
relationships and determined their
importance, duration, and so forth. In terms of
romantic associations, she
reported having had four significant
relationships while in college. Her
history revealed relatively long-term
involvements with men (e.g., two
relationships of 0.5 year, one relationship of
1.5 years, and one relationship
of 2.0 years); however, she described each
relationship as generally unsatisfying.
She entered relationships if someone
expressed interest in her, and
she stated that she had boyfriends “because I
thought I was supposed to.”
With apparent bewilderment, she claimed to
“do things to bring about the
end of relationships,” despite feeling empty
and panicky when by herself.
In response to her self-generated turmoil, she
described a pattern of quick,
frantic attachment to any available alternative
to avoid being alone. She
acknowledged a lack of sexual drive and
response in her intimate relationships,
although sexual activity was a frequent and
key component of these
involvements. At intake, Ms. S reported the
recent break-up of a 2-year
romantic relationship with Mr. K, 10 years her
senior, whom she described
as “just like my father.” She characterized the
relationship as emotionally
and physically abusive on the part of both
herself and Mr. K. She was angry
for having stayed in the relationship for so
long, although she lamented, “I
don’t know who I am without reference to
him.” She referred to herself as
single at the beginning of treatment, the
context of which was the termination
of her involvement with Mr. K 2 weeks earlier.
This 2-week period
was the longest time she could remember not
being involved with a man
during her early adult years. At the time of our
first session, Ms. S said she
was glad that she was not in another
relationship. However, she expressed
concern that she might be a lesbian. Her
sexual identity and preferences
were a focus of attention during the course of
therapy.
At the outset of treatment, Ms. S had no
coherent sense of personal
identity. The fact that she was biracial served
to compound this confusion.
She was at a loss to take a stand on virtually
any issue, no matter how
mundane, as her tendency was to “follow the
lead of others and . . . do what
is expected.” She spoke of surrendering her ill-
defined sense of self when
with other people to avoid rejection or
criticism. Especially during the early
weeks of therapy, Ms. S literally “tried on”
different identities in an
attempt to clarify who she was. These efforts
were manifest as dramatic
changes in her hairstyle and manner of dress,
personal habits, and choice of
72 Ornduff
sexual partners. Over time these
experimentations dwindled, but matters
of personal identity and self-definition
remained important themes
throughout therapy.
I saw Ms. S twice weekly for individual
psychotherapy. She was routinely
prompt for sessions and presented with a
readiness for each hour,
though the work was often difficult and
overwhelming for her. Early
sessions focused on her distress related to the
break-up of her relationship
with Mr. K, her ambivalent relationship with her
mother, and dream
material characterized by overt themes of
danger and victimization. I did
not challenge the veracity of the patient’s
reported childhood sexual abuse;
information that emerged over time was
consistent with her self-report and
included an eventual admission by her father
of numerous episodes of
fondling and molestation that spanned some
15 years.
Predictably, the development of a therapeutic
relationship with Ms. S
was both arduous and painstaking and
revolved primarily around issues of
trust. For example, she had difficulty trusting
her judgment about what
information to reveal in session and with
whom, if anyone, she should share
details of her treatment. She was also
uncertain about the pace and depth
of therapy and expressed fears that she would
discover “too much” about
herself, the abuse, and the impact of her
history on her past and current
functioning. These concerns required a
willingness on her part to explore
apparent attempts to undermine therapeutic
movement; the development
of the ability to tolerate and modulate intense
feelings; and the recognition
that she, I, and the treatment could withstand
her affective storms. Themes
of trust were ever present for Ms. S.
With respect to countertransference, issues of
trust were similarly
prominent. For example, I was conscious about
not expressing obvious
overconcern about certain of Ms. S’s decisions,
behaviors, and so forth;
however, I occasionally left sessions with
feelings of worry and uncertainty
about her as well as about the direction and
intensity of the treatment. At
such times, I felt transparent and exposed,
feelings that I was compelled to
examine and manage. It was also difficult to
reconcile certain discrepancies
in Ms. S’s presentation, both within and across
sessions: frightened–frightening,
bold–timid, guarded–open, harsh–kind,
insightful–simple, generous–
stingy, curious–apathetic.
Special Section: Restitution 101 73
Abuse, Coping, and
Treatment
Kathleen M. Chard and Thomas A.
Widiger
University of Kentucky
The authors were asked to provide in this
commentary a discussion of the
psychotherapy case of Ms. S, including a
consideration of diagnosis, therapeutic
relationship, treatment methods, and
therapy process. In this paper,
they recommend a possible treatment
plan for Ms. S using cognitive behavioral
techniques, and provide a diagnostic
conceptualization in terms of the
Five Factor Model of general personality
functioning.
We have been asked to provide in this
commentary a discussion of the
psychotherapy case of Ms. S. We have
been asked to discuss diagnosis,
therapeutic relationship, treatment
methods, and therapy process. Several
standardized treatments for adult
survivors of child abuse and interpersonal
violence exist, and many of them use a
cognitive or cognitive–
behavioral framework (see Foa, Keane, &
Friedman, 2000; Follette,
Ruzek, & Abueg, 1998). Although most of
these treatments emphasize
some type of recapitulation of the event,
they can differ greatly in regard
to therapy conceptualization and
treatment methods. Ms. S seems well
adapted for cognitive techniques because
of her high level of introspection
and her tendency to describe problems in
terms of disruptive cognitive
schema (e.g., “If my mother buys me a
gift, it means she loves me”).
Therefore, in this article we recommend a
possible treatment plan for Ms.
S that uses a blend of cognitive–
behavioral techniques.
Kathleen M. Chard, Department of Education and
Counseling Psychology, University of
Kentucky; Thomas A. Widiger, Department of
Psychology, University of Kentucky.
Correspondence concerning this article should be
addressed to Thomas A. Widiger,
Department of Psychology, University of Kentucky,
115 Kastle Hall, Lexington, KY 40506-
0044. E-mail: widiger@pop.uky.edu
Journal of Psychotherapy Integration Copyright 2005 by the
Educational Publishing Foundation
2005, Vol. 15, No. 1, 74–88 1053-0479/05/$12.00 DOI: 10.1037/1053-
0479.15.1.74
74
DIAGNOSIS AND CHARACTERIZATION
The Diagnostic and Statistical Manual of
Mental Disorders (4th ed.,
text rev.; DSM–IV–TR; American
Psychiatric Association [APA], 2000)
diagnoses that might apply best for Ms. S
are borderline personality
disorder and posttraumatic stress disorder
(PTSD). Symptoms of PTSD
(delayed onset) were her primary
motivation for seeking treatment (e.g.,
intrusive images of having been abused,
nightmares, and severe distress).
However, it appears that, before
developing PTSD, Ms. S was suffering
from features of a borderline personality
disorder, notably the presence of
identity disturbance. Ms. S “had no
coherent sense of personal identity”
(Ornduff, 2005, p. 72), she was unsure of
her sexual identity, and she “was
at a loss to take a stand on virtually any
issue” (p. 72). “Matters of personal
identity and self-definition remained
important themes throughout therapy”
(p. 73). There also appears to an
indication of frantic efforts to avoid
abandonment, the diagnostic criterion
considered to be most important in
diagnosing borderline personality disorder
(the DSM–IV–TR personality
disorder diagnostic criteria are presented
in a descending order of diagnostic
value; Frances, First, & Pincus, 1995).
“These abandonment fears are
related to an intolerance of being alone
and a need to have other people
with them” (APA, 2000, p. 706), expressed
explicitly in Ms. S’s “frantic
attachment to any available alternative to
avoid being alone” (p. 72).
However, there are, at best, only indirect
or subtle indications for
many of the remaining borderline
diagnostic criteria. There is no indication
of recurrent suicidal behavior, gestures, or
threats. There is no explicit
reference to a chronic affective instability
due to a marked reactivity of
mood or chronic feelings of emptiness. Ms.
S does appear to have some
feelings of bitterness toward her mother
and father, but there is no indication
of inappropriate, intense anger or difficulty
controlling anger pervasive
in her relationships with others. She is
described as having “an
instrumental view of relationships”
(Ornduff, 2005, p. 72) rather than
intense relationships marked by feelings
of devaluation (rage, anger) and
idealization. She might evidence a self-
destructive impulsivity with respect
to sexual relationships, but there is no
indication of comparable dyscontrol
with respect to substance use, spending,
reckless driving, or binge eating.
She does appear to have long-standing
feelings of mistrust and suspiciousness,
but it is unclear whether they ever reach
the level of the paranoid
ideation typically seen in persons with
borderline personality disorder.
There are no explicit references to
dissociation, but there are signs of
subtle, peritraumatic dissociation (e.g.,
the pervasive feelings of confusion
and lack of a clear sense of self could
reflect feelings of depersonalization).
There are also indications of maladaptive
personality functioning not
Special Section: Abuse, Coping, and Treatment
75
included within the DSM–IV–TR criteria for
borderline personality disorder
(APA, 2000). Ms. S is described as having
“long-standing feelings of
sadness, loneliness, self-doubt, self-
hatred, dread, and overwhelming
worry” (Ornduff, 2005, p. 69). She is
described as being “anhedonic” and
(as indicated above) as having an
instrumental view of relationships. She is
said to have no close friends.
An alternative model for the description of
personality described
briefly in the text of the DSM–IV–TR is the
five-factor model (FFM; Costa
& Widiger, 2002). The FFM is a heavily
researched and well-established
model of personality that is now used
extensively in many areas of applied
psychology, including behavioral
medicine, geriatric psychology, and
industrial–
organizational psychology (McCrae &
Costa, 1999). The FFM has
substantial cross-cultural, temporal
stability, heritability, and convergent
and discriminant validity support (McCrae
& Costa, 1999). It consists of
five broad dimensions of personality:
Neuroticism (Negative Affectivity)
versus Emotional Stability, Extraversion
(Positive Affectivity) versus Introversion,
Openness (Unconventionality) versus
Closedness to Experience,
Agreeableness versus Antagonism, and
Conscientiousness versus
Undependability. Each of these five broad
domains can be differentiated
into more specific facets. For example, the
facets of Agreeableness versus
Antagonism are trust versus mistrust,
straightforwardness versus deception,
altruism versus exploitation, compliance
versus opposition, modesty
versus arrogance, and tender mindedness
versus tough mindedness. Most
important, the FFM allows the clinician to
provide a fairly specific yet also
comprehensive profile description of both
the adaptive and the maladaptive
aspects of any particular individual, as
there are both adaptive and
maladaptive aspects for each of the 60
poles of the 30 facets. For example,
adaptive levels of facets of Agreeableness
include being trusting, honest,
giving, cooperative, humble, and
empathic, whereas maladaptive levels
include being gullible, naive, sacrificial,
docile, meek, and soft hearted.
Adaptive levels of facets of Antagonism
include being skeptical, cunning,
self-protective, forceful, confident, and
tough minded, whereas maladaptive
levels include being paranoid,
manipulative, exploitative, aggressive,
arrogant, and callous. In short, rather than
summarize in one word the
complex constellation of personality traits
that are present within any
particular individual, the FFM allows the
clinician to provide a more
individualized personality profile.
Table 1 provides a few descriptive
adjectives for each of the 30 facets
of the FFM, along with a description of Ms.
S. Many of the symptoms of
borderline personality disorder are
expressions of facets of Neuroticism.
The word neuroticism does not convey
well the severity of the dysfunction
experienced by borderline patients.
Neuroticism is a better descriptor for
persons at only the mildest levels of this
domain of personality functioning.
76 Chard and Widiger
However, imagine a person at the very
highest possible levels of psychological
vulnerability, anxiousness,
depressiveness, angry hostility, self-
consciousness,
and impulsivity; such a person would be
diagnosed with borderline
personality disorder (Widiger, Trull,
Clarkin, Sanderson, & Costa,
2002). For example, self-consciousness at
the moderate levels just involves
feelings of embarrassment, uncertainty,
and insecurity; at the very highest
levels it is expressed by confusions of the
self and the highest degree of
self-doubt. In our FFM description of Ms. S,
this is the only component of
the FFM for which she received a rating for
the highest level of
dysfunction.
Ms. S’s “long-standing feelings of sadness,
loneliness, self-doubt, selfhatred,
dread, and overwhelming worry” (Ornduff,
2005, p. 69) are also
represented well by the Neuroticism facets
of anxiousness, depressiveness,
and vulnerability. Her long-standing
feelings of distrust are represented
explicitly by the Antagonism facet of
mistrust. Ms. S also said that she has
virtually no close friends. She views
relationships in only an “instrumental
manner.” She is also described as being
anhedonic. These characteristics
are also described well in terms of the FFM
Introversion facets of abnormally
low gregariousness and low positive
emotions. There is also an
indication of abnormally low
assertiveness.
However, it is also apparent from Table 1
that we know very little
about other components of Ms. S’s
personality. We speculate that she may
be above average in facets of
Conscientiousness, but this is only a
guess, as
it is based on the indirect evidence that
she holds two part-time jobs,
attends summer school, and was notably
“well prepared” for her first
meeting with the therapist. These
moderately high levels of
Conscientiousness
bode well for a persistent, responsible,
and disciplined completion of
therapy. Very little information is provided
to assess facets of Openness
and most of the facets of Agreeableness
versus Antagonism. The clinical
description is confined largely to the
symptoms of PTSD and borderline
personality. Additional assessments are
necessary to provide a more complete
description of her personality. Ms. S does
appear to have considerable
deficits in interpersonal relatedness, and it
is unclear whether and to
what extent they might reflect additional
facets of Introversion, Antagonism,
or even Agreeableness (e.g., excessive
docile compliance). Her level
of Openness can be particularly important
in assessing therapeutic responsivity
to self-reflection and self-exploration.
Finally, a more general issue is that some
of the apparent indicators of
her personality might be better
understood as symptoms of PTSD
interacting
with normative developmental conflicts
(Ad-Dab’bagh & Greenfield,
2001). Her sadness, loneliness, and
distrust are described as long
standing and therefore predated the onset
of the PTSD, but she has been
suffering from a more complex,
subthreshold PTSD for quite a long time.
Special Section: Abuse, Coping, and Treatment
77
Table 1. Five-Factor Model Description of Ms. S
Trait High level of trait Scale score Low level of trait
Neuroticism (Negative Affectivity) versus Emotional
Stability
Anxiousness Fearful, apprehensive 7 6 5 4 3 2 1
Relaxed, unconcerned, cool
Angry hostility Angry, bittera 7 6 5 4 3 2 1 Even
tempered
Depressiveness Pessimistic, glum 7 6 5 4 3 2 1
Optimistic
Self-consciousness Confused, guilty 7 6 5 4 3 2 1
Self-assured, glib, shameless
Impulsivity Tempted, urgency 7 6 5 4 3 2 1
Controlled, restrained
Vulnerability Overwhelmed, panic, dismay 7 6 5 4 3
2 1 Stalwart, brave, fearless, unflappable
Extraversion versus Introversion
Warmth Affectionate, attached 7 6 5 4 3 2 1 Cold,
aloof, indifferent
Gregariousness Sociable, outgoing 7 6 5 4 3 2 1
Withdrawn, isolated
Assertiveness Dominant, forceful 7 6 5 4 3 2 1
Unassuming, quiet, resigned
Activitya Vigorous, energetic, active 7 6 5 4 3 2 1
Passive, lethargic
Excitement seekinga Reckless, daring 7 6 5 4 3 2 1
Cautious, monotonous, dull
Positive emotions High spirited 7 6 5 4 3 2 1 Placid,
anhedonic
Openness (Unconventionality) versus Closedness to
Experience
Fantasya Dreamer, unrealistic, imaginative 7 6 5 4 3
2 1 Practical, concrete
Aesthetica Preoccupied, aberrant, aesthetic 7 6 5 4 3
2 1 Unaesthetic, uninvolved
Feelingsa Sensitive, responsive 7 6 5 4 3 2 1
Constricted, alexythymic
Actionsa Unpredictable, unconventional 7 6 5 4 3 2 1
Routine, habitual, stubborn
Ideasa Strange, odd, peculiar, creative 7 6 5 4 3 2 1
Pragmatic, rigid
Valuesa Permissive, broad minded 7 6 5 4 3 2 1
Traditional, inflexible, dogmatic
78 Chard and Widiger
Table 1. (continued)
Trait High level of trait Scale score Low level of trait
Agreeableness versus Antagonism
Trust Gullible, trusting 7 6 5 4 3 2 1 Skeptical,
cynical, suspicious, paranoid
Straightforwardnessa Naive, honest 7 6 5 4 3 2 1
Cunning, manipulative, deceptive
Altruisma Sacrificial, giving 7 6 5 4 3 2 1 Stingy,
selfish, greedy, exploitative
Compliancea Docile, cooperative 7 6 5 4 3 2 1
Oppositional, combative, aggressive
Modestya Meek, self-effacing, humble 7 6 5 4 3 2 1
Confident, boastful, arrogant
Tender mindednessa Soft, empathic 7 6 5 4 3 2 1
Tough, callous, ruthless
Conscientiousness versus Undependability
Competencea Perfectionistic, efficient 7 6 5 4 3 2 1
Lax, negligent
Order Ordered, methodical, organized 7 6 5 4 3 2 1
Haphazard, disorganized, sloppy
Dutifulness Rigid, reliable, dependable 7 6 5 4 3 2 1
Casual, undependable, unethical
Achievement Workaholic, ambitious 7 6 5 4 3 2 1
Aimless, desultory
Self-disciplinea Dogged, devoted 7 6 5 4 3 2 1
Hedonistic, negligent
Deliberationa Ruminative, reflective 7 6 5 4 3 2 1
Hasty, careless, rash
Note. All traits are scored as follows: 7 _ problematic
very high on the trait; 6 _ problematic high on the
trait (clear presence of clinically significant
impairments); 5 _ high on the trait (higher than the
average, typical person; may have minor
impairments); 4 _ neither high nor low on the trait
3 _ low on the trait (lower than the average, typical
person; may have minor impairments); 2 _
problematic low on the trait (clear presence of
clinically significant impairments); 1 _ problematic
very low on the trait. Values in bold italics indicate
the scores received by Ms. S.
a We were unable to estimate the level of this trait for
Ms. S.
Special Section: Abuse, Coping, and Treatment
79
Identity issues are also not uncommon for
young adults, and these normal
developmental issues can be exacerbated
substantially by the presence of
sexual or physical abuse. In sum, it might
be overly pathologizing to
diagnose Ms. S with a personality disorder,
which suggests the presence of
a more chronic, debilitating prognosis than
is warranted. All of the above
speculations concerning Ms. S’s
personality traits are tentative until a
more
comprehensive assessment of the history,
course, and associated features of
the PTSD has been completed.
THERAPEUTIC RELATIONSHIP
The case presentation of Ms. S includes a
very productive and helpful
treatment by Dr. Ornduff. We offer our
own, more speculative suggestions
on what we might have done had Ms. S
approached our treatment program.
