Re:One CT conceptualization of Borderline Personality Disorder

I doubt if many CBT therapists will disagree strongly with this formulation that highlights cognitive processes like dichotomous thinking, chronic threat monitoring and inappropriate coping strategies,or safety behaviours, that cause the perpetuation of difficulties and prevent cognitive/emotional change. But maybe it needs to go further.

The formulation and treatment of Axis I disorders has recently been advanced by the inclusion of novel perspectives that emphasise the role of metacognitive processes (e.g Adrian Wells, John Teasdale). It seems to me that cognitive formulations generally need to take account of such processes in addition to those already outlined (although many of these can be construed as metacognitive in nature anyway). One of the main features of emotional disorder generally is the failure of the individual to decentre from their internal world of thoughts and feelings and view them with any degree of detachment or objectivity. The success of Cognitive behaviour therapy generally may be explained, at least partially, by the degree to which it helps the client to develop this capacity.

A feature of BPD is the complete lack of such a metacognitive capacity. These individuals cannot readily think about their thinking or their emotions. This makes interventions like thought records very difficult to do. In my experience these clients will, more often than not, fail to complete such tasks probably because they lack the ability or because it is too threatening to do so. Possibly the failure to develop a metacognitive capacity is related to the experience of trauma in childhood. Learning not to think may be protective in such environments.

If we include such notions in the formulation of BPD it helps to explain the relative success of Dialectical Behaviour Therapy as some of the central interventions can be viewed as explicitly teaching the client to develop such a capacity (e.g. mindfulness training, emotional education). Group based interventions may have the added advantage of helping the individual to begin to think about their thinking and emotion in a more complex interpersonal milieu that helps to activate such reactions.

I also think that metacognitve-based formulations of BPD can help explain the various cognitve responses that these individuals reveal like perseverative mental responses and self-focused attention. The detrimental effects of such processes have been shown to play a major role in the mood disorders and surely they are equally as important in BPD.

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Re:One CT conceptualization of Borderline Personality Disorder, by GMcCarron, 08/14/03

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