Hypothesized Mechanisms of Change in Cognitive Therapy for Borderline Personality Disorder.pdf

Hypothesized Mechanisms of Change in Cognitive

Therapy for Borderline Personality Disorder

Amy Wenzel, Jason E. Chapman, Cory F. Newman,

Aaron T. Beck, and Gregory K. Brown

University of Pennsylvania

Preliminary evidence suggests that cognitive therapy (CT) is effective in

treating borderline personality disorder (BPD). According to cognitive theory,

BPD patients are characterized by dysfunctional beliefs that are relatively

enduring and inflexible and that lead to cognitive distortions such as

dichotomous thinking. When these beliefs are activated, they lead to

extreme emotional and behavioral reactions, which provide additional con-

firmation for the beliefs. It is hypothesized that a change in dysfunctional

beliefs is the primary mechanism of change associated with CT. How-

ever, additional mechanisms of change are likely also at work in CT, includ-

ing enhancement of skills, reduction in hopelessness, and improvement

in attitude toward treatment. Each of these mechanisms is discussed in

light of cognitive theory, data from an open clinical CT trial, relevant lit-

erature, and therapeutic interventions. Findings from the CT trial support

the role of cognitive change during therapy and its continuation after

516, 2006.

Keywords: borderline personality disorder; cognitive therapy; cognitive

theory; dysfunctional beliefs

A salient feature of patients who have borderline personality disorder (BPD) is their

tendency to engage in dichotomous thinking, as they often evaluate themselves, other

people, and their environment in extreme terms and demonstrate little flexibility in assim-

ilating new information to modify their rigid beliefs (e.g., Arntz, 1994; Veen & Arntz,

2000). This pattern of distorted perception often results in angry outbursts, impulsive

behavior, and

Correspondence concerning this article should be addressed to: Aaron T. Beck, M.D., Psychopathology Research

Unit, Department of Psychiatry, University of Pennsylvania, 3535 Market St., Room 2032, Philadelphia, PA

19103; e-mail: abeck@mail.med.upenn.edu.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20244

or severe and sudden symptoms of anxiety and depression. One purpose of

cognitive therapy (CT) is to help patients develop tools to identify and evaluate such

cognitive distortions, given that a realistic appraisal of one’s circumstances will reduce

504

Journal of Clinical Psychology, April 2006

the severity of accompanying distress (e.g., Beck, 1995; Beck, Freeman, & Davis, 2004;

Beck, Rush, Shaw, & Emery, 1979). In addition, individuals who have BPD often have

dysfunctional thoughts about their own desirability and the trustworthiness of others, and

well-developed CT strategies have been designed to modify these beliefs. Although CT

comprises techniques with established utility in addressing cognitive distortions and dys-

functional beliefs, to date only one open clinical trial has examined the efficacy of stan-

dard CT in the treatment of BPD (Brown, Newman, Charlesworth, Crits-Christoph, &

Beck, 2004). Results from this trial indicated that patients reported significant decreases

in suicide ideation, hopelessness, depression, and borderline symptoms at the end of

treatment and suggest that CT is worthy of future systematic research in the treatment of

this disorder.

Although there is preliminary support for the effectiveness of CT for BPD, less is

known about the factors that are responsible for the changes that occur during the course

of treatment. The identification, measurement, and evaluation of the “active ingredients”

in CT for the treatment of BPD are important steps toward the continued refinement of

this intervention. Thus, the purpose of this article is to propose specific mechanisms of

change in CT for BPD. According to cognitive theory, the major hypothesized mecha-

nism of change involves a change in dysfunctional core beliefs that BPD patients hold

about themselves and the trustworthiness of others (Beck et al., 2004). However, we also

propose some additional mechanisms of change, including enhancement of skills, reduc-

tion in hopelessness, and improvement in attitude toward treatment. We discuss each of

these mechanisms in light of cognitive theory, preliminary empirical data, relevant liter-

ature, and therapeutic interventions associated with CT.