First, as cognitively oriented therapists,
we would work to establish
a relationship based on “collaborative
empiricism,” in which the client is as
integral to the treatment as the therapist
(Beck, Rush, Shaw, & Emery,
1979). The first part of this process is
engaging the client in the therapy by
fully explaining the treatment rationale,
projected length of treatment,
interventions to be used, anticipated
symptom response, and efficacy to
date. Ms. S is described as being very
compliant with treatment. However,
in many trauma therapies, the client
becomes more symptomatic as he or
she processes the memories; thus, having
the client invested in the treatment
is very important.
The next stage involves obtaining a
therapeutic commitment from the
client. The client must agree that
treatment is needed, agree to the outlined
treatment objectives, and agree to specific
treatment arrangements, such as
time, place, frequency, fee, and access to
the therapist between sessions.
For child abuse survivors, there may be
ambivalence or avoidance about
working on issues related to the trauma
that could interfere with therapy
success. This avoidance is very normal,
especially in light of a possible
diagnosis of PTSD, which contains
avoidance as one of the requisite
symptom categories. Ms. S shows some
typical signs of ambivalence, from
her difficulty making decisions to her fear
of discovering “too much” about
herself and the impact of the abuse on her
current life. To address this
avoidance, the therapist should ask the
client to recall ways the avoidant
behaviors have not worked for her in the
past and remind her of how
effective the treatment has been for other
clients with the same type of
symptom presentation.
Finally, the client should be asked to
predict what types of barriers
might interfere with treatment. Ms. S
would probably note that she has
80 Chard and Widiger
very limited social support, has a difficult
relationship with her mother, and
has found therapy to be difficult to this
point. To create a positive therapeutic
alliance, the therapist should brainstorm
with Ms. S for ways to limit
these factors from intruding into her
therapy. For example, Ms. S might be
discouraged from making any major
decisions at the suggestion of other
people until she has proceeded through a
significant portion of the therapy.
Throughout the above discussions, the
therapist should strive to make
Ms. S feel that she is a valuable part of the
treatment process, that her
concerns and needs are valid, and that
she has equal power in the sessions.
As a woman who reports being controlled
by others most of her life, Ms.
S would likely feel empowered by the
presentation style of the therapist
and thus feel more committed to the
treatment process. However, Ms. S
might have a tendency to over-rely on the
therapist and might become too
compliant, thus hindering the
collaborative nature of the relationship. If
this were to happen, she might not feel
able to freely discuss her thoughts
and feelings out of fear of offending or
disagreeing with the therapist. The
therapist should be very hesitant about
offering opinions or giving direct
feedback or instruction. The therapist
should also confront Ms. S if it
appears that Ms. S is working harder on
pleasing the therapist than working
on her own problems.
TREATMENT METHODS
Continuing with the collaborative theme
we have established, we
would offer Ms. S the ability to make an
informed choice about her
continued treatment. After completing
assessments that help to clarify the
client’s diagnoses, we would discuss the
findings with her. Often, child
abuse survivors find this process very
helpful, because of their concern that
they are “going crazy.” The diagnosis of
PTSD and the past peritraumatic
dissociation suggest that the client is
having a natural response to a very
stressful event and that this response can
be treated with therapy. In
addition, the diagnosis of a personality
disorder suggests that Ms. S has
developed poor coping skills in response
to unhealthy relational patterns
created in the context of the abuse. Again,
this frees the client from
self-blame and puts the focus on
treatment options.
At this point, the therapist would present
several treatment modalities
to Ms. S that could help reduce her
presenting symptoms, with an explanation
of the benefits and drawbacks of each.
Cognitive treatments that
might be very beneficial to Ms. S include
prolonged exposure (Foa, Rothbaum,
Riggs, & Murdock, 1991), cognitive
processing therapy for sexual
abuse (CPT-SA; Chard, Weaver, & Resick,
1997), and dialectical behavior
Special Section: Abuse, Coping, and Treatment
81
therapy (DBT; Linehan, 1993a). The first
two have empirical support for
their effectiveness treating symptoms
associated with adult survivors of
childhood sexual abuse, whereas the third
has extensive research support
for its use in treating borderline
personality disorder and related
symptoms.
In addition, CPT-SA has been shown to be
effective with clients who
present with complex PTSD symptom
patterns, and sections of DBT (e.g.,
affect regulation or distress tolerance)
have been used in conjunction with
other cognitive techniques for the
treatment of PTSD (Cloitre, Koenen,
Cohen, & Han, 2002). In the DBT modules,
the client is taught skills to use
when confronted with thoughts, feelings,
or situations that cause him or her
to react in unhealthy ways. In the trauma
treatments, Ms. S would be
exposed to the traumatic memory, either
through first person retelling or
by writing about the events. Researchers
have speculated that the traumatic
event creates a pathological fear structure
in some individuals, and
therapy must reactivate this fear structure
through exposure to the memory
and provide new information to the client
that is incompatible with the
existing fear elements (Foa et al., 2000).
This additional information is
usually provided through some type of
cognitive restructuring.
Because Ms. S presents with comorbid
disorders that may not fit one
treatment or the other, the therapist
might want to encourage the use of
two treatments at the same time or
conduct treatment in a two-stage
model, with one treatment following the
other. The therapist could help
the client choose between these options
by thoroughly evaluating her social
support network, suicidal ideation, self-
harming behaviors, and potential
therapeutic adherence. On the basis of the
case material presented, Ms. S
would probably state that she would like
to pursue trauma therapy so that
she can address her feelings about trust
and her problems with relationships,
but she would be ambivalent because of
her concerns about discovering
too much about herself. Ms. S would
probably select CPT-SA because
of her cognitive focus, but she might ask
for a few sessions from the
Emotion Regulation module in the DBT
program to give her more skills to
cope with the trauma work. If Ms. S
revealed that she was having problems
with “in the moment” inappropriate
reactions to situations, the therapist
could suggest using the Distress Tolerance
module from DBT instead.
THERAPY PROCESS
By combining a DBT module with CPT-SA,
the therapist could provide
Ms. S with a broader base of coping skills
for handling situations with
friends and family, also giving her more
ways to deal with the heightened
emotions she would feel during
recapitulation. The sessions spent in DBT
82 Chard and Widiger
would also allow Ms. S to build more trust
with the therapist prior to
beginning work on the actual traumatic
events. The Emotion Regulation
module is designed to teach clients how to
regulate their affect level in the
hopes of reducing feelings of anger,
depression, frustration, and anxiety
(Linehan, 1993b). The module has five
homework assignments and 10
handouts, and it can be conducted in five
or six sessions. The exercises
focus on teaching the client to identify the
event that prompted an emotional
response as well as how he or she
interpreted the event. In addition,
clients are taught to identify how they
express their emotions and what
impact the emotions have on their life. Ms.
S would probably find these
modules very helpful in dealing with her
feelings of sadness, loneliness, and
worry as well as her problems with
interpersonal relationships. The first
session would begin with an explanation
of emotion regulation and the
techniques to be covered in the module.
The first topic considers emotion
myths (e.g., “Other people are the best
judge of how I am feeling”) and
generates challenges for these myths. The
next topic is learning how to
identify and describe various emotions,
ranging from love to shame. In the
third session Ms. S would be taught how
emotions can be used to communicate
with others, to motivate action, and for
self-validation. In the fourth
session, the therapist would introduce the
concepts of negative and positive
emotions and ways to decrease the former
and increase the latter. In the
final DBT session, the therapist would
discuss ways to let go of emotional
suffering and use action to change
emotions. For example, the therapist
might teach Ms. S to do more things that
make her feel confident and
accept that all people make mistakes.
After the five DBT sessions were
completed, Ms. S would be consulted
to see whether she would still like to
pursue trauma therapy and whether
she felt ready for the additional work at
that time. If she agreed, the
therapist would begin CPT-SA by
explaining the treatment rationale in
greater detail (Chard, Johnson, & Owens,
2002). CPT-SA is a 17-week
therapy that can be conducted as
combined group and individual or
individual-
only therapy sessions. The first session
has three parts, starting with
a discussion of PTSD and related
symptoms, during which Ms. S would be
asked to identify ways her symptoms are
interfering with her life. Ms. S has
already indicated that she is having
intrusive thoughts about the abuse
incidents, nightmares, difficulty with
hypervigilance, and problems with
avoidance. When asked what she hoped to
gain from therapy, Ms. S would
probably recount the four issues that
concerned her in her first session of
therapy: (a) her recent recall of child
abuse and its implications; (b) her
history of bad relationships; (c) her
feelings of confusion regarding her
career and sexual identity; and, finally, (d)
her chronic feelings of dread,
worry, and inadequacy as well as her
intrusive negative thoughts. These
issues are very commonly seen in trauma
survivors presenting for treat-
Special Section: Abuse, Coping, and Treatment
83
ment and should be normalized as
understandable reactions to the traumatic
event. In regard to treatment goals, Ms. S
would probably say that
she wanted the intrusive thoughts to go
away, to feel better about herself,
to have healthier relationships, and to
figure out what she wants to do with
her life. By obtaining the client’s goals, the
therapist has a list of objectives
that the client would like to reach, and this
list can be recounted to the
client when he or she is feeling less
motivated to work in the therapy.
During the second part of the first session,
the therapist focuses on why
the treatment works by explaining the
cognitive processing model and the
need to process the memory in a safe
place to integrate the feelings and
cognitions associated with the trauma.
The therapist would discuss the
concepts of assimilation and
accommodation and our tendency as
humans
to believe in the fundamental attribution
bias that good things happen to
good people and bad things happen to
bad people. This belief can cause a
person to have great difficulty reconciling
how he or she can be a good
person if a terrible thing, such as child
abuse, happened to him or her.
Throughout this discussion, Ms. S should
be encouraged to include specific
examples from her life to show how they
integrate with the treatment. For
example, Ms. S seems to easily identify
with the self-blame and guilt
associated with child abuse, as seen in her
reported self-doubt and selfhatred.
Finally, at the end of the first session, Ms.
S would be given an
outline of the treatment and her
homework assignment. It is very likely
that Ms. S would respond well to receiving
the outline of therapy and
would feel a sense of control over her
treatment by knowing what is going
to happen next. Researchers have
hypothesized that individuals with
borderline
personality disorder (and complex PTSD)
are using unhealthy
coping skills developed in childhood as a
response to the abuse (Morrow &
Smith, 1995), and attempts by the
therapist to help create and maintain
healthy skills and boundaries may be
rewarding for the client. The homework
assignment for the first session is for the
client to begin identifying
“rules” or “beliefs” that he or she uses to
organize his or her world. The
therapist explains that people organize
their world with beliefs such as,
“One should stop at a red light,” or, “I
should shake hands when I meet
someone new.” People develop these
beliefs very early in life as they
interact with family, teachers, peers, and
the church. When an individual is
abused, he or she develops many beliefs
within the context of abuse; thus,
many are negative beliefs about the self
and concerns about safety, trust,
power and control, self-esteem, and
intimacy (McCann, Sakheim, &
Abrahamson,
1988). Ms. S should have little difficulty
with this assignment on
the basis of her awareness of intrusive
thoughts and her growing knowledge
of the impact of the abuse on her life.
The second and third sessions of CPT-SA
continue to focus on exposure
to the cognitive model and a deeper
awareness of the client’s beliefs.
84 Chard and Widiger
Ms. S would be asked to write an Impact of
the Event Statement outlining
how the abuse has affected her across the
five key areas we have listed.
When she brought the statement to the
session, the therapist would help
Ms. S identify more rules that are a direct
result of the abuse experience.
Ms. S would then be taught the A-B-C
sheets (on the basis of Beck &
Emery, 1985) to help her understand the
connection between her thoughts
and her emotions. The therapist would
begin to brainstorm with Ms. S for
alternative thoughts that she could say to
herself in different situations and
discuss the resulting emotions that
develop when she changes her thoughts.
Ms. S would not be told that her thoughts
or feelings are incorrect; she
would only be encouraged to look at her
thoughts, gather more information,
and decide on her own whether there are
alternative reactions to
situations she encounters. For example,
Ms. S might initially state, “I
cannot be alone,” and, after discussing
this issue, might restate the idea as,
“I am scared to be alone.” This would help
her realize that not being alone
is a choice that she makes because of her
concerns about safety or
connectedness.
In Sessions 4 through 6, Ms. S would
participate in the recapitulation
phase of the therapy. As homework
assignments, Ms. S would be asked to
write about two or three of her most
distressing incidents of abuse. The
therapist should not assign the events but
should help her choose which
events seems to be causing the most
difficulty, as gauged by reexperiencing
and arousal symptoms associated with the
memory. Ms. S would bring each
account to session and read them to the
therapist twice without interruption.
This would allow Ms. S to begin processing
the abuse and gaining
control over the memory. Next, the
therapist and Ms. S would review the
account for remaining rules that might be
affecting her current life (e.g.,
“No man will love me if he knows my dad
abused me”). For additional
homework during these 3 weeks, Ms. S
would be asked to explore these
rules and other daily beliefs with the A-B-C
sheets.
The focus of Sessions 7 through 9 would
be on examination of disruptive
rules. The therapist would introduce two
cognitive tasks: Challenging
Questions and Disruptive Thinking
Patterns (adapted from Resick &
Schnicke, 1993). Challenging Questions
asks the client to identify one rule
that is causing him or her problems and
then answer 12 questions about
that rule. Examples of questions include,
“What is the evidence for and
against this belief?” “In what ways does
this belief confuse a habit with a
fact?” and “In what ways does your belief
distort what really happened?”
The goal is to help Ms. S modify her rules
so that they take into account all
available information, including her
current life situation, not just the
abuse-based information. In Session 9 Ms.
S would use the Disruptive
Thinking Patterns module to identify ways
that she may be using seven
global thinking patterns. These patterns
include “drawing conclusions
Special Section: Abuse, Coping, and Treatment
85
when evidence is lacking or even
contradictory” and “mind reading.” At
the end of the session, the Challenging
Beliefs Worksheet (CBW) would be
introduced, and Ms. S would be shown
how it incorporates the A-B-C
sheet, the Challenging Questions module,
and the Disruptive Thinking
Patterns module in a comprehensive
manner.
In Weeks 10 through 16, Ms. S would be
asked to use the CBW to
challenge her rules related to safety, trust,
power and control, self-esteem,
communication and assertiveness,
intimacy with herself and others, and
social support. Each week, she would be
given a written module that
reviews ways that abuse survivors can
develop unhealthy cognitions in that
area and possible alternative cognitions
that involve less victim blaming.
The client is asked to complete seven
CBW sheets each week, with at least
one focusing on that week’s module topic.
Ms. S would be given a handout
on healthy and unhealthy ways to take
and to give power. In her initial
sessions, Ms. S recounted having difficulty
with issues related to all of the
module areas included in the treatment.
The take-home readings would
allow her to see that she is not alone and
that hers are normal reactions for
abuse survivors. In addition, the CBW
would help her use her current life
situation and knowledge to challenge the
beliefs developed through the
abuse and replace them with healthier,
more empowering choices.
Finally, in Week 17 Ms. S would be asked
to bring in a new Impact of
the Event Statement, and she would
compare the new statement with the
one from Session 2. This would allow Ms. S
to see firsthand the gains that
she had made and to identify areas in
which she might want to continue
working. At this point in therapy, Ms. S
would probably be faster than the
therapist at challenging her disruptive
thoughts and would even be able to
do this in her head, without writing
anything down. The therapist would
give Ms. S blank copies of the CBW so that
she could continue to use the
treatment module when problems arose in
the future. Last, the therapist
would ask Ms. S to discuss future
concerns, continued social support, and
any possible needs for future therapy. For
example, if Ms. S wanted to
enter family therapy with her mother to
resolve some of their issues, she
would be encouraged to wait at least 2
months so that she had time to
crystallize the techniques that she learned
in CPT-SA.
FINAL COMMENTS
Many clients with a symptom presentation
similar to Ms. S’s have been
treated successfully with cognitive
techniques alone or in combination with
DBT modules (Chard et al., 2002). Even
so, there are issues that a therapist
should be aware of that can complicate
treatment if not addressed. First,
86 Chard and Widiger
Ms. S is very ambivalent about working on
her traumatic stress, even
though it is apparent to her that her other
issues stem from the trauma.
Although she is an “articulate, motivated”
(Ornduff, 2005, p. 69), client in
many ways, Ms. S is hesitant to address
the abuse because of the negative
cognitions about herself and others that
she attaches to the abuse. She is
fearful that working on the abuse will
bring more negative thoughts to the
surface. If this fear is left unchecked, Ms. S
could drop out of therapy and
continue her cycle of unhealthy
relationships and potentially self-
destructive
behaviors. There are several ways to
address this potential problem.
During the explanation of the treatment
rationale, the therapist should
make sure to discuss avoidance as a key
component of PTSD. The client
should be encouraged to see her desires
to avoid as a normal part of the
disorder and to see the therapist as an ally
in breaking through the
avoidance. To help with this process, the
therapist might offer Ms. S a
pager number at which he or she can be
reached in emergencies or suggest
contract writing, during which the
therapist would call to check on Ms. S at
a previously established time.
Ms. S may also have difficulty in therapy
because of her problems with
interpersonal relationships. Individuals
who have borderline personality
disorder (or complex PTSD) often have
difficulty trusting others, and they
attempt to push the therapist away to
confirm the belief that no one likes
them. It is critical that the therapist
identify these behaviors (e.g., showing
up late for session, calling the office
excessively, blaming the therapist for
her problems) as cries for help. If Ms. S
begins sabotaging the therapy
because of her thoughts of inadequacy,
the therapist should gently confront
her by telling her which behaviors are
unacceptable while still affirming the
therapeutic relationship.
At the end of therapy, it is likely that Ms. S
will have a significant
reduction in her PTSD symptoms, negative
cognitions, and low self-esteem.
In addition, she will likely have fewer
personality disorder symptoms,
having learned healthy alternatives to
coping. In the future, Ms. S may
desire couples counseling or family
therapy to address any lingering concerns
regarding her relationship with her mother
and/or significant others.
Finally, Ms. S might want to consider
individual therapy to discuss her
possible gender identity issues if these
questions were not resolved in the
intimacy modules.
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88 Chard and Widiger
Restitution, Myth, and
Reality
Joel Paris
McGill University
Commenting on a case presentation
entitled “Restitution 101,” a number of
problems are pointed out. The diagnosis
of the patient is not properly
documented, and the history is marred by
probable false memories. The
interpretation of Ornduff (2005) that
understanding previous experiences of
child abuse was helpful to the patient is
questioned. An alternative approach,
using both psychodynamic and cognitive
principles, is suggested.
The case of Ms. S is presented as an
example of the psychotherapy of
a client with a personality disorder.
Unfortunately, the clinical material is
insufficient to establish a diagnosis. One
cannot even say whether the client
meets the general criteria for personality
disorder listed in the Diagnostic
and Statistical Manual of Mental Disorders
(4th ed., text rev.; American
Psychiatric Association, 2000), not to
speak of any of the specific categories
on Axis II.
Some aspects of the case do suggest the
presence of personality pathology.
First, the presenting symptoms are of
long-standing mild depression:
Dysthymia beginning in adolescence or
youth is highly comorbid with
Axis II disorders (Pepper et al., 1995).
Second, the client describes longterm
problems in relationships that seem to be
independent of Axis I
symptoms. What are missing are more
detailed longitudinal data to document
consistent difficulties over time and
impairment in multiple areas of
functioning.
However, other aspects of the case are
not fully supportive of an Axis
II diagnosis. The client does not have a
history of serious disabling symptoms
or previous therapy, and she has been a
successful student. She came
to treatment with a recent problem, an
unhappy love affair with an older
man. Although she currently lacks friends,
we are not told whether that
Correspondence concerning this article should be
addressed to Joel Paris, Department of
Psychiatry, McGill University, 1033 Avenue des Pins
Quest, Suite 104, Montreal, Quebec
H3A 1A1, Canada. E-mail: joel.paris@mcgill.ca
Journal of Psychotherapy Integration Copyright 2005 by the
Educational Publishing Foundation
2005, Vol. 15, No. 1, 89–93 1053-0479/05/$12.00 DOI: 10.1037/1053-
0479.15.1.89
89
pattern is long standing and goes back to
childhood. To find out more, I
would need to take a much more detailed
history. In my experience, many
cases of personality disorder can be
diagnosed in an initial assessment if
data on long-term functioning are
available. However, some cases require
more extended evaluation, sometimes
with the client alone, and sometimes
with family members and significant
others.
In this case, I need to know whether the
client has always had problems
with men and whether she has different
problems with women. I also want
more specific data on conflicts with her
mother and her brother. (It might
be useful to meet with family members to
get more information.) The
picture the client paints of her mother
cannot be taken at face value; the
relationship may well have been
“domineering,” but it is also possible that
she experienced it that way because of
her personality traits. In general,
perceptions of parenting are subject to
recall bias and can be as much a
reflection of current as of past difficulties
(Yarrow, Campbell, & Burton,
1970). However, there are enough data to
support the conclusion that this
client has had a negative and estranged
relationship with her father. He was
largely absent and, at the very least,
showed a lack of respect for boundaries
when present. The question remains as to
what exactly happened
between father and daughter.
This case presentation comes with a
provocative title. “Restitution
101” implies that childhood sexual abuse
was the primary cause of the
client’s problems and that the therapeutic
approach required is obvious. I
am not convinced that the conclusion is
justified or that there is anything
elementary about this case. I see the
history as a confusing amalgam of
memories, some true, some false. The
field of psychotherapy has gone
through a period of turmoil about the
validity of “recovered memories”
(Loftus, 1993). The present case offers a
good example of why these issues
remain controversial. The current
consensus among memory researchers
(Schachter, 1996) is that childhood
experiences are remembered in a
reconstructive fashion. Recollections from
the earliest years of childhood
also tend to be factually unreliable as a
result of the normal phenomenon
of “infantile amnesia,” because an
immature brain cannot lay down longterm
memories.
In the course of her therapy, the client
described a number of abusive
incidents with her father. Each of these
needs to be assessed separately. It
is unlikely that major distortions affect
memories of recent events, such as
the father’s inappropriate behavior during
the client’s adolescence. However,
the report of sexual abuse with
penetration by her father at age 3 has
most of the hallmarks of a false memory
(Loftus, 1993). First, the client’s
memories of incest emerged only recently,
after a specific suggestion by a
physician who examined her. Second, they
derive from a period of life
when most events are subject to amnesia,
yet they are present with a vivid
90 Paris
and dramatic quality, inconsistent with the
indistinct quality of most childhood
memories. Third, recollections of incest
might have been inadvertently
reinforced in the course of therapy, as
shown by the fact that they
became more detailed over time.
(Therapists believe they are neutral yet
still ask leading questions and make
unintended reinforcing comments.)
Finally, no one seems to have met with
anyone except the client. We do not
know whether the father actually
confirmed that particular incidents
actually
occurred or whether he made a general
apology that was seen by the
client as confession. Moreover, we do not
know whether anyone else in the
family is in a position to provide
independent confirmation of abuse.
Memories, even when factually false, can
have powerful metaphoric
truth. The client is telling her therapist
that she has been damaged emotionally
by her father. In this respect, she is quite
right. But it does not
follow that sexual abuse is the main cause
of her presenting problems or
that restitution should be the focus of
therapy.
The report goes on to describe a
supportive treatment whose primary
aim was the creation of trust. This is, of
course, a universal aspect of good
therapy. Yet support does not always
succeed, particularly in clients with
personality disorders (Livesley, 2003). As
experienced therapists know,
empathy and active listening can
sometimes elicit paradoxical responses, in
which clients react to their developing
attachment with increased mistrust.
Managing these difficulties is one of the
main challenges of treating personality
disorders. In this case, however, the client
had high ego strength
with a history of academic success, and
she evidently responded well to the
therapeutic relationship.
If restitution should not be the focus, how
would I have approached
this case? I would have begun by sharing
with the client my understanding
of her problems and explaining how I
planned to proceed. This would have
involved defining the frame of therapy
(i.e., the client talks and the therapist
comments) as well as its goals (i.e., to
provide a better understanding
of why the client is having emotional
difficulties and to work on better ways
of handling these problems).
More specifically, I would have expected
to work with the client on
some of the underlying issues behind the
presenting complaints. One does
not have to be a Freudian to believe that
this client has been seeking the
love of men to compensate for the
absence of a father. I would therefore
want to explore a pattern of seeking
intimacy with older men to the
exclusion of other relationships. I would
also wonder whether the client is
choosing unsatisfactory men who are
likely to leave her or whether she
becomes anxious about intimacy and finds
a way to break off close relationships.
I would not take it for granted that her
perceptions of the
previous boyfriend were fully accurate or
that he was abusive to the client
in the same way as the father. (There are
two sides to any story, and it is
Special Section: Restitution, Myth, and Reality
91
the therapist’s job to fill in the blanks.) As
for the client’s problems with
women, I would explore whether she is
afraid of rejection, torn by competitive
feelings, or unable to confide in peers.
Up to this point, my plan corresponds,
more or less, to traditional
psychodynamic therapy. However, I have
learned that the best results
emerge with an eclectic approach that
combines the best of two traditions:
a psychological understanding of life
experience, and a cognitive approach
to change. The psychotherapy literature
does not show that interpretations
that establish links between the past and
the present are consistently
effective. Experienced therapists from a
wide range of orientations spend
most of their time working in the here and
now.
To accomplish behavioral change, one
needs to use a cognitive approach:
identifying maladaptive schema,
managing emotional responses,
and problem solving. This client probably
needs to examine her negative
view of herself and her expectations that
intimates will either be saviors or
betrayers. In relation to emotion, she may
need to find ways to modulate
her responses and avoid maladaptive
behaviors used to regulate dysphoria.
In relation to problem solving, she may
need to find ways to handle
intimacy more effectively, both in making
intelligent choices of partners
and in managing the inevitable conflicts
that arise in any close relationship.
This approach contrasts with the model of
“Restitution 101,” which
only offers a healing narrative of
victimization, a less consistently effective
approach than one that encourages clients
to take full responsibility for
their own difficulties. Finally, we do not
know whether the client was able
to make use of therapy to establish more
successful intimate relationships.
However, even if treatment was helpful,
that does not prove that restitution
was its crucial element. As Jerome Frank
(Frank & Frank, 1991)
suggested long ago, therapists help clients
with all sorts of explanations, as
long as they have one. This conjecture has
been supported by a large body
of research showing that clients respond
to the common or “nonspecific”
factors in therapy (Lambert & Bergin,
1994). In contrast, there is no
evidence base for the concept that
restitution is a useful way to treat
clients— either those who have suffered
childhood sexual abuse or those
who have false memories of abuse.
REFERENCES
American Psychiatric Association. (2000). Diagnostic
and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: Author.
Frank, J. D., & Frank, J. B. (1991). Persuasion and
healing (3rd ed.). Baltimore: Johns
Hopkins University Press.
Lambert, M. J., & Bergin, A. E. (1994). The
effectiveness of psychotherapy. In S. L. Garfield
92 Paris
& A. E. Bergin (Eds.), Handbook of psychotherapy
and behavior change (4th ed., pp.
143–189). New York: Wiley.
Livesley, W. J. (2003). The practical management of
personality disorder. New York: Guilford
Press.
Loftus, E. F. (1993). The reality of repressed
memories. American Psychologist, 48, 518–537.
Ornduff, S. R. (2005). Case report: Restitution 101.
Journal of Psychotherapy Integration, 15,
69–73.
Pepper, C. M., Klein, D. N., Anderson, R. L., Riso, L. P.,
Ouimette, P. C., & Lizardi, H.
(1995). DSM II-R Axis II comorbidity in dysthymia and
major depression. American
Journal of Psychiatry, 152, 239–247.
Schachter, D. L. (1996). Searching for memory. New
York: Basic Books.
Yarrow, M. R., Campbell, J. D., & Burton, R. V. (1970).
Recollections of childhood: A study
of the retrospective method (Monograph 138 of the
Society for Research in Child
Development). Chicago: University of Chicago Press.
Special Section: Restitution, Myth, and Reality
93
Object Relations and the
Nature of Therapeutic
Interventions
Kenneth R. Silk
University of Michigan Health System
This discussion of a case addresses
tailoring a multifaceted therapeutic
intervention based on assessing the
nature of the patient’s object relations. In
this case, the patient’s ambivalent and
confused sense of self and attachment
that developed because of the history of
abuse suggests an approach that
aims to develop a “soft” attachment of
the patient to the therapist. The nature
of the attachment should be explored
using interpersonal therapeutic
techniques
to understand current relationships rather
than to depend on the
development and analysis of transference.
Cognitive– behavioral interventions
will help limit distortions that occur
because of an ego that weakens
under stress. Though the therapist is
thinking and analyzing the therapeutic
data in terms of object relations, the
interventions can come from a number
of theoretical perspectives.
The first issue to discuss in the case
presentation of Ms. S is the
diagnosis. Although it would be ideal if
every patient one saw neatly fit into
a specific diagnostic category, there are,
in my opinion, two main hindrances
that block this. The first is that the
diagnostic categories are not
“true” categories but rather theoretical
constructs, and those theories as
well as categories are subject to
modification and iteration. (Certainly in
the 1970s and 1980s, psychiatry became
enamored with categories and the
wish—at times the belief—that there
actually were distinct categories.
There is now considerable thought being
given to whether some dimensional
diagnoses ought to be considered, though
it is difficult to predict
what will happen in upcoming debates
between the “splitters” and the
“lumpers.”) The second is that people who
come into therapy, in most
instances, have not read the Diagnostic
and Statistical Manual of Mental
Correspondence concerning this article should be
addressed to Kenneth R. Silk, Department
of Psychiatry, University of Michigan Health System,
MCHC Box 0295, 1500 East
Medical Center Drive, Ann Arbor, MI 48109-0295. E-
mail: ksilk@umich.edu
Journal of Psychotherapy Integration Copyright 2005 by the
Educational Publishing Foundation
2005, Vol. 15, No. 1, 94–100 1053-0479/05/$12.00 DOI: 10.1037/1053-
0479.15.1.94
94
Disorders (4th ed.; DSM–IV; American
Psychiatric Association, 1994)
before showing up at the office or clinic
(though more patients are reading
the DSM–IV, or at least more information
as to what constitutes a given
diagnostic category is readily available on
the Internet).
Ms. S, a young, biracial woman, arrives at
the office with three concerns:
(a) “her recent recall of two incidents of
sexual abuse that [allegedly]
occurred during her early childhood and
involved her father,” (b) a long
“history of poor interpersonal
relationships,” and (c) “pervasive feelings
of
confusion . . . involving personal identity,
sexual preference, and career
choice” (Ornduff, 2005, p. 69). She also
expresses a number of symptoms
that appear to be related to anxiety and/or
“trauma” resulting from sexual
abuse. These symptoms are “feelings of . .
. self-hatred, dread, and overwhelming
worry; intrusive negative thoughts;
hypervigilance; and distrust
of herself and others” (p. 69). The
“sadness, anhedonia, initial insomnia
and nightmares, difficulty with
concentration, and feelings of guilt and
worthlessness” (p. 70) could certainly
support a diagnosis of posttraumatic
disorder, particularly because they are not
chronically present but surface
at times throughout the day. (However,
symptoms such as these could be
attributable to dysthymia or to a
personality disorder as well.) One might
assume that these latter emotions are
being triggered by some set of
external events that perhaps activates
certain memories, either consciously
or unconsciously, but that information is
not given. We know the thoughts
or concerns about the abuse are becoming
more and more disruptive to Ms.
S and to her ability to concentrate and,
presumably, do her schoolwork,
though we do not have details as to how
successful she is in her academic
work.
Thus, we can conclude that Ms. S probably
meets the criteria for
posttraumatic stress disorder, though
more information is certainly needed
to truly confirm the diagnosis. Of the six
areas of the diagnosis that need to
be met, I am most concerned with
Criterion C—“persistent avoidance of
stimuli associated with the trauma and
numbing of general responsiveness
(not present before the trauma) in at least
three areas” (American Psychiatric
Association, 1994, p. 428). The fulfilling of
the three areas gives me
some pause. Ms. S’s anhedonia and her
feeling of not having many friends
could fulfill both the feeling of detachment
from others and the markedly
diminished interest or participation in
significant activities. Her involvement
with men appears to reveal a restricted
range of affect and, perhaps,
of responsivity, and her behavior in
treatment (i.e., her difficulty opening
up in therapy and her concerns about the
pace and depth of the therapy)
may be a manifestation of efforts to avoid
thoughts, feelings, or conversations
associated with the trauma. It makes
sense for Ms. S to behave in this
manner in the therapy, given that
research (Nigg, Lohr, Westen, Gold, &
Silk, 1992) has revealed that people who
have been traumatized, particu-
Special Section: Object Relations and Therapy
95
larly people with borderline personality
disorder, expect malevolence from
caretakers and perhaps the world.
Although this malevolence is not strictly
in the form of paranoia, in that the
patients believe someone is against
them or plotting to harm them, it does
include the concept that, in the end,
people are not kind, supportive, empathic,
or protective. Certainly this
sense of malevolence is paralleled in Ms.
S’s experience of her mother as
infantilizing, overinvolved, and critical.
Furthermore, a sexually abusive
father certainly poses both confusion and
threat to interpersonal (including
therapeutic) relationships, in that the
survivor of abuse learns that the
closer he or she becomes to someone, the
more dangerous that person
becomes and the more vulnerable to hurt
the previously abused individual
is. Thus, attachment, particularly for
someone who has been primed for
rejection by an overly critical mother yet
who has a hunger for attachment
in that she feels “empty and panicky when
by herself” (Ornduff, 2005, p.
72), can become extremely ambivalent
and complicated, and, thus, one can
expect these issues to be played out in
the treatment.
One cannot simply dismiss the diagnosis
of a personality disorder in
Ms. S, but I am hesitant to provide her
with one. Her identity confusion and
her fear of abandonment might lead one
to think about attachment problems
and the object relations that might
underlie such self- and other
representations. We are told that she is
not suicidal and does not use
suicide as a threat. No information is
provided as to rage attacks or anger.
Ms. S has some elements of interpersonal
isolation and, perhaps, instability,
but we do not have evidence of emotional
lability or instability, though
she certainly has a good deal of
interpersonal sensitivity, probably
reinforced
by an overinvolved yet critical mother.
Thus, I would, at this
juncture, defer an Axis II diagnosis until I
received more detailed information
as to the type and nature of her
friendships, particularly in late
latency and throughout adolescence. I
would need details about these
relationships and would need to explore
contradictions, because it is unclear
to me whether this young woman is truly
functioning as poorly as one
might expect given what she reports. In
fact, we know she is, or seems to
be, doing fine in her schoolwork, and she
is able to form and maintain
interpersonal relationships with men over
a number of years, despite her
questions about her own sexual
orientation. In addition, one must bear in
mind that questions about identity
(probably compounded for Ms. S by her
biraciality), sexual orientation, and career
choice are certainly not unusual
for someone of college age. Therefore, we
must try to separate normal
developmental conflicts from true
pathology, a distinction that is not
readily apparent in some of the ways Ms.
S presents herself.
One can expect a therapeutic relationship
that is uneven at best. Ms. S
may become more upset and agitated or
more ready to flee the therapy
when she is feeling close to the therapist,
because, again, being close to
96 Silk
someone increases the threat that
individual poses to her. Thus, the “ideal”
therapeutic relationship is one of “soft”
attachment, in which the patient is
allowed to back off from what she
experiences as too intense a session or
an involvement in therapy. (It is not
unusual for patients, particularly those
with a personality disorder, to become
stubborn, defensive, negative, and
critical of the therapy in the session that
follows a session in which important
therapeutic work was accomplished.) The
therapist needs to guard
against feeling rejected at these times
when the patient needs to back off.
He or she needs to be aware of when the
patient feels she has overcommitted
herself or her feelings to the therapy (i.e.,
the therapist) and gently
point out these concerns about the
intensity of the involvement or attachment
to the therapy. However, nothing in the
therapy should be forced,
and confrontations should come rarely and
be couched in terms that are
almost impossible for the patient to
misinterpret as criticism. This may not
come easily, because although the patient
fears attachment, she longs for
the guidance and care of a warm, benign,
parental figure. Thus, the therapist
leaves the session experiencing “worry
and uncertainty about her as
well as about the direction and intensity of
the treatment” (Ornduff, 2005,
p. 73). The patient thus needs to approach
the attachment to the therapist
at her own pace, even as some of her
thoughts and behaviors draw from the
therapist a stance more protective than
the patient is ready to acknowledge
she may actually seek.
In the process of therapy with this patient,
therefore, there are at least
two areas that need to be closely
monitored. The first is attachment and
distance, and I have said enough about
this in the preceding paragraphs.
The second is monitoring her ego
strength. By this I mean that the therapist
needs to attend closely to how well Ms. S’s
object relations are holding up
and be ready to define reality for her ego
if there is any indication of
psychosis or distortions in cognition that
might threaten her current functioning
in the world. Ms. S, in many respects, is
functioning quite well,
given what we can assume to be the
paucity of healthy figures with whom
she could identify in her childhood. The
therapist needs to make sure that
the healthy parts of Ms. S stay healthy
even while trying to explore, ever so
gently, some of the more troubling
aspects of her past and current
functioning.
Thus, the therapist needs to be able to
shift techniques or, at least,
to borrow techniques from other schools
of thought when needed. Ego
supportive work must be done, and it is
very important to monitor the
balance between exploratory and ego
supportive work, adjusting constantly.
Further, the patient needs to have some
behavioral or coping
techniques as well. Sometimes therapists
explore and weaken defenses
before the patient has the opportunity to
build and use new techniques; for
someone like Ms. S, this can be
dangerous. Thus, before the therapist
does
things to weaken the current defenses,
Ms. S needs to learn and practice
Special Section: Object Relations and Therapy
97
some cognitive– behavioral or dialectical–
behavioral coping techniques so
that she can use them in times of stress.
The practicing part is important,
because, when stressed, people have the
tendency to fall back on more
primitive and more reflexively learned but
not necessarily ego-adaptive
defensive styles.