Cognitive Theory of Borderline Personality Disorder

At the heart of cognitive theory for BPD is the presence of dysfunctional beliefs that

influence patients’ perceptions about themselves, others, and their environment (Beck

et al., 2004; Layden, Newman, Freeman, & Morse, 1993). According to cognitive theory,

dysfunctional beliefs stem from negative learning experiences in childhood (Newman,

1998) that inhibit the development of flexible information processing (Arntz, 1994). In

adulthood, these dysfunctional beliefs are relatively enduring and inflexible, making it

difficult for patients to respond to complex and ambiguous demands. Moreover, these

beliefs are self-perpetuating because they influence the manner in which patients process

and interpret information in their environment, making it difficult for them to attend to

information that disconfirms their beliefs. Complicating this pattern of cognition further

is the observation that in many cases, two or more seemingly contradictory sets of beliefs

are activated in rapid succession. This cognitive profile, in turn, leads to extreme, dichot-

omous interpretations; heightened anxiety; depression, frustration, and shame; and urges

to engage in extreme behaviors to reduce the tension created by this antagonism (cf.

Layden et al., 1993).

The contents of beliefs associated with BPD cut across themes associated with a

number of Axis II pathologies. For example, Butler, Brown, Beck, and Grisham (2002)

identified 14 items from their Personality Beliefs Questionnaire (PBQ) that discrimi-

nated between patients who have BPD and patients with other personality disorders.

These items were from their Dependent, Paranoid, Avoidant, and Histrionic scales and

included beliefs such as dependency (e.g., “I am needy and weak”), helplessness (e.g., “I

am helpless when left on my own”), distrust (e.g., “People will get at me if I don’t get

them first”), fears of abandonment (e.g., “If people get close to me, they will discover the

real me and reject me”), fears of losing control (e.g., “Unpleasant feelings will escalate

Journal of Clinical Psychology DOI 10.1002/jclp

Change in BPD

505

and get out of control”), and attention seeking behavior (e.g., “People will pay attention

only if I act in extreme ways”). Arntz, Dietzel, and Dreessen (1999) identified a series of

20 assumptions specific to BPD and found that the degree to which BPD patients believed

these assumptions did not vary with the induction of positive and negative moods; that

finding suggests that faulty beliefs associated with this pathology are persistent and

engrained. Recently, Arntz, Dreessen, Schouten, and Weertman (2004) reported a revised

version of their inventory of BPD assumptions, which included themes of loneliness,

unlovability, rejection, abandonment of others, and viewing of oneself as bad and deserv-

ing of punishment.

Identification of dysfunctional beliefs is of paramount importance in CT because it

serves as a framework to understand and address seemingly contradictory emotional

reactions and behavioral responses. By accurately identifying their patients’ core beliefs,

cognitive therapists will understand the rules and assumptions that guide their patients’

experience, the automatic thoughts that are most likely to emerge in particular situations,

the intensity of negative affect associated with difficult situations, and subsequent behav-

ioral responses. Many BPD patients have a limited behavioral repertoire caused by inad-

equate learning experiences during childhood, and the activation of dysfunctional beliefs

further decreases the probability that they will choose the appropriate response in demand-

ing situations. For example, BPD patients frequently experience intense and unstable

interpersonal relationships and may exhibit behaviors that are violent, dependent, demand-

ing, self-harming, or suicidal in nature. Thus, their skills deficits contribute to failed

relationships and difficulty in reaching goals, which further intensify their negative affect.

In addition, BPD patients often engage in harmful and impulsive behaviors as a way

to release tension, to make a dramatic statement to others, and/or to be distracted from

emotional pain. These are some of the compensatory strategies that provide the BPD

patients with temporary “relief” but that actually serve to make their situation worse. The

result is a vicious circle of distorted cognition, negative affect, strong impulses, and

maladaptive behavioral responses that confirm or perpetuate the original distorted beliefs.

Further, the strains that BPD patients’ behaviors place on their relationships also cycle

back and “confirm” their unlovability, incompetence, and abandonment beliefs. This cycle

creates a sense of hopelessness in these patients, as they believe that they are powerless

to make positive changes in their life.