This therapeutic approach may, at first
glance, appear eclectic, but it
combines many elements of interpersonal
psychotherapy with a strong
reliance on object relations theory. The
therapy is not strictly psychodynamic,
in that it does not emphasize uncovering
work per se but rather tries
to get the patient to talk about
relationships in the here and now.
Although
it is true that the relationship with the
therapist may be one of the most
important “here and now” relationships, I
do not encourage transference
per se to develop. The encouragement of
transference, particularly in
patients with a somewhat weak ego, may
cause regression in the therapy.
Ms. S already has a tendency to regress
because of the complicated nature
of the attachment that she will experience
in relation to the therapy and the
therapist. It would be most helpful if the
therapist explored Ms. S’s ambivalence
about attachment in other current
relationships and then, in the
discussion of those relationships, brought
the issues back into the examination
of the therapeutic relationship. The
therapist could do this by gently
asking, “I wonder whether you sometimes
think that I might be critical of
you in the way you think your boss
sometimes thinks of you. Now, I know
you know that we therapists are supposed
to stay neutral about all these
things, but I sometimes think, especially
because your mother was so
dismissive of you, that I am secretly
critical as well.”
The therapist could add some cognitive–
behavioral ideas to this mix.
Such an addition might be put forth as
follows: “You know, when you are
under stress, your thinking narrows down.
Sometimes when you think your
boss is annoyed with you, you realize that
it is mostly in your head. But
other times it seems more real than that,
and I would guess that the more
real you are thinking it is, the more
stressed you had been feeling before
you even came to work. Perhaps we can
use this as a sort of a barometer
as to your stress level. When you are sure
that your boss and your
roommate are both annoyed with you, it
may be a sign that you are under
a lot of pressure. And when you are under
such pressure, it may be best not
to make too many decisions as to what
you might want to do or what you
might wish to say to your boss. As you
know, I think maintaining perspective
is probably one of the things that can lead
us to behave in more healthy
ways, and if we can identify when we have
lost perspective, then we can
make sure we lay low for a while until our
thinking and perspective
broaden again.” I am not certain that I
would say these things exactly this
way for this particular patient, but I hope
these statements provide some
general examples of how I would
intervene.
98 Silk
Other times, I more directly confront and
even disagree with a patient.
If it is clear to me that the patient is
simply focusing on one narrow
interpretation of an event or interchange,
then I say that I think that and
provide for him or her a number of other
possible understandings or
interpretations of the event. I emphasize
that I am not sure which, if any,
is the correct way to think about it, and I
also make sure that I say that the
patient’s interpretation may be the correct
one. My point, I emphasize, is
not to argue which understanding is the
right one; rather, it is that in almost
every situation, there are multiple ways of
understanding interactions and
conversation, and perspective entails
trying to keep different options and
understandings open in one’s mind. I think
of this as trying to define reality
for the patient, particularly when his or
her emotions may have distorted
reality in ways that can certainly be
detrimental in the short run and, if
allowed to harden, a major burden and
deficit in the long run.
In these circumstances, when the patient
resists or pushes back, I
simply back off. I do this not because I
have given up hope that he or she
will understand the event differently but to
model the idea that even I, the
therapist, am willing to consider other
points of view—that is, it is more
important to keep a broad perspective
than to be right. Often I do this
simply by saying, “OK, if you feel that
strongly about it,” or I convey the
idea by shrugging my shoulders and
saying, “Yes, it is true; I do not really
know.”
Thus, therapy will probably go two steps
forward and three steps back
for a while (as in the example I provided,
in which the patient becomes
negative and resistant after a session in
which I feel we did excellent work)
until there is some beginning trust that
the patient has in the safety of the
therapy. Then, perhaps, it could proceed
to three steps forward and two
steps back, as the patient becomes more
comfortable using new coping
techniques and the safety of the therapy
is not violated even as more
difficult topics are broached. There are
certainly patients who seem to
remain in the posture of two steps
forward, three steps backward for
extended periods of time. When this
occurs, I try to point out the dilemma
to the patient with something like the
following: “I feel that whenever we
make some progress, you appear to pull
back from it. I wonder whether
you have any thoughts as to what that is
about or whether there is
something that I could do to make it
easier (and maybe safer) for you in
here. I know this takes a tremendous
amount of your time, energy, and
financial resources, and I would certainly
like to make it easier for you, but
I am stumped at the moment.” I say this
to model a number of different
things: (a) that it is not impossible to
discuss disagreements or differences,
(b) that I am very eager to work in a
collaborative way, and (c) that I am
not omniscient but can be stuck and do
not always know the answer.
The therapist needs to be cautious of
being too helpful, particularly in
Special Section: Object Relations and Therapy
99
areas that seem out of the boundaries of
the therapy. This does not mean
that the therapist should not be supportive
of the patient’s ego and define
reality when needed. However,
appropriate physical distance, respect for
the space and the feelings of the patient,
and a mutual understanding that
the therapy is a way of pointing the
patient in the right direction rather
than leading or pulling a weakened person
along are paramount to a
successful course of treatment.
I introduce to the patient my style of
working in the following way. I
suggest in the first appointment that I
would like to know more about the
patient before committing to areas that I
think are important to explore. I
tell him or her that no later than the third
session I will have some of the
areas narrowed down. I then say that I
would like to hear what’s on his or
her mind rather than ask a lot of questions
(though I assure the patient that
I am not shy and will certainly, in the
course of the therapy, ask a lot of
questions), because if I ask the questions,
at the end of the session we have
a terrific sense of what was on my mind
but no sense of what was on the
patient’s mind. I do not, however, allow
the session to begin with a long,
painful silent period. I may ask, “How was
your week?” or “Have you had
any thoughts or reactions about last week,
when we talked about your
roommate?” I also mention that, in the
course of treatment, I may want to
give the patient tools that might help him
or her to cope better. These tools
can come in the form of medications or in
the form of a recommendation
to a dialectical– behavioral therapy group
that my clinic runs on a continuous
basis, in which a specific and different (on
a rotating basis) coping skill
is taught every month. I also emphasize
that my recommendation of such
additional work or medication does not
mean that I think of the patient as
sicker than when I first met him or her.
Rather, I emphasize that I may, in
the course of the treatment, learn about
certain patterns of behavior,
interpersonal situations, or symptoms that
bring up in my mind a more
specific intervention around that particular
issue that might be quite useful.
REFERENCES
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Nigg, J. T., Lohr, N. E., Westen, D., Gold, L. J., & Silk,
K. R. (1992). Malevolent object
representations in borderline personality disorder
and major depression. Journal of
Abnormal Psychology, 101, 61–67.
Ornduff, S. R. (2005). Case report: Restitution 101.
Journal of Psychotherapy Integration, 15,
69–73.
100 Silk
A Behavioral Approach to
the Case of Ms. S
Amy W. Wagner
University of Washington
This article provides a behavioral
formulation and treatment plan for the
case of Ms. S. Given the complexity of Ms.
S and the status of current
research, interventions proposed
emphasize empirically supported
principles
of change over any specific protocol. This
particular behavioral approach
incorporates aspects of dialectical
behavior therapy and functional analytic
psychotherapy in addition to more
traditional behavior therapy. The utility
of the therapeutic relationship in this
approach is described.
My approach to psychotherapy is
behavioral, such that I conceptualize
the development and maintenance of
behaviors according to learning
theory (operant conditioning, classical
conditioning, etc.). I view the context
in which behavior occurs as critical to
accurate conceptualizations and
change. I focus on the function of behavior
over the form of behavior (i.e.,
what the behavior does for the person as
opposed to what it looks like), and
I place high value on accurate
assessments of (the function of) behavior,
adhering to the adage, “Assess; do not
assume.” I have a broad perspective
on behavior and view most things that
humans do as behavior (including
feeling, thinking, behaving, and even
some glandular squirting), all influenced
by the same principles of learning, and all
worthy of consideration in
the development, maintenance, and
change of problems. My interventions
pull from empirically supported treatments
and principles that are targeted
to my behavioral formulations. I have
been influenced by functional analytic
psychotherapy (Kohlenberg & Tsai, 1991),
a radical behavioral approach
to psychotherapy that places high
importance on attending to and
addressing clinically relevant in-session
behavior and views the therapeutic
relationship as critical to change.
I also have a strong background in
dialectical behavior therapy (DBT;
Correspondence concerning this article should be
addressed to Amy W. Wagner, Department
of Psychiatry and Behavioral Sciences, Box 359911,
University of Washington,
Seattle, WA 98105. E-mail:
awwagner@u.washington.edu
Journal of Psychotherapy Integration Copyright 2005 by the
Educational Publishing Foundation
2005, Vol. 15, No. 1, 101–114 1053-0479/05/$12.00 DOI:
10.1037/1053-0479.15.1.101
101
Linehan, 1993a), and this informs my case
formulations and interventions
in significant ways. DBT is, in part, based
on a theory of borderline
personality disorder (BPD) that
emphasizes the role of chronic invalidation
in the development of severe emotion
dysregulation that is characteristic
of this disorder. Therefore, when I see
evidence of emotion dysregulation
in my clients (whether or not they meet
criteria for BPD), I assess for
a history of invalidation. DBT is designed
to directly treat the emotion
dysregulation (and associated problems)
of individuals with BPD, and it
does so in part by adding validation
strategies to traditional behavior
therapy (change) strategies. Likewise, if I
conceptualize the development
and maintenance of emotion
dysregulation in my clients (BPD or
otherwise)
as related to invalidation of emotional
experiences (e.g., they evidence
current self-invalidation or uncertainty
about how to feel or react),
I use validation strategies in my work.1
DBT is also a stage-oriented treatment
that bases the focus and content
of treatment on clients’ stage of disorder.
In essence, DBT prioritizes
interventions to treat first those behaviors
that are most likely to threaten
the client or the therapy process (e.g.,
suicidal behavior), then moves to
treating emotional disruptions and other
life problems. The dialectical
philosophy in DBT implies that
(apparently) opposing viewpoints can
simultaneously be true and that change
occurs through the synthesis of
oppositions. In therapy, this translates to a
holistic (or systemic, contextual,
or transactional) perspective of behaviors
and change (the therapist is
always looking for “what is left out”) and
to the artful balancing of
acceptance-based strategies and skills
with the change strategies of behavior
therapy. In addition to validation
strategies, DBT incorporates additional
acceptance-based strategies and teaches
clients acceptance-based
skills (e.g., mindfulness). As a world view,
a dialectical perspective has
applicability in therapy across diagnostic
groups. Similarly, I incorporate
acceptance-based interventions with
traditional behavior therapy in my
work across clients.2
Okay, so how does this apply to the case
of Ms. S?
1For a review of research that supports the
application of DBT to a range of disorders
that are characterized by emotion dysregulation, see
Koerner and Dimeff (2000).
2The synthesis of acceptance-based interventions
with traditional cognitive– behavioral
therapy is becoming increasingly common and
gaining empirical support across disorders. The
reader is referred to Hayes, Strosahl, and Wilson
(2002); Jacobson, Christensen, Prince,
Cordova, and Eldridge (2000); Marlatt (2002);
Roemer and Orsillo (2002); and Segal, Williams,
and Teasdale (2002).
102 Wagner
DIAGNOSIS AND CHARACTERIZATION
The case of Ms. S is interesting to discuss
conceptually, as she does not
appear to fit neatly into a diagnostic
category of the Diagnostic and
Statistical Manual of Mental Disorders
(American Psychiatric Association,
1994). She has some symptoms of
depression but does not meet the
frequency or intensity criteria for major
depressive disorder. She has
several symptoms of posttraumatic stress
disorder (PTSD), but, again, it is
unclear from the description whether she
meets the intensity and frequency
criteria that warrant the diagnosis
(avoidance symptoms were not
mentioned,
and I would assess this further). In
addition, it is unclear whether
the abuse can be considered a Criterion A
event, because her reactions to
the abuse are not fully described. Some of
her problems overlap with the
criteria for BPD, such as chaotic
interpersonal relationships and identity
confusion, but, once again, Ms. S does not
meet the full criteria for this
disorder. Further, many of the problems
she presents with do not appear in
any diagnostic category (e.g., difficulty
trusting others, self-hatred), though
it is hard to deny the importance of
addressing these problems in therapy.
Despite this less-than-clear-cut diagnostic
picture, Ms. S’s presentation is
actually typical of the modal outpatient
and brings to light some of the
limitations of the current diagnostic
system.
Ms. S’s presentation also raises interesting
questions about intervention.
I value psychiatric diagnoses in part
because of their utility in determining
which therapy is warranted on the basis of
the treatment outcome
literature (i.e., if a psychotherapy has data
to support its efficacy for a
certain diagnostic group, it is the
treatment of choice for a client with the
same diagnosis). Yet, because the
majority of treatment protocols have by
and large been evaluated on discrete
diagnostic groups, their applicability
to clients with more complicated
presentations (e.g., multiple diagnoses or
multiple problems that fail to meet the full
criteria for any diagnosis, as in
the present case) is unknown. For this
reason, in my clinical practice I rely
heavily on the use of ideographic case
formulations based on thorough
functional analyses of the presenting
problems (Davison, 2000; Goldfried
& Davison, 1994) and determine
treatment interventions on the basis of
these case formulations. My case
formulations are guided by behavioral
theory, and my interventions pull from
empirically supported principles of
change (Rosen & Davison, 2003). In this
way, my general approach again
overlaps with DBT, which has been
characterized by Linehan (1993a) as a
principle-driven psychotherapy that
includes protocols. The approach has
utility with individuals with BPD, who
frequently present with a variety of
coexisting difficulties and diagnoses, and
likewise has applicability to the
typical clinical outpatient.
Special Section: Behavioral Case Formulation
103
For Ms. S, I would conduct functional
analyses on her presenting
problems, with the goal of identifying the
factors related to the development
and maintenance of her problems. For
example, when assessing her
feelings of sadness and anhedonia, I would
focus on discrete periods of
increased sadness and anhedonia
(perhaps identified through daily
selfmonitoring)
and inquire about the context in which
these feelings occurred;
her actions, thoughts, and additional
emotional reactions; and the
consequences
(of her actions, thoughts, and emotional
reactions). Through
several functional analyses, I would look
for patterns that suggest points for
intervention. Because the theoretical and
empirical literatures highlight the
role of decreases in reinforcement and
avoidance in the development and
maintenance of depression, I would stay
alert to the ways this was manifesting
for Ms. S and the ways her additional
problems might be contributing.
I would similarly assess her intrusive
memories of childhood sexual
abuse (looking for environmental and
emotional cues that set these off and
consequences that might contribute to the
maintenance—e.g., avoidance
behavior) and hyperarousal. I would
assess the factors related to the
maintenance of her relationship
difficulties, particularly her tendency to
become involved quickly with men she
does not feel strongly about and to
stay in relationships that are abusive, and
her difficulty assessing the
trustworthiness of others. I would examine
her interpersonal skills, the
beliefs she has about herself and others,
her emotional reactions, and
contextual factors. Likewise, I would
assess her feelings of self-hatred and
her uncertainty about her views, beliefs,
goals, and sexual identity. A
contextual approach includes attention to
the role of the broader context in
which behavior occurs as well as the
immediate context. I would therefore
assess the influence of cultural and racial
factors in Ms. S’s difficulties (e.g.,
self-hatred, identity confusion). I would
look for ways these diverse factors
and problems interrelate and attempt to
develop an integrated formulation
to point to specific targets and
interventions for therapy.
On the basis of the information provided in
the case description, I
attempt a very tentative behavioral case
formulation of Ms. S, though, in
actual practice, I would assess in the
manner I have described prior to
developing a formulation for treatment-
planning purposes. I view case
formulations as working hypotheses and
would therefore stay open to
changing the formulation as new
information became available. From this
perspective, it seems reasonable to begin
a case formulation with the
information presented.
Ms. S is experiencing intrusive memories
of childhood sexual abuse
and accompanying arousal and
hypervigilance. She reports a history of
childhood sexual abuse, and a recent visit
to a gynecologist appears to have
cued memories of these experiences.
There are likely ongoing cues in her
environment that elicit these memories,
and, in addition, she may be
104 Wagner
engaging in some avoidance behaviors
(i.e., behaviors that function as
avoidance) that are maintaining the
memories (e.g., trying not to think
about the experiences when the memory
arises, judging herself for the
experiences).
Ms. S’s feelings of sadness and anhedonia
appear related to several
factors. It seems likely that her negative
feelings and beliefs about herself
(regarding the sexual abuse as well as her
current life struggles) are
contributing to her negative mood. In
addition, Ms. S is likely experiencing
feelings of grief related to the ending of
her recent relationship and
perhaps related to her new realizations
about the way she was treated by
her father. Further, she appears to have
had few experiences in her life that
give her reinforcement (roughly translated
as pleasure and meaning). She
has virtually no social support or
meaningful relationships, and she appears
to get little pleasure from her school and
work activities (which take up
most of her time). This may, in part, relate
to a general pattern of avoidance
of cues to her childhood abuse and, more
generally, negative affect. In
addition, given her difficulty identifying
her preferences and desires, she
may have trouble creating a life that is
inherently reinforcing.
Ms. S’s difficulties in relationships appear
related to several additional
factors. On the basis of her relationship
with both of her parents, it can be
hypothesized that she has not learned
how to determine whether someone
is trustworthy, how to develop intimacy, or
how to balance dependence and
independence in relation to others. For
example, her father (someone she
was presumably emotionally close to and
dependent on in some respects)
caused her physical harm, sexually
abused her (which she appears to have
experienced as both positive and negative
at the time), and was very
unpredictable. This makes it difficult for
Ms. S, as an adult, to know
whether certain behaviors in others are
dangerous, acceptable, loving, and
so forth. In addition, her mother treated
her as incapable and conveyed
disapproval and rejection when Ms. S
demonstrated more independent,
self-generated behavior, yet Ms. S
perceived her mother as very capable.
From this, Ms. S could have learned to
discount her own needs, beliefs, and
desires in relation to others and to
downplay her accomplishments and
strengths, simultaneously believing that
she should be doing better than she
is. This might additionally have led Ms. S
to feel she is not worthy of
friendships or positive relationships in
general.
The anxiety that Ms. S experiences may,
in part, relate to her childhood
sexual abuse (reminders of her abuse can
elicit fear and anxiety). In
addition, on the basis of her learning
history, she may currently experience
anxiety in reaction to the high
expectations she has for herself as well as
the
belief that she may lose people close to
her if her behavior does not live up
to their expectations. Some of her current
difficulties may be maintained by
Special Section: Behavioral Case Formulation
105
their function in temporarily reducing
anxiety, such as worrying, working
excessively, and avoiding friendships.
Further, it seems likely that Ms. S’s history
contributes to her overall
feelings of self-hatred, uncertainty about
herself (sexual orientation, goals,
etc.), and depression, specifically because
of the invalidating characteristics
of her experiences. Linehan (1993a)
defined an invalidating environment as
one that pervasively and chronically
conveys to a child that his or her
emotional reactions and self-generated
behavior are faulty, inappropriate,
pathological, or unimportant. Over time,
this interferes with the child’s
ability to recognize, label, communicate,
and change or regulate internal
experiences; leads to an excessive
reliance on others to determine how to
feel, think, and act; and leads to the
development of self-invalidation. The
behavior of both of Ms. S’s parents has
prototypic elements of invalidation
and likely contributed to her difficulty
trusting her own perceptions and
reactions, knowing what she wants in
relationships and life in general, and
valuing herself. Finally, because Ms. S is
biracial, it could be hypothesized
that Ms. S has experienced episodes of
invalidation throughout her life in
the form of racism. Her confusion about
her identity might similarly relate
to uncertainty about (or lack of
acceptance of) her racial affiliation.
TREATMENT METHODS
I use case formulations to guide my
therapy. To these I add knowledge
about the factors required for effective
intervention (from the empirical
and theoretical literature) and clients’
priorities for treatment. In terms of
stages of disorder and therapy, Ms. S is
fairly highly functioning and does
not have any behaviors that directly
threaten her well-being or therapy.
She has maintained a heavy school and
work load, she is not suicidal, she
does not appear to engage in additional
dysfunctional behaviors that can
function as emotional avoidance (though I
would assess thoroughly for the
following behaviors, which can function as
emotional avoidance: alcohol
and drug use, eating-disordered behavior,
dissociative behavior, and selfinjurious
behavior), and she seems committed to
and motivated for therapy.
According to Linehan’s (1993a)
terminology, Ms. S is more of a Stage
II client (with primary problems related to
emotional suffering and identity
confusion), as opposed to a Stage I client
(for whom behavioral dyscontrol
is primary), and therefore I would not
impose specific targets for therapy.
However, as is the case with Stage I DBT,
if Ms. S began to engage in
life-threatening or therapy-interfering
behavior, those behaviors would
become the primary focus of therapy,
given the risk they pose to her
well-being and the therapy process. I
would orient Ms. S to this expectation
and its rationale at the onset of therapy.
106 Wagner
I would initially propose that the therapy
focus on depression, given
the salience of Ms. S’s recent relationship
break-up, the difficulties she is
beginning to experience in school and
work, and the potential impact of
continuing school and work problems on
increasing her depression. I would
suggest a focus on depression prior to her
PTSD-related problems, because
talking about childhood sexual abuse
would likely lead to an increase in her
emotional experiencing, which could
further affect her school and work
performance and increase her depression.
In addition, there is some empirical
evidence that depression can interfere
with the effectiveness of
exposure-based interventions for PTSD
(e.g., Ehlers et al., 1998), which are
the treatment of choice, given the case
formulation (discussed further
below). I would begin by having Ms. S
track her daily activities and the
mood associated with these activities. I
would pay particular attention to
disruptions in her routine and biological
functioning that might be contributing
to her depression, such as inactivity,
excessive or insufficient sleep,
and excessive or insufficient eating, and I
would do problem solving (e.g.,
sleep hygiene) and activity scheduling to
work on this. To help Ms. S reach
these goals, I would thoroughly orient her
to the role of these disruptions
in depression and help her break the goals
down into reasonable steps (i.e.,
shaping). Consistent with the components
of behavioral activation (Martell,
Addis, & Jacobson, 2001), I would work
with Ms. S to identify the
activities in her life that are reinforcing,
the behaviors she engages in that
function as avoidance, the ways she might
not be fully engaging with the
reinforcing properties of activities in her
life (e.g., through worry and
rumination), and new activities she could
add to her life that would be
reinforcing (and, as such, consistent with
her values and goals).
This process would necessarily begin to
address problems in addition
to depression. For example, as Ms. S
worked to add to activities to her life,
she would likely struggle with identifying
what she likes, wants, values,
strives for, and so forth. Therefore, to
build a life that is inherently
reinforcing, she needs to work on
increasing her awareness of her
experiences
and beliefs and further developing her
values, goals, and preferences.
Toward this, she may benefit from skills
training aimed at increasing her
ability to identify and label emotions and
other internal experiences (e.g.,
training in Linehan’s, 1993b, emotion
regulation skills, mindfulness skills).
I might suggest assignments in which she
engages in new activities and pays
attention to her experiences while
participating in these activities as a
means of gaining additional awareness
about her own reactions and preferences.
Similarly, because Ms. S has identified a
desire to have more
meaningful relationships, increasing
reinforcement would also include attention
to the factors that interfere with her
development of meaningful
relationships. The specific interventions
would be dependent on a thorough
assessment of these factors but, on the
basis of the information provided
Special Section: Behavioral Case Formulation
107
about Ms. S, would likely include skills to
increase her awareness of her
reactions in relation to others (e.g.,
mindfulness training); identification of
her beliefs about herself and others that
may influence her choices in
friends and partners (and challenging of
these beliefs when warranted);
skills to increase her tolerance of the
emotions she experiences when she is
not in a relationship (therefore decreasing
the likelihood that she will move
quickly into a relationship prior to getting
to know the person well); and
further identification of her desires,
values, and goals in relationships
(again, through mindfulness and
experimentation).
Although it is difficult to convey, the point
I’m trying to make is that
I do not view therapy as completely linear,
as multiple problems are often
being addressed simultaneously.
Nonetheless, having a clear target (in this
case, depression) helps to ensure that
progress is made on this target, which
is often not the case when therapy jumps
from problem to problem
independently of case formulation. For
example, during work on depression
with Ms. S, if our therapy moved to
increasing her awareness of her
values, goals, and preferences, I would be
sure to link this back to the way
her increased awareness could be useful
in identifying the kind of life she
wants (i.e., experiences as reinforcing),
which is essential for reducing
depression. Additional work on her identity
and relationship problems
might not happen at this point in therapy
but might recur when we focused
on PTSD-related problems or might have a
discrete focus at another point
in therapy, independently of the treatment
of other problems.
I would recommend that therapy focus
directly on the treatment of Ms.
S’s PTSD-related problems when her
depression was reduced (to at least
the mild range) and when she had learned
and incorporated skills for
reducing depression. Prior to this direct
focus, I would help Ms. S manage
her intrusive symptoms (particularly if
they were highly distressing) by
identifying cues that elicit the intrusive
symptoms and developing methods
to eliminate, avoid, or cope with the cues.
For example, if Ms. S experienced
an increase in nightmares following
contact with her father, early in
therapy I likely would suggest that she
(temporarily) avoid contact with her
father. I might also teach her skills, such
as mindfulness, for focusing her
attention when she is experiencing
unwanted memories.
When treating Ms. S’s PTSD-related
problems directly, I would again
base specific interventions on my case
formulation. I have hypothesized
that her intrusive and arousal symptoms
were developed through classical
conditioning and are maintained by
current cues and avoidance behavior.
Empirically supported principles of change
for this formulation are exposure
and response prevention. I would first
thoroughly orient Ms. S to the
rationale, goals, and expectations for
exposure. I would then work with Ms.
S to develop a hierarchy of her intrusive
memories (according to the degree
of distress they evoke, the frequency with
which she experiences the
108 Wagner
memories, and the degree to which they
interfere with desired activities)
and begin exposure with the more
distressing and frequently experienced
memories (on the basis of the possibility
that habituation to more distressing
memories may generalize to less
distressing memories; Batten, 2002).
Typical exposure to memories involves
describing the memories out loud
while imagining the scene, with as much
detail as possible, over and over,
until the memory loses its conditioned
association with the initial event.
Research suggests that effective exposure
requires contact with the cue and
habituation to the cue (e.g., Jaycox, Foa, &
Morral, 1998), and, therefore,
the specific methods used might vary for
Ms. S to achieve these goals. For
example, if Ms. S was initially unwilling
(i.e., felt too overwhelmed) to talk
about her memories, I might propose that
she initially write out her
memories, read them to herself, and then
read them in session (shaping).
Likewise, if Ms. S did not experience much
emotion during her description
of her memories, I would create a context
that elicited more emotion, such
as having her add more sensory details,
speak in the first person, and so
forth. Other methods that have been
shown to facilitate habituation include
intersession exposure practice (e.g., by
listening to audiotapes of the
previous session’s exposure) and
lengthening the session. I would consider
these methods for Ms. S as needed to
achieve habituation.
Simultaneously, treatment would address
avoidance. During the imaginal
exposure, I would stay awake to possible
(and subtle) ways that Ms. S
might be avoiding contact with the cues.
These could be volitional or not
(and, likewise, in conscious awareness or
not) and could include dissociation,
changing the topic, distracting, judging
herself, omitting certain parts
of the memory, and secondary emotions
(e.g., anger in response to fear). I
would work to block avoidance by pointing
out these behaviors when they
occurred and directing Ms. S back to the
memory. In addition, Ms. S might
be engaging in behaviors outside of
therapy that function as avoidance of
cues to her childhood abuse, and I would
address this type of avoidance as
well. In part, I would identify these
behaviors by assessing the situations
and experiences Ms. S is aware of
avoiding because they remind her of her
abuse and that are getting in the way of
her goals (no obvious examples
were provided in the case summary, but
these might include sexual intimacy
or contact with certain family members).
In this case, treatment
would involve gradual exposure to these
situations and experiences (in vivo
exposure), blocking avoidance, and
allowing for habituation.
An additional, necessary component of
exposure-based therapies is
that corrective information is obtained
from the process (e.g., Foa &
Rothbaum, 1998). This can occur in many
forms, including realizing that
the emotion can be tolerated for longer
than expected and without disastrous
consequences, experiencing a decrease in
emotions in the presence of
cues (habituation), remembering or
attending to additional details of the
Special Section: Behavioral Case Formulation
109
trauma that change one’s beliefs and
feelings about the event, and obtaining
information from the therapist that
changes one’s beliefs and feelings
about the event (e.g., that the
dependence and immaturity of children
greatly inhibit their ability to say “no” to
an adult abuser, that it is normal
to have liked some aspects of the abuse).
Therefore, I would structure the
exposure to maximize the chances that
corrective information would be
obtained (e.g., altering the length or
frequency of sessions to ensure
habituation, choosing situations for
exposure that are not overly or
insufficiently
emotionally evocative) and highlight the
new information that is
obtained from the process. Instruction and
practice in dialectical thinking
could similarly help Ms. S process her
experiences in new ways. In DBT,
this translates, in part, to adopting a belief
system that allows for multiple
truths and recognizing the transactional
nature of reality. For Ms. S, the
notion of multiple truths might be helpful
for understanding how her
father’s actions could be both loving and
hurtful and how she could feel
different and even contradictory feelings
for him at the same time. The
transactional perspective can further
remove conflicts around blame and
fault and lead to greater self-acceptance
and self-validation.
Ms. S presents with additional problems
that likely originated, in part,
with her childhood sexual abuse but that
may not change through the
process of exposure (e.g., her difficulty
recognizing, trusting, and communicating
her emotional experiences, her difficulty
trusting others, her selfhatred,
and her uncertainty about her preferences
and goals). This is
because, as discussed in the case
formulation, other factors relate to the
maintenance of these problems beyond
classically conditioned associations
and avoidance. Nonetheless, many of the
interventions I have mentioned
above have applicability to these
additional problems, and, therefore, I
would address them indirectly throughout
therapy (e.g., mindfulness would
aid Ms. S’s ability to identify her internal
experiences; dialectical thinking
might reduce her self-blame and increase
her self-acceptance). In addition,
the therapeutic relationship is a powerful
and important context in which
these views can be influenced, and it is
particularly important for Ms. S, as
I discuss next.
THERAPEUTIC RELATIONSHIP
As mentioned, I view the therapy
relationship as critically important
for change. In part, this is because many
of the problems for which clients
seek therapy are interpersonal in nature.
Likewise, when problem behaviors
occur in the context of therapy, the
therapist has much greater access
to information about the factors that elicit
and maintain these problems
110 Wagner
and, therefore, has much greater ability to
intervene effectively. Further,
the therapy relationship is often a very
powerful source of reinforcement
for new behavior and can be used
strategically (and naturally) to influence
and maintain change. Toward creating an
effective therapeutic relationship,
I strive to be genuine (in voice tone and
manner), I am explicit in my
behavior and expectations, and I express
my feelings and views when this
is in the client’s best interest.
Ms. S reports difficulty trusting others and
a pattern of becoming
involved quickly with men who are
harmful to her. She also seems to have
difficulty trusting and forming her own
views and opinions, and this, too,
appears related to her relationship
difficulties. I would stay aware of similar
patterns that might emerge in our
relationship and address these when
relevant. For example, I would expect that
Ms. S would initially be wary of
me and the therapy process and might
present as very “together” and
invulnerable. I would look for discrete
examples of this (e.g., direct statements
that she does not trust me or reticence to
express herself) and then
assess her thoughts and feelings, the
context, and my behavior to understand
the factors related to her distrust.
Interventions at this point could
take many forms, depending on this
assessment, but might include
encouraging
her to take risks with me by expressing
herself despite her fear
(exposure), cognitive restructuring
(evaluating what she knows about me,
my reactions), or, perhaps, encouraging
her to seek more information to
determine whether I am trustworthy. I
would then work with her on
generalizing these interactions and
interventions to other areas of her life.
In addition to helping Ms. S build trust with
others, the therapy
relationship could be used to help her
develop and trust her own experiences.
I expect that, as therapy progressed, Ms. S
would become highly
concerned about my opinions and views
and have difficulty expressing her
own opinions and views in my presence.
Initially, some degree of feedback
and input from me would be important
because, on the basis of the case
formulation, she has not learned how to
identify emotions and beliefs and
likely invalidates those experiences she
can identify. This might occur in
the context of any topic in which she is
expressing or attempting to express
an emotion or belief. I could give Ms. S
feedback by providing information
on “normative” experiences, agreeing
with or supporting her expressed
experiences when they seem accurate or
understandable, attending to her
with interest, and so forth (i.e., Linehan’s,
1993a, definition of validation).
Given the goal of increasing her self-
validation, self-awareness, and
selfgenerated
behavior, it would be important to reduce
the degree to which I
provided this over time (i.e., shaping) and
instead encourage Ms. S to rely
on her own reactions and experiences.
I would also use this process of providing
validation and increasing her
reliance on self-validation to help Ms. S
clarify her career goals and
Special Section: Behavioral Case Formulation
111
questions of sexual identity. Though these
topics would likely take a lower
priority in treatment (with depression and
her PTSD-related problems
being the initial focus), ongoing attention
to increasing self-awareness and
self-validation in the context of a genuine
and validating therapeutic relationship
would likely contribute to increased clarity
about these issues as
therapy progressed. Throughout therapy, I
would work to stay aware of
when Ms. S was engaging in new and
relevant behavior and respond in
ways that reinforced these changes when
they occurred (e.g., through
praise, warmth, and responsiveness).
Changing long-standing and intense
views of oneself (e.g., self-hatred and self-
invalidation) is a slow process,
however, and will likely be an ongoing
process for Ms. S, influenced in part
by changes in her life experiences over
time.
THERAPY PROCESS
I’ve described much of the process my
therapy would take with Ms. S,
including the use of assessment, the order
of targets, and the form and use
of the therapy relationship over time. To
be a bit more explicit about the
structure, I would recommend weekly
individual therapy and suggest an
initial contract period of 20 sessions, with
a plan to assess progress and
goals at that point. I view individual
therapy as useful for achieving a
thorough case formulation and for
providing interventions specific to the
factors maintaining the patient’s
difficulties (this degree of precision can be
difficult to achieve in a group setting). In
addition, the individual therapy
relationship would allow Ms. S to work on
her difficulties with relationships,
as discussed above. However, I could also
argue that Ms. S would
benefit from a group therapy context, in
which she could have opportunities
for building trusting relationships with a
variety of others as well as
learn that others have had similar
experiences (e.g., in an abuse-focused
group), which would thereby reduce her
beliefs about stigmatization and
self-blame. Skills for regulating emotions
and increasing self-awareness
could also be taught in a group context
(see Cloitre, Koenen, Cohen, &
Han, 2002).
In my first session with Ms. S, I would
review my consent form and
limits to confidentiality, emphasizing the
reporting laws in my state (given
her history). I would provide information
about my general approach to
therapy as well as options for alternative
therapy, particularly given her
lack of previous therapy experience. I
would assess her reasons for seeking
therapy, collaboratively develop a problem
list, and begin the process of
obtaining functional analyses of these
problems. I might provide some
psychoeducational information about
depression and/or childhood sexual
112 Wagner
abuse, and I likely would give her an
assignment to begin self-monitoring
her depression and PTSD-related
problems. I would make a point to ask
her at the end of the session what the
session was like for her and to answer
any questions she might have.
In general, I would be more structured
early in therapy, given her lack
of experience with therapy and her
difficulties with self-awareness as well
as to obtain needed information. I would
gradually and explicitly decrease
my imposition of structure as a means of
strengthening her identification
and communication of feelings, beliefs,
and needs. I would assess her
functioning throughout the course of
therapy, both subjectively and objectively
with self-monitoring and self-report
measures when possible.
It is important to keep in mind, given Ms.
S’s relationship difficulties
and history of rejection and abuse by
people she has been close to, that
termination from therapy could be difficult
for her (e.g., eliciting feelings of
rejection or fear about her ability to cope).
I would stay aware of this and
assess and intervene as I had with other
relationship issues that emerged
during therapy. I would bring up
termination well before the end of
therapy and determine the timing of
termination as collaboratively as
possible. I view the ending of therapy as
similar to the ending of other
important relationships and as an
opportunity to say goodbye in a way that
is meaningful and perhaps new to the
client. As Ms. S likely has not had
many experiences ending relationships in
positive ways, I would discuss
options for doing this and determine the
actual format collaboratively as
well. Finally, I would end with a focus on
relapse prevention, including
reviewing the course of our work together,
highlighting the factors most
relevant to the changes she had made,
and likely scheduling a follow-up
“booster” session a few months out.
REFERENCES
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Batten, S. V. (2002, November). Next-step
treatments for PTSD: What should we do with
nonresponders, comorbid conditions, and
complicating factors? (M. Cloitre, E. A. Hembree,
S. M. Orsillo, & J. I. Ruzek, panelists). Clinical
roundtable presented at the 36th
Annual Convention of the Association for the
Advancement of Behavior Therapy,
Reno, NV.
Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H.
(2002). Skills training in affective and
interpersonal regulation followed by exposure: A
phase-based treatment for PTSD
related to child abuse. Journal of Consulting and
Clinical Psychology, 70, 1067–1074.
Davison, G. C. (2000). Stepped care: Doing more with
less? Journal of Consulting and Clinical
Psychology, 68, 580–585.
Ehlers, A., Clark, D. M., Dunmore, E., Jaycox, L.,
Meadows, E., & Foa, E. B. (1998).
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The role of mental defeat and
alienation. Journal of Traumatic Stress, 11, 457–471.
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Foa, E. B., & Rothbaum, B. O. (1998). Treating the
trauma of rape. New York: Guilford Press.
Goldfried, M. R., & Davison, G. C. (1994). Clinical
behavior therapy (Expanded ed.).
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Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2002).
Acceptance and commitment therapy:
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Cognitive and Behavioral Practice, 9,
164–166.