Thus, there is a high likelihood that BPD patients will view themselves as not being

able to have normal relationships and that they will actually suffer damage in their alli-

ances with important others, including therapists. Arntz (1994) observed that patients

who have BPD are often ambivalent toward psychotherapy; although they desire help and

acceptance from the therapist, they also fear rejection. Because of their ambivalence,

these patients are at risk for noncompliance and early termination from treatment. After a

series of unsuccessful courses of psychotherapy, not surprisingly patients who have BPD

develop a negative attitude toward treatment , which decreases the probability that a strong

therapeutic relationship will develop, that they will invest in treatment, and ultimately,

that treatment will be successful.

Hypothesized Mechanisms of Change

Belief Change

It is hypothesized that the principal mechanism of change in CT for BPD is the modifi-

cation of dysfunctional beliefs. In the early stages of therapy, modification of beliefs

begins to occur as a result of restructuring the automatic thoughts that emerge in particular

Journal of Clinical Psychology DOI 10.1002/jclp

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Journal of Clinical Psychology, April 2006

situations. Beliefs are absolute representations of the individual, the world, and others but

are often difficult for patients to articulate, particularly in the early stages of CT. How-

ever, as patients become socialized to the cognitive model and observe themes associated

with their automatic thoughts, they gain insight into the beliefs that drive these thoughts

and other cognitive dysfunctions. Automatic thoughts and beliefs are treated as hypoth-

eses to be tested.

Some empirical support exists for the notion that change in dysfunctional cognition

is an important mechanism of change in CT for depression. For example, Jarrett and

Nelson (1987) examined specific components of CT in order to identify those associated

with patient change. The components were self-monitoring (i.e., self-guided monitoring

of thoughts and assumptions as they relate to mood), logical analysis (i.e., the skill of

systematically evaluating and revising inaccurate thoughts by evaluating evidence and

identifying thinking errors), and hypothesis testing (i.e., the skill of developing “experi-

ments” to test the accuracy of thoughts). A sample of depressed participants received

each of the three components in a predetermined order, and participants’ thoughts were

measured by using the Automatic Thoughts Questionnaire (Hollon & Kendall, 1980).

Results indicated that exposure to the logical analysis and hypothesis testing components

of CT were associated with reductions in both the frequency and the degree of belief in

depression-related dysfunctional thoughts. Additionally, DeRubeis and associates (1990)

found some support for the role of patients’ attitudes, attributional style, and hopeless-

ness as mediators of change in CT of depression. Moreover, Oei and Sullivan (1999)

examined the efficacy of group cognitive-behavioral therapy for depression and reported

that recovered patients endorsed fewer negative automatic thoughts and dysfunctional

attitudes than nonrecovered patients. Although preliminary, these findings provide some

evidence for cognitive change as a mechanism of change in CT of depression, though the

extent to which these findings hold in the treatment of BPD remains unclear.

In order to examine the degree to which borderline beliefs change with CT, we

administered the BPD scale of the Personality Beliefs Questionnaire (PBQ; Butler et al.,

2002) to patients enrolled in our open clinical trial (Brown et al., 2004). The mean PBQ-

BPD scores at baseline, treatment termination, and 18-month follow-up are presented in

Table 1. Paired samples t tests were conducted to determine whether PBQ-BPD scores

changed during these intervals. Because the small sample size is not optimal for uncov-

ering statistical significance, we also calculated effect sizes for correlated samples to

establish the magnitude of these differences (Dunlap, Cortina, Vaslow, & Burke, 1996).

Results of these analyses revealed a statistically significant reduction in the PBQ-BPD

score between baseline and treatment termination, t (22)

4.96, p

.001, d

.88, and

between baseline and follow-up, t (16)

5.14, p

.001, d

1.19, but not between

treatment termination and follow-up, t (17)

1.36, p

.19, d

.24. According to the

Table 1

Mean Personality Beliefs Questionnaire—Borderline Personality Disorder Scores

Total Sample

Responders

Nonresponders

Baseline

31.15 (10.60; n 27)

31.65 (11.46; n 22)

28.92 (5.72; n 5)

Termination

22.17 (12.11; n 25)

21.32 (13.00; n 20)

25.60 (7.64; n 5)

18-Month follow-up

17.37 (11.26; n 19)

16.27 (11.38; n 15)

21.50 (11.27; n 4)

Note. The first values in parentheses are standard deviations. Sample sizes vary because there were not complete data sets on

some patients.