Jacobson, N. S., Christensen, A., Prince, S. E.,
Cordova, J., & Eldridge, K. (2000). Integrative
behavioral couple therapy: An acceptance-based,
promising new treatment for couple
discord. Journal of Consulting and Clinical
Psychology, 68, 351–355.
Jaycox, L. H., Foa, E. G., & Morral, A. R. (1998).
Influence of emotional engagement and
habituation on exposure therapy for PTSD. Journal of
Consulting and Clinical Psychology,
66, 185–192.
Koerner, K., & Dimeff, L. A. (2000). Further data on
dialectical behavior therapy. Clinical
Psychology: Science and Practice, 7, 104–112.
Kohlenberg, R. J., & Tsai, M. (1991). Functional
analytic psychotherapy: Creating intense and
curative therapeutic relationships. New York: Plenum
Press.
Linehan, M. M. (1993a). Cognitive– behavioral
treatment of borderline disorder. New York:
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Linehan, M. M. (1993b). Skills training manual for
treating borderline personality disorder.
New York: Guilford Press.
Marlatt, A. G. (2002) Buddhist philosophy and the
treatment of addictive behavior. Cognitive
and Behavioral Practice, 9, 44–49.
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001).
Depression in context: Strategies for
guided action. New York: W. W. Norton.
Roemer, L., & Orsillo, S. M. (2002). Expanding our
conceptualization of and treatment for
generalized anxiety disorder: Integrating
mindfulness/acceptance-based approaches with
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Psychology: Science and Practice, 9, 54–
68.
Rosen, G. M., & Davison, G. M. (2003). Psychology
should determine empirically supported
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(2002). Mindfulness-based cognitive therapy
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relapse. New York: Guilford Press.
114 Wagner
Schema-Focused Cognitive
Therapy and the Case
of Ms. S
Jeffrey E. Young
New York, New York
DIAGNOSIS
In terms of a formal Diagnostic and
Statistical Manual of Mental
Disorders (4th ed.; DSM–IV; American
Psychiatric Association, 1994)
diagnosis, I would diagnose Ms. S with
borderline personality disorder
(BPD) on Axis II and posttraumatic stress
disorder (PTSD) on Axis I. The
BPD diagnosis is based on the following
evidence of DSM–IV criteria:
1. Ms. S seeks any “quick, frantic
attachment . . . to avoid being alone”
(Ornduff, 2005, p. 72).
2. She is ambivalent about her mother,
idealizing and devaluing her
(“both proud of and intimidated by” her; p.
71).
3. She exhibits identity disturbance
(“feelings of confusion . . . involving
personal identity, sexual preference, and
career choice”; p. 69).
4. Ms. S has affective instability
(“frightened–frightening, bold–timid,
guarded–open, harsh–kind . . . curious–
apathetic” and “affective
storms”; p. 73).
5. She has chronic feelings of emptiness
(“empty and panicky when by
herself”; p. 72).
In terms of PTSD, Ms. S exhibits many of
the characteristic symptoms:
1. She experienced early sexual abuse,
with violent undercurrents, as a
child and continuing over a 15-year
period.
2. She experiences recurrent, intrusive
images, thoughts, flashbacks,
and nightmares related to the abuse.
3. Prior to treatment, she denied the
abuse and tried to control the
Correspondence concerning this article should be
addressed to Jeffrey E. Young, independent
practice, 561 Tenth Avenue, New York, NY 10036. E-
mail: young@schematherapy.com
Journal of Psychotherapy Integration Copyright 2005 by the
Educational Publishing Foundation
2005, Vol. 15, No. 1, 115–126 1053-0479/05/$12.00 DOI:
10.1037/1053-0479.15.1.115
115
images. She also failed to recall important
aspects of the abuse until
later in treatment.
4. The images interfere with her
concentration and affect her ability to
function normally.
CASE CONCEPTUALIZATION
From a schema therapy perspective, Ms. S
almost perfectly fits the
model for conceptualizing BPD. According
to schema theory, BPD is
characterized by four primary modes: the
abandoned and abused child, the
detached protector, the punitive parent,
and the angry child modes. A
mode is similar to an ego state. A schema
mode is defined as follows: “those
schemas or schema operations—adaptive
or maladaptive—that are currently
active for an individual.” A dysfunctional
schema mode is activated
when specific maladaptive schemas or
coping responses have erupted into
distressing emotions, avoidance
responses, or self-defeating behaviors that
take over and control an individual’s
functioning. An individual may shift
from one dysfunctional schema mode into
another; as that shift occurs,
different schemas or coping responses,
previously dormant, become active
(Young et al., 2003). These shifts are
referred to as “flipping” modes.
I elaborate on each of the four borderline
modes, illustrating them with
examples from Ms. S. Although I need
more information to confirm
whether she actually has each of these
modes, there are signs that all four
are present.
Abandoned and Abused Child Mode
In this mode, the borderline patient
experiences all of the vulnerable
emotions, including sadness and fear, that
go along with abuse and abandonment:
In the Abandoned Child mode, patients appear fragile
and childlike. They seem
sorrowful, frantic, frightened, unloved, lost. They feel
helpless and utterly alone,
and are obsessed with finding a parent figure who
will take care of them. In this
mode, patients seem like very young children,
innocent and dependent. They
idealize nurturers and have fantasies of being
rescued by them. They engage in
desperate efforts to prevent caretakers from
abandoning them. (Young, Klosko, &
Weishaar, 2003)
I list below some of the evidence that Ms.
S exhibits this mode:
1. her fear of being abandoned by her
mother if she becomes more
independent;
116 Young
2. her fear of rupturing her relationship
with her mother “like I did
with my father”;
3. her feelings of emptiness and panic
when relationships end;
4. her frantic attachments to men, made
to avoid being alone; and
5. her history of sexual abuse, the
intrusive images, and the accompanying
distress.
Detached Protector Mode
In the detached protector mode, the
borderline patient blocks out his
or her needs and feelings, complies with
the expectations of others to avoid
punishment, and keeps an emotional
distance from other people to protect
himself or herself from harm.
When borderline patients are in the Detached
Protector mode, they often appear
normal. They are “good patients.” They do
everything they are supposed to do and
they act appropriately. . . . The problem is that, when
patients are in this mode, they
are cut off from their own needs and feelings. Rather
than being true to themselves,
they are basing their identity on gaining the
therapist’s approval. They are doing
what the therapist wants them to do but they are not
really connecting to the
therapist.
Signs and symptoms of the Detached Protector mode
include depersonalization,
emptiness, boredom, substance abuse, binging, self-
mutilation, psychosomatic complaints,
“blankness,” and robot-like compliance. Patients
often switch into the
Detached Protector mode when their feelings are
stirred up in sessions in order to
cut the feelings off. (Young et al., 2003)
On the basis of Ms. S’s case material,
there is considerable evidence
that she experiences this mode as well:
1. She shuts off her needs and feelings to
avoid rejection or criticism.
2. She follows the lead of others, doing
what is expected.
3. She lacks a clear sense of identity.
4. She is afraid that she will discover too
much about herself.
5. She is afraid of experiencing intense
emotions.
6. She has very few friends.
7. She exhibits significant trust issues in
the therapy relationship.
Punitive Parent Mode
The third mode is the punitive parent. In
this mode, the patient
internalizes the punitive, rejecting, and
critical behavior of his or her
parents during childhood and then
punishes himself or herself:
Special Section: Schema-Focused Cognitive
Therapy 117
Signs and symptoms include self-loathing, self-
criticism, self-denial, self-mutilation,
suicidal fantasies, and self-destructive behavior.
Patients in this mode become their
own punitive, rejecting parent. They become angry
at themselves for having or
showing normal needs that their parents did not
allow them to express. They punish
themselves—for example, by cutting or starving
themselves—and speak about
themselves in mean, harsh tones, saying such things
as they are “evil,” “bad,” or
“dirty.” (Young et al., 2003)
Ms. S shows signs of this mode:
1. She manifests “self-doubt, self-hatred”
(Ornduff, 2005, p. 69).
2. She has feelings of guilt and
worthlessness.
3. She has a “self-punishing sense that
she somehow brought about
and deserved” (p. 71) the sexual abuse.
4. She remained in a relationship with Mr.
K that was emotionally and
physically abusive.
Angry Child Mode
The angry child is probably the mode most
often associated with
borderline patients in the mind of
practitioners. In this mode, the anger
that has been suppressed while the
patient was in the detached protector
mode explodes in inappropriate ways:
“They may appear intensely rageful,
demanding, devaluing, controlling, or
abusive. They act impulsively to get
their needs met, and may appear
manipulative or reckless” (Young et al.,
2003).
Two statements in the case material
suggest that Ms. S may have a
suppressed angry child mode:
1. She has feelings of being betrayed by
and lied to by her parents.
2. She has feelings of anger and contempt
toward her mother.
I would want to explore in more detail the
possibility of more signs and
symptoms indicative of each mode. I
would also want to know which modes
are most evident during therapy sessions;
on the basis of the case description,
I hypothesize that Ms. S is in the detached
protector mode much of
the time with the therapist.
Although there is abundant evidence in
the case material for the
abandoned and abused child, punitive
parent, and detached protector
modes, I would like to examine more
carefully whether Ms. S shows other
symptoms of detachment, such as
depersonalization, spacing out, or
numbness.
I would also need to investigate the issue
of how she handles her
anger. According to the schema therapy
model and my clinical experience,
it is rare for patients with BPD to have so
little rage toward people who
have mistreated them. I hypothesize that
Ms. S’s anger is being suppressed
118 Young
in the detached protector mode. There is a
possibility that some of her
somatic symptoms are linked to this
unexpressed anger. Often the angry
child is the most difficult mode for higher
functioning borderline patients to
access. They typically fear severe
punishment and abandonment if they
express anger. Furthermore, they often
feel that they deserve to be mistreated
and thus do not have the right to be angry
(the punitive parent
mode). Ms. S’s ambivalent relationship
with her mother places her in a
no-win situation. If she expresses her
anger or independent wishes, her
mother may abandon her; if she
suppresses her feelings, she can never
individuate and also suffers the
consequences of unexpressed rage.
ORIGINS
Schema therapy hypothesizes four
characteristics of the childhood
environment that contribute to the
development of BPD.
Unsafe
The early environment is usually
physically, sexually, or verbally abusive,
or there is the threat of explosive anger or
violence. This certainly
applies to Ms. S, who experienced sexual
abuse by her father, which she
described as violent rape.
Depriving and Unstable
The childhood environment of patients
with BPD is usually characterized
by absent or inconsistent parental
nurturing and empathy. In addition,
the patient’s parents do not usually
provide a sense of stability and
predictability.
Although her mother was in some ways
overinvolved with Ms.
S’s life, there is no indication that she was
consistent in her caring or that
she provided affection, empathy, or
nurturance. Furthermore, Ms. S’s
mother failed to protect her from her
father. Ms. S seemed to develop the
compulsive self-reliance of children who
have not had adequate nurturing
or a stable base (in the case material, she
was described as self-sufficient in
many respects as early as 2 years old).
Special Section: Schema-Focused Cognitive
Therapy 119
Punitive and Rejecting
The parents of borderline patients usually
treated the child in a harshly
critical, punishing manner. In addition, one
or both parents usually rejected
the child. In the case of Ms. S, her mother
was alternately infantilizing or
critical and rejecting. The degree of
punitiveness needs to be explored
further.
Subjugating
The parents of borderline patients usually
punish or withdraw love
from the child if the child expresses his or
her individual needs and feelings.
This appears to be the case with Ms. S.
Any independent behavior on the
part of Ms. S as a child led to her mother’s
disapproval and rejection.
THE THERAPEUTIC RELATIONSHIP
The schema therapist strives to create a
relationship that is termed
limited reparenting. This involves fostering
a degree of dependence on the
therapist, so that the therapist can, over
time, fill many of the unmet needs
in patients with BPD. This might include
more frequent contact (perhaps
through E-mail or by phone), more
personal self-disclosure, strong
encouragement
for the patient to express strong feelings,
nurturing, and direct
praise. Of course, the reparenting is
limited to what is generally considered
appropriate in therapy, although we push
the envelope somewhat further
than do most other therapies.
I anticipate that Ms. S would go through
the typical stages of
borderline patients in a therapeutic
environment characterized by limited
reparenting:
1. an initial detachment and mistrust;
2. a gradual letting down of her guard, as
she becomes strongly connected
to and somewhat dependent on the
therapist;
3. attempts to have even more contact
with the therapist because her
needs are being partially gratified, often
accompanied by anger
when the therapist cannot provide
enough;
4. fear that the therapist will abandon her
if she says what she really
wants or feels;
5. gradual acceptance of the therapist’s
reparenting (including its limitations).
This usually coincides with a process of
emotional development,
emotional regulation, growth, and
stability. The patient
120 Young
feels both cared for by and caring toward
the therapist, an increased
sense of well-being, and openness about
her needs and emotions;
6. gradual individuation and separation
from the therapist.
In the case of Ms. S, I anticipate a similar
progression. However, the
therapist would have to be particularly
careful to encourage the patient’s
self-expression and autonomy, as her
dependence increases. Otherwise,
Ms. S is likely to feel that she must
suppress her individuality to maintain
the connection with the therapist, as she
did with her mother. The therapist
would have to actively encourage and
support any efforts on the part of the
patient to express her independence, just
as a healthy parent does with a
child, even as the patient is feeling
emotional dependence on the therapist.
TREATMENT METHODS
Schema therapy is integrative and
incorporates techniques drawn from
cognitive– behavior therapy, experiential
therapies (especially gestalt therapy),
attachment models (e.g., Bowlby’s work;
see Ainsworth & Bowlby,
1991), and object relations.
For each of the four schema modes, a set
of specific treatment strategies
has been developed. In general, for
patients with BPD, such as Ms. S,
the model anticipates that the limited
reparenting will be the most important
component of treatment (as described in
the previous section). In
addition, the following techniques are
incorporated:
1. Imagery and dialogues, in which Ms. S
gets an image of herself in
each of the four modes (during different
sessions). Initially, the therapist,
serving as the healthy adult mode, enters
the image with the patient and
uses the appropriate strategies to heal the
mode. Then the patient plays the
healthy adult in the image and carries on
a dialogue with herself in each of
the other modes.
For example, Ms. S might picture herself in
the angry child mode with
her mother. The therapist would enter the
image and express the child’s
anger to the mother, while the child
observes. Later, Ms. S, as the healthy
adult, would vent anger at her mother in
the image, while the therapist
serves as a coach.
2. Much later in treatment, as she learned
how to deal with each of the
four modes, Ms. S would do imagery work
with PTSD. She would be
encouraged to picture scenes, through
imagery, in which her father abused
her sexually. These scenes would be
approached in gradual steps, for short
periods of time (not through a flooding
procedure). Each image would be
discussed thoroughly immediately
afterward, and the patient would be
encouraged to discuss whatever thoughts
and feelings emerged (e.g., fear,
Special Section: Schema-Focused Cognitive
Therapy 121
shame, anger). The therapist would
validate whatever emotions Ms. S
expressed, although he or she would
begin to challenge any feelings of
self-blame or shame. This process would
be continued over many sessions,
until all the related memories had
emerged. The therapist would enter the
images whenever the patient became
overwhelmed, to help soothe the
patient and provide a sense of safety.
These procedures are generally
consistent with existing cognitive–
behavioral therapy approaches to
trauma.
3. Through the use of cognitive
techniques, the therapist examines
evidence to test the validity of
dysfunctional thoughts and suggests
coping
strategies to deal with each mode. For
example, the therapist could develop
a flashcard for Ms. S for each mode that
she could carry around with her
outside the session. The flashcard
presents the healthy adult response to
the thoughts typical of each mode. For
example, the therapist would
construct a flashcard for Ms. S to deal with
her punitive parent mode, in
which she experiences self-loathing. The
card would explain why she did
not deserve the abuse from her father,
why she should not allow Mr. K to
abuse her, and why her mother’s
criticisms are wrong. Whenever she
flipped into the punitive parent mode, she
could read the flash card.
4. Using behavioral techniques, the
therapist would guide Ms. S in
breaking self-defeating life patterns. For
example, the therapist would help
her make healthier partner choices by
working with her to set healthy
criteria for the men she gets involved
with, to better meet Ms. S’s needs.
Once she had made a good partner
choice, the therapist would help her to
assert her rights and individuality rather
than merge her identity with the
partner’s or comply with all his wishes.
She would also learn how to handle
conflict in relationships and to express
anger appropriately. Role playing
for rehearsal would be used extensively.
5. Depending on the degree of affective
instability, Ms. S would be
taught emotional regulation skills. These
skills are drawn from Marsha
Linehan’s (1993) dialectical behavior
therapy, including mindfulness meditation,
distress tolerance, and engaging in
pleasurable activities.
6. Although I do not foresee limit setting
as a serious problem with Ms.
S, who seems highly motivated, schema
therapists sometimes set limits
regarding the degree of contact with the
therapist, missed sessions, and
other problems that arise.
THERAPY PROCESS
The process of schema therapy with BPD
is highly variable and does
not follow any rigid structure. The
therapist tracks the patient’s modes in
122 Young
session from moment to moment and uses
appropriate strategies for each
mode. For example, when the patient is in
the detached protector mode,
reluctant to experience feelings or
connect with the therapist, the therapist
draws from the following strategies:
1. Label the detached protector mode.
Help the patient to recognize
cues that he or she is in this mode.
2. Explore the development of this mode
in childhood and empathize
with its adaptive value as a means of
coping with early trauma and
neglect.
3. Review the pros and cons of the
patient’s detachment from his or
her feelings and from the therapist in the
session. The therapist
emphasizes that the patient has to learn
to cope with his or her other
modes to get better, not detach from
them. The therapist also
reminds the patient of the positive
feelings he or she has when he or
she feels connected to the therapist
instead of alone and empty.
4. Practice dialogues (in imagery or using
the two-chair technique)
between the detached protector and
healthy adult modes.
5. Ask the patient to close his or her eyes
and picture himself or
herself as a child (e.g., “What does she
look like? How does she feel
right now?”). By doing this imagery, the
patient almost always flips
into one of the other modes and out of the
detached protector.
6. Continue with other experiential work,
depending on which mode
emerges in the image. Bring the therapist
into the image as the
healthy adult to demonstrate adaptive
responses to each mode.
Although therapy always proceeds
according to the mode the patient
is currently in, there are three common
stages over time. They are not
discrete but blend into each other.
Bonding and Emotional Regulation
In this first stage, the therapist attempts
to bond with the patient in the
abandoned and abused child mode by
building trust. At the beginning of
treatment with BPD patients, I do not
typically explain much about the
therapy itself. Instead, I focus on listening
empathically to whatever issues
the patient wants to discuss. As the
patient raises problems, I explain how
therapy can help him or her resolve each
one. For example, if Ms. S
mentioned the intrusive memories of
sexual abuse, I might tell her that one
of the goals of therapy would be to slowly
help her remember more fully
the details of the abuse; that confronting
the memories rather than blocking
them in therapy should gradually reduce
her unexpected, intrusive
Special Section: Schema-Focused Cognitive
Therapy 123
memories outside of the session; and that
we would also examine later how
her childhood abuse might be affecting
her current life in ways that she is
not yet aware of.