Journal of Clinical Psychology DOI 10.1002/jclp

Change in BPD

507

guidelines described by Cohen (1988), the effect sizes characterizing changes between

baseline and termination and baseline and follow-up were large, and the effect size char-

acterizing changes between termination and follow-up was small.

In addition, we evaluated PBQ-BPD change with respect to patient treatment re-

sponse status. Treatment responders were defined as patients who had fewer than five

Diagnostic and Statistical Manual of Mental Disorders , fourth edition (DSM-IV), BPD

criteria at 18-month follow-up (cf. Brown et al., 2004). Of the 19 data sets available from

the 18-month follow-up period, 15 (79%) were considered treatment responders. Results

of an independent samples t test revealed a nonsignificant difference between the groups,

t (15)

.09, but a large effect size, d

.33).

In summary, BPD patients who participated in the open clinical CT trial reported

significant reductions in borderline beliefs between baseline and termination. These gains

persisted 18 months after treatment. The greatest belief changes were associated with

items assessing distorted self-perceptions, such as “If people get close to me, they will

discover the ‘real’ me and reject me.” Belief changes were of a more moderate level for

items assessing mistrust, such as “I have to be on guard at all times.” Although these data

suggest that BPD patients substantially altered dysfunctional beliefs during the course of

the treatment trial, the lack of control group precludes the ability to draw conclusions

about the degree to which these changes are above and beyond those that would be

expected by the passage of time, and the lack of comparison to another form of psycho-

therapy precludes the ability to draw conclusions about the degree to which these changes

are specific to CT. Additionally, little is known about the manner in which these belief

changes occur, such as whether new beliefs replace previously held beliefs, new beliefs

compete with existing ones, or existing beliefs are modified (Robins & Hayes, 1993).

Nevertheless, the impressive effect sizes suggest that change in beliefs is a viable mech-

anism of change in CT, in accordance of predictions made by cognitive theory.

.76, SD

Other Hypothesized Mechanisms of Change

Enhancement of Behavioral Skills. The central proposed mechanism by which treat-

ment change is achieved in CT is a change in dysfunctional beliefs. However, the sys-

tematic evaluation of cognitive distortions reduces negative affect, thereby allowing patients

to select appropriate behavioral responses in a more thoughtful way and to practice the

skills learned in therapy. Thus, CT allows patients who have to develop and implement

new behaviors to negotiate interpersonal conflict and manage personal distress. In the fol-

lowing section we briefly address additional skill-based mechanisms of change on the basis

of existing empirical findings, cognitive theory, and our targeted intervention for BPD.

Behavioral experiments involve the formulation of specific, testable hypotheses about

the patient’s behavior with the aim of gathering evidence for the evaluation and refine-

ment of underlying beliefs (Brown & Newman, 1999). In CT for BPD, these experiments

are used as methods to test currently held beliefs and predictions and translate newly

developed beliefs into behavioral change. Research examining the role of behavioral

experiments in changes associated with CT is limited. Bennett-Levy (2003) found that

among members who participated in a CT training engaging in behavioral experiments

Journal of Clinical Psychology DOI 10.1002/jclp

.99.

Item-level PBQ-BPD analyses also were performed to evaluate change that occurred

between baseline and 18-month follow-up. Results of paired samples t tests and effect

size estimates for each of the items are presented in Table 2. These exploratory findings

demonstrate that statistically significant reductions occurred in patients’ degree of belief

in 11 of the 14 (79%) PBQ-BPD items between baseline and the 18-month follow-up.

More importantly, the effect size estimates ranged from .39 to 1.35 ( M

1.84, p

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