Bonding with the patient in the abandoned
child mode usually involves
negotiating with the detached protector
that creates a wall between the
therapist and patient. Empathy, validation,
and limited reparenting are
crucial to the success of this process.
Emotional regulation skills are also
taught during this stage.
Schema Mode Change
The second stage involves intense work
battling the punitive parent
mode and helping the patient access the
angry child. The patient is helped
to translate the work done in session into
his or her life outside. The
therapist also negotiates and sets limits
during this phase. The therapist,
through supervision, works on his or her
own schemas that are triggered by
the patient so that they do not interfere
with the therapy.
Individuation
The final stage focuses on helping the
patient to develop a secure sense
of identity, including understanding his or
her needs, feelings, and preferences
(including, for Ms. S, the resolution of
sexual and career confusion).
The final emphasis is on working with the
patient to develop a healthy,
satisfying intimate relationship outside of
therapy. As this happens, the
patient becomes increasingly less
dependent on the therapist, and the
frequency of sessions is gradually tapered
off until the patient no longer
requires regular sessions. The patient is
encouraged to contact the therapist
after termination whenever necessary, so
that termination does not feel
like another abandonment.
POTENTIAL PROBLEMS
Schema therapy anticipates several
potential problems with BPD patients,
including Ms. S. Below are four of the most
common.
1. The patient becomes increasingly
dependent on the therapist, to the
point that he or she has difficulty
individuating. This is a particular
risk with Ms. S, who has a dependent,
ambivalent relationship with
124 Young
her mother. Schema therapists deal with
this by sensitively and
nonpunitively pointing out to the patient
when he or she appears to
be relying on the therapist instead of
making friends of his or her
own or making his or her own decisions.
The patient is encouraged
to be more independent but to maintain a
strong connection to the
therapist. The therapist may have to
withdraw subtly by reducing
the level of reparenting or by refusing to
offer advice when asked.
2. A related problem is that the patient
may not want to terminate
treatment when it is appropriate to do so.
We have found, however,
that if we aggressively push the patient to
develop close friendships
and a fulfilling intimate relationship, he or
she no longer feels the
same need for reparenting or frequent
sessions. Once the patient is
in a solid relationship (or its equivalent
through friendships), the
therapist actively encourages the patient
to cut back the frequency
of sessions gradually until termination.
3. A third common problem is that the
patient begins to miss sessions
when certain upsetting emotional themes
arise, such as abuse. We
deal with this through a combination of
teaching emotional regulation
skills, proceeding slowly at the patient’s
own pace, working
with the detached protector mode, and
setting limits on absences.
4. The final obstacle, to which I alluded
earlier, is the triggering of the
therapist’s own schemas. Each schema
therapist has either a cotherapist
or a supervisor who helps the therapist
monitor his or her
reactions to the patient. When the
therapist’s schemas seem to be
impeding progress, the supervisor uses
standard schema therapy
techniques to help the therapist monitor
and heal his or her own
schemas. Furthermore, other issues arise
in working with BPD that
are common for many therapists and are
not necessarily indicative
of the therapist’s schemas being
triggered. Supervision is essential in
these situations as well.
With Ms. S, for example, the therapist is
already aware of several
feelings that might create problems:
worrying about the direction and
intensity of treatment, feeling transparent
and exposed, and feeling confused
about discrepancies in Ms. S’s behavior.
Worrying about the direction
of therapy may simply reflect the absence
of a good conceptual model
for working with BPD. Feeling transparent
and exposed sounds like a
schema issue for the therapist, although I
would need to investigate the
feelings more closely to see what the
patient is doing that triggers these
reactions. Discrepancies in the patient’s
presentation are part of the mode
model: The patient behaves differently
depending on which mode he or
she is in. Educating the therapist about
modes should help alleviate this
concern.
Special Section: Schema-Focused Cognitive
Therapy 125
CONCLUSION
Ms. S is a typical example of the higher
functioning BPD patients that
schema therapy treats, and she fits quite
well into the mode model. Therefore,
I anticipate that the strategies that
schema therapy normally uses with
BPD will also work with her. The case
material provides evidence for each
of the four BPD modes.
The two areas that need to be explored
with special care are the ways
the patient deals with anger and her
relationship with her mother. Both of
these may arise as significant problems
later in the therapy, so more
information about these two issues may
avert missteps on the part of the
therapist. The therapist will probably have
to do considerable work to
access the degree of anger the patient
probably feels toward both her
parents and Mr. K. There is also the risk
that the patient will react to the
therapist’s limited reparenting with the
same ambivalence that she displays
toward her mother, leading her to
suppress her individuality out of fear
that the therapist will reject her.
An important issue that needs specific
attention is the PTSD arising
from the long-term sexual abuse by her
father. The schema therapist uses
established procedures to deal with the
memories that are part of PTSD
(adapted in some ways to fit a reparenting
model), exercising care not to
move faster than the patient can tolerate.
Finally, the therapist has to monitor
carefully his or her own reactions
to the patient, many of which arise when
his or her own schemas are
triggered. Supervision may be necessary
to help the therapist understand
and work with his own schemas.
REFERENCES
Ainsworth M. D. S., & Bowlby, J. (1991). An
ethological approach to personality development.
American Psychologist, 46, 331–341.
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Linehan, M. M. (1993). Skills training manual for
treating borderline personality disorder. New
York: Guilford.
Ornduff, S. R. (2005). Case report: Restitution 101.
Journal of Psychotherapy Integration, 15,
69–73.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003).
Schema therapy: A practitioner’s guide.
New York: Guilford Press.
126 Young
Points of Contention and
Convergence
Kathleen M. Chard
University of Kentucky
Joel Paris
McGill University
Kenneth R. Silk
University of Michigan Health System
Amy W. Wagner
University of Washington
Thomas A. Widiger
University of Kentucky
Jeffrey E. Young
New York, New York
In this portion of the clinical exchange,
Drs. Kathleen Chard and Thomas
Widiger, Joel Paris, Kenneth Silk, Amy
Wagner, and Jeffrey Young discuss
areas of agreement and disagreement
about their concepts of the case, as
described in their separate articles in this
issue of the journal, of the patient with
traits of borderline personality disorder
described in “Restitution 101.” Issues of
diagnosis, phenomenology, case
formulation, and treatment models and
techniques
are compared with an eye toward
integrating the various viewpoints.
KATHLEEN M. CHARD AND THOMAS A.
WIDIGER
We begin by expressing our appreciation
for the opportunity to participate
in this classic exercise. We feel somewhat
like the six men from
Kathleen M. Chard, Department of Education and
Counseling Psychology, University of
Kentucky; Joel Paris, Department of Psychiatry, McGill
University, Montreal, Quebec,
Canada; Kenneth R. Silk, Department of Psychiatry,
University of Michigan Health System;
Amy W. Wagner, Department of Psychiatry and
Behavioral Sciences, University of Washington;
Thomas A. Widiger, Department of Psychology,
University of Kentucky; Jeffrey E.
Young, independent practice, New York, New York.
Correspondence concerning this article should be
addressed to David M. Allen, Department
of Psychiatry, College of Medicine, University of
Tennessee Health Science Center, 135
North Pauline, Sixth Floor, Memphis, TN 38105. E-
mail: dmallen@utmem.edu
Journal of Psychotherapy Integration Copyright 2005 by the
Educational Publishing Foundation
2005, Vol. 15, No. 1, 127–139 1053-0479/05/$12.00 DOI:
10.1037/1053-0479.15.1.127
127
Indostan who went to see the elephant,
though all of them were blind. We
are indeed, in one sense, all blind,
because our perception of Ms. S is
through the eyes of Sidney R. Ornduff
(2005). We are also blind to the
original intentions of David M. Allen for our
invitation to participate. Our
assumption is that the case of Ms. S is
intended to illustrate issues in the
treatment of an adult survivor of childhood
sexual abuse who has borderline
personality traits. In the spirit of providing
our contribution to this
effort, we did not question the description
of the “elephant” as it was
provided to us. For heuristic purposes, we
accepted that Ms. S was sexually
abused in childhood and that Ornduff’s
description of her was generally
accurate.
As Joel Paris (2005) suggested, one could
(and clinically should)
question whether Ms. S was, in fact,
sexually abused. We also share the
concerns of Kenneth R. Silk (2005)
regarding the appropriateness of a
personality disorder diagnosis, given Ms.
S’s age, the presence of the
posttraumatic stress disorder (PTSD)
symptomatology, and the need for
additional assessments. In an ideal world,
each of these diagnostic concerns
would have been addressed more
effectively if each of us would have had
the opportunity to conduct our own
independent assessment of Ms. S. We
might then truly parallel the blind men of
Indostan. In a text by Wiggins
(2003), respected representatives of five
major paradigms of personality
assessment provided relatively
independent assessments of the same
person
(an intriguing and provocative young
lawyer, Madeline G). Each of the
clinicians (i.e., Behrend, Ben-Porath, Blatt,
Costa, Gurtman, McAdams,
Piedmont, and Pincus) relied on the
preferred concepts and assessment
tools of their respective paradigm. Their
convergent and contrasting portrayals
are quite noteworthy and engaging. The
considerable time and
expense that was required to conduct this
exercise (particularly for Madeline
G) prohibit a comparable exercise with Ms.
S. Nevertheless, we would
have liked to have administered to Ms. S
measures of the five-factor model
of adaptive and maladaptive personality
functioning (Costa & Widiger,
2002) in addition to more systematic
assessments of PTSD and childhood
abuse.
Assuming that Ms. S was, in fact, sexually
abused and does have
borderline personality traits, our approach
to her treatment resembles
most closely that of Amy W. Wagner
(2005). Our approach to the treatment
of persons with borderline personality
traits and a history of sexual
abuse in childhood relies extensively on
the clinical wisdom of and the
empirical support for dialectical behavior
therapy (DBT; Linehan, 1993).
We share, in particular, an interest in
addressing the actual and perceived
invalidation experienced by Ms. S. We are
also interested in Wagner’s
functional analysis of discrete periods of
sadness and emptiness (identified
via daily self-monitoring assignments) to
identify the context in which they
occur and the consequences they entail.
We also acknowledge that we did
128 Chard et al.
not adequately recognize or address
potential cultural and ethnic factors in
Ms. S that were noted by Silk (2005) and
Wagner.
Yet it is also evident that we draw heavily
from the more general
cognitive therapy literature and, in this
respect, share many of the perceptions
and techniques of Jeffrey E. Young (2005).
Much of our work is
directed at the irrational cognitive
schemas that reflect the pathogenic
experiences of childhood. One’s view of
the world is largely a reflection of
one’s past, and when one’s world view is
as disturbed and as distorting as
Ms. S’s, it is hardly surprising that matters
of trust are predominant. We
note, though, that Young at times appears
closer to Kohut than to Beck.
We are not critical of his incorporation of
psychodynamic principles. We
agree that anger can indeed be
suppressed and that insight into the
historical
development of one’s irrational cognitive
schemas can be as beneficial
as altering those schemas directly through
cognitive restructuring techniques.
We are perhaps reluctant, though, to
foster explicitly a degree of
dependency on the therapist. We share
Silk’s (2005) preference not to
encourage the development of a
transferential relationship. Frankly, it is
our experience that no encouragement of
a transferential relationship is
really necessary in most survivors of
sexual abuse with borderline personality
traits. Nevertheless, we agree with Young
that improvement does
develop in part through the experience of
the more psychologically healthy
relationship with the therapist, who we
also agree can be an important
symbolic representation of a (healthy or
unhealthy) parent.
In any case, we close by emphasizing that
our approach intends to be
flexibly responsive to the needs and
interests of the individual client yet
also guided by empirically supported
treatment modules (Chard, Weaver,
& Resick, 1997). At our sexual abuse
clinic, we have found that ongoing
systematic assessments of the
effectiveness of our interventions are
invaluable
in helping us to adjust our practice in a
manner that is optimally
responsive to each individual.
JOEL PARIS
With respect to diagnosis, I am in
agreement with Silk (2005) and
Wagner (2005) and in disagreement with
Chard and Widiger (2005) and
Young (2005). On the basis of the
information provided, we are looking at
a client who does not fit neatly into any
Diagnostic and Statistical Manual
of Mental Disorders (4th ed.; DSM–IV;
American Psychiatric Association,
1994) category. This is a common
situation in psychotherapy practice, and
there is a good reason why this should be
so. In general, diagnoses are more
precise and clinically useful in patients
with severe mental disorders but
fuzzier and less useful in better
functioning clients. Even a diagnosis of
Special Section: Points of Contention and
Convergence 129
PTSD (offered tentatively by Silk) does not
really make sense, because we
do not really know what Ms. S’s trauma
was and because her presenting
symptoms are not related to any specific
incident.
With respect to treatment, although each
of my colleagues offers a
unique conceptual approach, I am not sure
how different they are. Research
on common factors in therapy suggests
that a “generic” model can
be used to describe all effective forms of
treatment (Orlinsky et al., 1994).
The essential elements are a strong
therapeutic alliance, understanding of
a client’s inner world, and an active
problem-solving approach. Each of the
treatment approaches described by my
colleagues makes use of these
elements. The question is whether the
specific models they adhere to yield
unique outcomes.
Recently, I have been working with a
group of therapists in a hospital
clinic for patients with borderline
personality disorder (BPD). Our training
backgrounds are various: psychodynamic,
behavioral, and interpersonal–
eclectic. To determine whether we were
providing any form of standard
therapy, we began to watch each other’s
sessions on videotape. It quickly
became apparent that we were using
many of the same interventions, even
when we conceptualized them differently.
Research on psychotherapy comparing
different methods applied to
similar clinical populations has
consistently failed to find differences
(Luborsky
et al., 2002). The few exceptions, such as
DBT (Linehan, 1993),
involve comparisons between well-
structured therapies and less-well
structured
“treatment as usual.” To determine
whether any specific intervention
is useful, beyond nonspecific factors, one
needs dismantling strategies
(which, for practical reasons, are rarely
carried out). Thus, I am skeptical
about applying any single model, however
well grounded it may be in
theory. When conducting therapy, I prefer,
much like Silk (2005), to make
use of the best ideas from several systems
(cognitive– behavioral, interpersonal,
and psychodynamic).
KENNETH R. SILK
One could summarize the five responses
to this case in the following
way: Three involve a treatment that is
primarily within the realm of
cognitive– behavioral therapy (CBT)
approaches, whereas two (including
my own) involve a more eclectic approach
strongly rooted in psychodynamic,
interpersonal, and object relational
principles. However, both Paris
and I have suggested that there needs to
be more than just an emphasis on
the psychodynamic aspects of the case;
there needs to be some work done
in a more cognitive– behavioral dimension
to bolster defenses and to
strengthen “ego” operations. Paris (2005)
put it well when he wrote that
130 Chard et al.
the treatment needs both “a psychological
understanding of life experience,
and a cognitive approach to change” (p.
92). This is also a way to
summarize what Young tried to
accomplish with his schema therapy
perspective.
The schemas are understood in terms of
early life experiences and
identifications, whereas the interventions
to modify the automatic adherence
to those schemas come from cognitive–
behavioral interventional
strategies. I also support a blend of what I
call interpersonal– object relations
understandings with cognitive– behavioral
approaches, as I indicated
in writing that “it is very important to
monitor the balance between
exploratory and ego supportive work,
adjusting constantly. Further, the
patient needs to have some behavioral or
coping techniques as well . . . to
build [i.e., strengthen the ego] and use
new techniques” (Silk, 2005, p. 97).
Conversely, the three commentaries that
emphasized primarily a cognitive–
behavioral approach did not ignore the
“psychodynamic” or interpersonal
nature of the therapy. As I stated, Young’s
(2005) schema therapy
certainly looks to and explores the past
and past relationships when trying
to identify problematic schema, and Young
spent a good deal of time in his
response discussing how the relationship
in the sessions would evolve and
how that relationship roots itself in the
identified schema. Chard and
Widiger (2005) also, although they
emphasized a cognitive approach to the
treatment (i.e., cognitive processing
therapy for sexual abuse combined
with some DBT principles), nonetheless
spent a good deal of time discussing
the therapeutic relationship, how to build
it, how to identify therapyinterfering
behaviors, and how to build a
collaborative alliance. These
issues do not lie primarily in the realm of
cognitive– behavioral principles;
rather, I view them as elements of a long-
standing interpersonal dysfunction
that repeats itself in the relationship with
the therapist. Wagner (2005),
in writing about functional analytic
therapy and DBT, stated that in
sessions she uses “a radical behavioral
approach to psychotherapy that
places high importance on attending to
and addressing clinically relevant
in-session behavior and views the
therapeutic relationship as critical to
change” (p. 101). Wagner discussed how
the problem of Ms. S’s mistrust of
the therapist needs to be looked for,
understood, and analyzed, primarily
in understanding childhood experiences
when Ms. S felt invalidated by her
immediate interpersonal environment.
The point I am trying to make is that even
though one might identify
oneself as a cognitive– behavioral, DBT,
schema-focused, or psychodynamic
interpersonal therapist, in the final
analysis, working with these
difficult, complex patients involves and
perhaps demands a more eclectic
approach. By eclectic, I do not mean
atheoretical or some strange and
ever-changing combination of therapeutic
approaches and techniques.
What I mean is that the therapist needs to
adhere to a theoretical stance
that allows an opportunity to organize the
patient data according to a
particular theory, but the interventions
may use interpersonal techniques
Special Section: Points of Contention and
Convergence 131
to discuss the present therapeutic
relationship, psychodynamic techniques
to appreciate more fully the sources of the
interpersonal difficulties or
formed schema, and cognitive–
dialectical– behavioral techniques to help
the patient overcome his or her preformed
interpersonal expectations and
to more safely move to other interpersonal
understandings and increase his
or her tolerance of stress. Thus, the
interventions may come from various
schools, though they also need to be
concordant with the theoretical
approach of the therapist. So, certainly, a
cognitive– behavioral therapist
can make statements that could be
viewed by others as transference
interpretative, even when the intervention
fits neatly into a CBT framework.
Similarly, an interpersonal psychodynamic
object relations therapist
can use CBT techniques to strengthen
ego, expand coping styles, and build
a more flexible therapeutic relationship,
and these types of interventions
can be fully supported within object
relations theory and therapy. We teach
our patients to have better control while
also moving toward increased
flexibility of response to different
situations. These teachings are useful to
us as therapists as well.
AMY W. WAGNER
Jeffrey E. Young
Young’s (2005) treatment of Ms. S from a
schema perspective is
consistent in many respects with my own
approach. The imagery work
parallels exposure interventions, the
cognitive techniques described are
similar to those I would use, and the
“behavioral” techniques and emotion
regulation skills pull from behavioral and
DBT interventions. My approach
departs somewhat from Young’s in case
formulation and therefore also in
the timing, order, and rationale for specific
interventions. The four primary
modes of BPD described by Young provide
a useful heuristic for conceptualizing
and organizing complex behavior. Indeed,
my clinical experience
working with people who meet criteria for
BPD closely matches this
description. My main concern with this
approach is that the labels are
somewhat pejorative and infer motivation
and/or causation of behavior.
This seems to have the potential for
maintaining negative views of people
with BPD (e.g., it is a bit difficult to have
compassion for someone viewed
as a punitive parent) as well as for
restricting the possible range of factors
under consideration in the maintenance of
problem behavior. For example,
in Young’s description of the angry child
mode, he stated, “the anger that
has been suppressed while the patient
was in the detached protector mode
explodes in inappropriate ways. . . . ‘they
act impulsively to get their needs
met’” (p. 118). This implies that if a client
is behaving in an angry way, it
132 Chard et al.
is because of suppressed anger,
expressed for the purpose of getting his or
her needs met by others. I assume that
treatment would then focus on
helping the client not to suppress his or
her anger and to find alternative
ways of getting his or her needs met.
Although this might be an accurate
case formulation and treatment
intervention, there are other possibilities—
for example, the person interacting with
the client might have done something
that would have evoked anger in most
people. I am interested in
seeing further study and empirical
validation of the constructs described by
Young.
Kathleen M. Chard and Thomas A.
Widiger
My approach probably comes closest to
that expressed by Chard and
Widiger (2005). They described their
orientation as cognitive– behavioral,
and, in their discussion of Ms. S
specifically, proposed techniques pulled
from prolonged exposure protocols,
cognitive processing therapy, and
DBT. They based their treatment
recommendations on a conceptualization
of Ms. S that highlights her symptoms of
PTSD and BPD and on treatments
that have extensive empirical support for
these disorders. I share their
attention to client commitment and
collaboration. The main way our
approaches seem to depart (and this is
relatively minor) is in the manner in
which treatment interventions are
determined. Chard and Widiger stated,
“The therapist could help the client choose
between these options by
thoroughly evaluating her social support
network, suicidal ideation, selfharming
behaviors, and potential therapeutic
adherence” (p. 82). Although
I would also consider these factors
(particularly in determining whether to
proceed with exposure for childhood
sexual abuse), I would further consider
Ms. S’s full range of presenting problems
and circumstances and use
behavioral analyses to determine relations
among problems and the specific
factors involved in the maintenance of
problem behaviors.
Kenneth R. Silk
I agree with Silk (2005) that insufficient
information is provided for
valid psychiatric diagnosis, and I
appreciate his reluctance to proceed in
the absence of additional information. I
also agree with his normalization
of some of Ms. S’s presenting problems,
on the basis of her
developmental stage. Silk based his case
formulation on object relations
theory, which does depart in some
fundamental ways from the CBT
approach I outlined (though not much
detail on the theory is presented
here). This theory seems particularly
useful for tolerating and making
Special Section: Points of Contention and
Convergence 133
sense of potentially difficult therapeutic
interactions. However, from my
(cognitive– behavioral) approach, I would
first assess such interactions
and perhaps have different interpretations
of the cause or function of
the difficulties. Silk described an eclectic
approach to treatment that
includes techniques from CBT and DBT,
along with what is described as
interpersonal psychotherapy with reliance
on object relations theory.
He suggested CBT and DBT to help the
client build “ego strength” (p.
97), which in this context seems to refer
to the capacity to tolerate
emotional experiencing and interpersonal
closeness. Although I agree
that many techniques from CBT and DBT
are useful in the development
of such capabilities as emotion regulation,
interpersonal effectiveness,
and distress tolerance, I do not see the
need to depart from cognitive–
behavioral theory or techniques when
addressing the client’s other
difficulties, including PTSD-related
problems, identity issues, interpersonal
difficulties, and so forth. From the detail
provided, it is not quite
clear what is involved in “exploratory”
work; thus, it is difficult to
compare the other aspects of this
approach with the approach I
described.
Joel Paris
Consistent with my own thinking (but not
mentioned in my article) is
Paris’s (2005) critical attention to the
veracity of the client’s report—in this
case, her history of childhood sexual
abuse and her account of the nature
of her relationships. There is ample
research to support the fallibility of
memory, and it is therefore imperative
that therapists stay aware of this in
the development of valid case
formulations and effective interventions. I
appreciate Paris’s attention to this. I also
agree with Paris that insufficient
information is available for accurate
psychiatric diagnosis. Paris described
his approach as psychodynamic, but it is
difficult to determine points of
convergence or divergence in case
formulation or treatment from the detail
provided. Paris further described an
eclectic approach to treatment that
incorporates “cognitive” components as
well. Although I, too, value flexibility
in treatment techniques, I base the
techniques I use on my case
formulation; the basis by which Paris
incorporates other techniques is not
clear from this description, which again
makes it difficult to compare and
contrast approaches.
JEFFREY E. YOUNG
General Points of Convergence
I see many points of agreement between
my case analysis, based on
schema therapy, and the views expressed
by the other authors. Beginning
134 Chard et al.
with diagnosis, I certainly agree with those
contributors who believe that
the DSM–IV categories for Axis II are
inadequate and that some kind of
dimensional approach is essential. Ms. S is
a case in point. Although I
believe she may technically meet enough
criteria to be diagnosed with
BPD, she is certainly not a “classic”
borderline patient: She does not
appear to be impulsive, have major anger
control issues, or exhibit suicidal
or parasuicidal behavior. More information
about the patient would help
clarify to what degree she exhibits
borderline features; however, on the
basis of the information available, I think
she could certainly be classified
at the high-functioning end of the
borderline spectrum. Also, I agree with
most of the other writers that the PTSD
diagnosis is clear cut in this case.
In terms of treatment, I agree with most of
the other authors that
cognitive techniques, DBT skills, and a
specific, validated treatment for
PTSD should all be components of the
therapy. We also seem to be in
agreement that the therapy relationship is
very important in working with
Ms. S, although we have different views
about what form the therapy
alliance should take. Most of us seem to
share concerns about the risk of
flight when emotions associated with the
abuse become the focus of treatment,
as well as the potential difficulties in and
the importance of establishing
trust, especially in light of the patient’s
history of abuse.
Finally, I agree with those contributors
who focused on the importance
of dealing with the patient’s “attachment”
issues. Her pattern of problematic
relationships with men and her highly
ambivalent relationship with her
mother should be important foci of
therapy.
General Points of Contention
I also see many areas in which the schema
therapy model differs from
most of the other case analyses. In terms
of case conceptualization, I am
troubled by the absence of a more unified,
cohesive conceptualization in
most of the other articles (with the
exception of Chard and Widiger’s
[2005]). With the schema model, I
explained the case of Ms. S in terms of
four distinct modes that are characteristic
of most patients with BPD. Most
of the case material can be readily
classified as an element of one of these
four modes. I hypothesized that Ms. S flips
from mode to mode, in reaction
to either environmental triggers or internal
triggers.
A mode conceptualization allows the
therapist to track the modes from
session to session, and the model
specifies which interventions are most
appropriate for each mode in each stage
of therapy. Cognitive, behavioral,
DBT, gestalt, and therapy relationship
strategies are employed as needed,
depending on the mode that is currently
active and on the phase of
treatment. Knowledge of a patient’s
modes thus guides the therapist in
Special Section: Points of Contention and
Convergence 135
deciding which interventions are likely to
be most effective at any given
point in time. The other articles, in
contrast, discuss the importance of
multiple techniques (e.g., DBT skills and
the therapy relationship), but the
case conceptualizations provide little
guidance regarding when to apply
each technique.
Another problem with most of the case
conceptualizations, from my
point of view, is that they are not
sufficiently integrative. Schema therapy
blends concepts from cognitive, gestalt,
attachment, psychodynamic, and
behavioral models within the mode
construct. It seems to me that the other
contributors, although they are technically
eclectic, focus for the most part
on a single conceptual model to
understand the case (i.e., object relations,
psychodynamic, or five-factor model).
Thus, their conceptual models are
often much more narrow than the
treatment modalities they incorporate.
Finally, in terms of conceptualization, the
other writers, in my opinion,
have difficulty explaining the many
dichotomies within the patient. Ornduff
(2005) was confused by the discrepancies
in the patient’s presentation:
“frightened–frightening, bold–timid,
guarded–open, harsh–kind, insightful–
simple, generous–stingy, curious–
apathetic” (p. 73). From a schema
perspective, these “dichotomies” are
completely predictable: The patient
presents differently depending on which
mode he or she is in at a given
point in time; one mode is often the
opposite of another. (This observation
was the genesis for the development of a
mode model for patients like Ms.
S.) These dichotomies, in my experience,
are central to working with
patients like Ms. S, yet they do not seem
to be addressed sufficiently in the
analyses of the other contributors.
There are also points of contention
regarding the treatment process. I
would say that the treatment approaches
presented in the other articles are
either excessively structured and
technique oriented (i.e., Wagner’s [2005]
and Chard and Widiger’s [2005]
approaches), as is usually the case with
cognitive– behavioral approaches, or too
unstructured and transference
oriented (i.e., Paris’s [2005] and Silk’s
[2005] approaches), as is typical with
most psychodynamically oriented
therapies. Schema therapy strikes a better
balance, I think, between structure and
flexibility and between teaching
coping skills and focusing on the therapy
relationship. The schema approach
specifies three phases of therapy as well
as specific techniques and
relationship strategies for each mode to
provide structure and direction, yet
the therapist is continuously adapting the
techniques and the nature of the
therapy relationship from session to
session to allow flexibility, on the basis
of which mode is currently activated in the
patient.
Another vital point of divergence is the
emphasis that schema therapists
place on “limited reparenting” with BPD—
the actual gratification of
many of the patients’ needs through the
therapy relationship. In some
ways, the model encourages emotional
reliance on the therapist to provide
a corrective emotional experience. Most of
the other authors do not view
136 Chard et al.
the therapy relationship in this way, even
though they emphasize working
with the therapy relationship. (Silk [2005]
came close to this idea when he
discussed “‘soft’ attachment” [p. 96], but
he stopped short of limited
reparenting when he warned that he does
not encourage transference
because it may lead to regression.
Schema therapists actively encourage a
close attachment, even if it leads to
periods of regression.) Schema therapy
also places much more importance on
working with the therapist’s own
schemas, especially with patients with
BPD. The schema approach is useful
in healing the therapist’s schemas when
they are triggered by a particular
patient or issue.
Schema therapy makes extensive use of
gestalt techniques such as
imagery and “dialogues.” These
techniques are not mentioned in the other
articles, except insofar as the standard
treatments for PTSD usually involve
experiential work. Finally, schema
therapists are much slower in working
on the PTSD with a patient as fragile as
Ms. S than most of the other
contributors seem to be. A schema
therapist can wait a year or more before
using a PTSD protocol with a BPD patient,
until he or she feels the patient
has built up sufficient trust in the therapist
and has learned coping skills for
each of the modes.
Specific Areas of Convergence and
Contention
I would like to make a few brief comments
about the individual articles
that I have not already covered in the
general discussion. I resonate with
much of Silk’s (2005) excellent, nuanced
discussion of the therapy relationship.
(This may be because I drew on elements
of object relations and
attachment theory in developing schema
therapy.) However, I feel that his
discussion of cognitive– behavioral
techniques gives the impression that
these are peripheral to the treatment as a
whole. Also, he did not address
the PTSD issues in the case.
I find Wagner’s (2005) blending of
behavior therapy, functional analytic
therapy, and DBT to be interesting and
useful. However, these models
do not yet seem to be fully integrated
conceptually to the degree that I
think schema therapy is. Despite this,
many of the interventions, and the
therapy process itself, overlap
considerably with my approach to the
case.
The greatest areas of difference in terms
of treatment seem to be Wagner’s
strong emphasis on behavioral analysis
and structure, in contrast with my
emphasis on experiential techniques from
gestalt therapy, much less structure,
and limited reparenting.
The article by Chard and Widiger (2005)
minimizes the elements of
BPD that I think are prominent in the case.
Their conceptualization on the
basis of the five-factor model provides a
very broad and inclusive view of
Special Section: Points of Contention and
Convergence 137
the characterological components of the
case. However, I think this
breadth is somewhat of a disadvantage,
because it does not provide a clear
focus for the case—it is not clear what the
core themes are. The emphasis
on CBT, PTSD treatment, and DBT is very
compatible with my own.
However, as I mentioned regarding
Wagner’s approach, I am much less
structured and place greater emphasis on
limited reparenting. I question
whether a patient with this degree of
ambivalence and confusion is able to
follow through and benefit from this
degree of structure and whether the
heavy emphasis on homework forms
would be helpful for her.
I feel the greatest degree of divergence in
reading Paris’s (2005) article.
I strongly agree with the importance he
placed on examining the patient’s
pattern of relationships with men and with
his inclusion of a cognitive
approach. However, I am very
uncomfortable with his strong doubt
regarding
both the validity and the importance of
the patient’s experiences of
sexual abuse. I feel that there is more
than enough evidence to conclude
that Ms. S has a history of abuse and that
the abuse is one of the main
contributors to the problems she presents
with. Whether each individual
intrusive memory is completely accurate
does not seem important to me in
treating this case, as the overall pattern of
abuse, in my opinion, is clear. I
worry that Paris would not be sufficiently
validating in terms of Ms. S’s
experience of abuse and that this might
undermine the success of treatment.
I also find that his rejection of
“victimization” and “restitution” as
effective “narratives” and his preference
for encouraging patients to take
full responsibility for their difficulties
could, at best, seem to lack empathy
for the patient and, at worst, come across
to the patient as “blaming the
victim.”
Before concluding, I note that what
actually happens during sessions
ultimately determines my reaction to each
contributor’s approach. I would
be fascinated to see in what ways the
similarities and differences in
conceptualizations
and strategies play themselves out in
clinical practice.
REFERENCES
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Chard, K. M., Weaver, T. L., & Resick, P. A. (1997).
Adapting cognitive processing therapy
for child sexual abuse survivors. Cognitive and
Behavioral Practice, 4, 31–52.
Chard, K. M., & Widiger, T. A. (2005). Abuse, coping,
and treatment. Journal of Psychotherapy
Integration, 15, 74–88.
Costa, P. T., & Widiger, T. A. (Eds.). (2002),
Personality disorders and the five-factor model
of personality. Washington, DC: American
Psychological Association.
Linehan, M. M. (1993). Cognitive-behavioral
treatment of borderline personality disorder. New
York: Guilford Press.
Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T.
P., Berman, J. S., Levitt, J. T.,
138 Chard et al.
Seligman, D. A., & Krause, E. D. (2002). The dodo
bird verdict is alive and well—mostly.
Clinical Psychology—Science & Practice, 9, 2–12.
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994).
Process and outcome in psychotherapy—
noch einmal. In A. E. Bergin & S. L. Garfield (Eds.),
Handbook of psychotherapy and
behavior change (pp. 270–379). New York: Wiley.
Ornduff, S. R. (2005). Case report: Restitution 101.
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69–73.
Paris, J. (2005). Restitution, myth, and reality. Journal
of Psychotherapy Integration, 15,
89–93.
Silk, K. R. (2005). Object relations and the nature of
therapeutic interventions. Journal of
Psychotherapy Integration, 15, 94–100.
Wagner, A. W. (2005). A behavioral approach to the
case of Ms. S. Journal of Psychotherapy
Integration, 15, 101–114.
Wiggins, J. S. (2003). Paradigms of personality
assessment. New York: Guilford Press.
Young, J. E. (2005). Schema-focused cognitive
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Special Section: Points of Contention and
Convergence 139
Postscript
Sidney R. Ornduff
University of Tennessee Health Science Center
The case contributor provides some final
comments with respect to the case
of Ms. S. Comments are directed toward
the points of convergence and
divergence provided by the expert
reviewers. While acknowledging variation
in the approaches taken in the
conceptualization and treatment of Ms. S,
the
author notes that the major difference
among the reviews is that of emphasis,
as each approach incorporates elements
of the others to a greater or lesser
degree.
At the outset, I thank the contributors for
their thoughtful and
thought-provoking comments on this most
interesting and challenging
psychotherapy case. I also express my
shared frustration that much of Ms.
S’s history was not included in the case
summary, as I limited my report to
material gleaned during the initial weeks
of treatment. The questions posed
by many of the reviewers were not unlike
my own as my work with Ms. S
began. With time, however, answers
emerged, thus providing critical
information
about the complexities of Ms. S’s past and
its impact on her
current functioning. In keeping with the
spirit of the Clinical Exchange, this
exercise has allowed me to gain new
insights and rethink my work with this
young woman from our earliest points of of how to proceed with fragile individuals,
contact. as the need for structure and
Among the many useful points raised by dependency, exploration and
the reviewers is the fact that interpretation, ebbs and flows throughout
Ms. S, like many, if not most, patients, the
presented with multiple complaints treatment process. This puts me in mind
that necessitated a multifaceted and of Winnicott’s (1960) contributions,
flexible approach to treatment. Despite in which he so eloquently reminded us to
the reviewers’ differing conceptualizations be receptive and responsive
of the case, from both a to the evolving demands of the therapy
diagnostic and a therapeutic perspective, I relationship. Two additional points
was refreshed by the general with which I concur, again from Silk, are
consensus that a healthy therapeutic the notion of therapist–theoretical
relationship plays a key role in facilitating orientation “fit” and the inherent
meaningful change and that one’s history sensibility of adopting a flexible stance as
is important in influencing we, like our patients, are confronted with
present behavior. Understanding of and alternative ways of
attention to these premises were understanding.
Correspondence concerning this article should be As is likely evident, I developed a great
addressed to Sidney R. Ornduff,
deal of compassion and respect
Department of Psychiatry, School of Medicine,
University of Tennessee Health Science for Ms. S during our nearly 2-year
Center, 135 North Pauline, Memphis, TN 38105. E- psychotherapy. Working with her was a
mail: sornduff@utmem.edu long, sometimes difficult, and rewarding
Journal of Psychotherapy Integration Copyright 2005 by the
Educational Publishing Foundation process. The importance of consistency
2005, Vol. 15, No. 1, 140–141 1053-0479/05/$12.00 DOI:
10.1037/1053-0479.15.1.140
and patience, the value of human
140 relatedness, and the pain and
instrumental in my treatment of Ms. S and satisfaction inherent in the struggle for a
appear to play important roles measure of “truth” are some of
in the treatment approaches endorsed by the valuable lessons I learned from this
each of the reviewers. therapy.
Although the approaches are variable in REFERENCE
terms of the focus on therapeutic Winnicott, D. W. (1960). The theory of the parent–
infant relationship. International Journal
process versus structured assignments, I
of Psychoanalysis, 41, 585–595.
was intrigued by the broad Special Section: Postscript 141
similarities among the therapeutic
approaches proffered by the panelists.
Of the five approaches, three involve
treatment that is primarily behavioral
or cognitive– behavioral, whereas the
remaining two are more eclectic and
rooted in contemporary,
psychoanalytically informed principles.
Despite
this apparent great divide, I think it is fair
to say that the major difference
among the reviews is that of emphasis, as
each approach incorporates
elements of the others to a greater or
lesser degree. The closing comments
of Joel Paris and Kenneth Silk are well
taken, as they note that working
with difficult and complex patients such as
Ms. S calls for an eclectic
approach to treatment. Such an
observation resonates with my own sense