COGNITIVE AND BEHAVIORAL PRACTICE 3,

183-208,

1996

Single Session Treatment of

a Borderline Personality Disorder

Arthur Freeman
James Jackson

Philadelphia College of Osteopathic Medicine

Introduction

Much has been written about brief or short-term therapy from a variety
of theoretical perspectives (Basch, 1992; Bloom, 1992; Budman & Gurman,
1988; Cade & O'Hanlon, 1993; Crits-Cristoph & Barber, 1991; Fisch, Weakland, & Segal, 1982; Garfield, 1989; Gustafson, 1986; Langley, 1994; Lankton
& Erickson, 1994; O'Hanlon & Davis, 1989; Preston, Varzos, & Liebert, 1995;
Sifneos, 1987, 1992; Walter &.Peller, 1992; Wells & Gianneti, 1990). Does it
work? Does it work better than long-term therapy? Is it the best alternative?
Or, is it only a manifestation of the zeitgeist of contemporary times and the
managed care treatment model?
These discussions are generally not dispassionate interchanges, but are usually
emotionally loaded by the philosophical, financial, theoretical, or conceptual
rationale for the short-term therapy. If one does brief or short-term therapy
out of a conviction that it is an important option in developing adequate treatment plans, there is less heat. If, however, the therapy is foreshortened because
it is forced by the "evil empire" of the managed care companies, there is often
great anger.
The short-term debate is exacerbated when the treatment conceptualization
includes a diagnosis of personality disorder. Among the diagnostic grouping
within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American
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Copyright 1996 by Association for Advancement of Behavior Therapy
All rights of reproduction in any form reserved.

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Psychiatric Association, 1994), no diagnosis seems to raise the therapist's emotions as much as that of the borderline personality disorder. For many, the term
"borderline" has become an accusation and epithet. It evokes images of noncompliance, unbridled anger, a stormy therapeutic alliance, self-injurious behavior, and dichotomous thinking and actions (Beck, Freeman, & Associates,
1990; Layden, Newman, Freeman, & Morse, 1993; Linehan, 1994). All of the
upset, however, fails to note that, as with any diagnosis, the patient can have
a mild, moderate, or severe form of that disorder. The mild form of the borderline disorder may be more amenable to treatment than the severe forms of Axis
I disorders. The combination of short term therapy and borderline personality
disorder is a volatile mix.
The.issue, we believe, is not how many sessions a therapist has to work with
a patient, but rather, what one does with the sessions. From our perspective,
short-term therapy must be easily available and accessible, structured for the
patient, active, directive, cooperative, problem-focused, solution-oriented, and
psychoeducational. It is not an issue of time spent, but the goals of the therapy,
and the strategies or goals and the consequent interventions used to meet those
goals. The mild and moderate forms of a disorder would be treated differently
than the more severe manifestation of that disorder. Given a choice, therapy
would best be dictated by the needs of the patient, not of the therapist or the
payment system. This is not always the case.
The following session attempted to demonstrate what could be done in the
shortest possible therapy, a single session with a borderline personality disordered
patient.
The context for this session was a workshop led by the first author (AF) on
the cognitive behavioral treatment of personality disorders. The workshop
organizer invited a patient in his practice to be interviewed as part of that workshop. The patient agreed and was interviewed for 45 minutes in front of a group
of practicing therapists. Prior to the interview, the workshop leader met with
the patient. Subsequent to the interview, a brief time was used when both the
workshop leader and the patient responded to questions from the group. After
that, the patient was debriefed by her therapist to assure that there were no
problems or issues stemming from the session.
The annotations to the session (interspersed throughout the transcript in
italic typeface) will highlight the workshop leader/therapist's development of
hypotheses and the treatment conceptualization, as well as the strategies that
led to the implementation of that conceptual model through the use of specific
therapeutic techniques.
Patient Data

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

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vast amount of data available about the patient, it is not included here. In an
ideal world, the therapist would have the data and the time to review it all.
In the real world, especially in emergent or crisis settings, the data may not
be available, or the therapist does not have the time to sift through it all. What
is included below is the barest outline, but enough to conceptualize, plan, and
enact the single-session therapy.
Debbie, a 43-year-old white woman, is employed as an elementary school
teacher. She completed both undergraduate and masters degrees at a state
teachers college. She has never been married and lives alone. With no close
friends, and few distant friends whom she sees very occasionally on holidays,
Debbie's environment is marked by a scarcity of social connections, including
those with her teaching colleagues. While relating well to the children she teaches,
she experiences interpersonal problems with teacher colleagues, administrators,
and with the parents of the children in her class.
For the last 10 years she has had no contact with her f a m i l y - h e r mother
and a younger sister. Her father died when she was 3 years old, and her mother
remarried when Debbie was 5. She was sexually abused from the ages of 6
to 12 by her stepfather. On several occasions she had told her mother about
the abuse, but her mother did not believe her, and nothing was done. The abuse
stopped when Debbie was 12.
Debbie has been diagnosed as a borderline personality and has been in therapy
with several different therapists over the last 18 years. She has been seeing her
present therapist for one and a half years. She has reported both anxiety and
depressive symptoms, anger where she verbally "explodes" at people at work,
and self-damaging behavior. She had asked that the nature of the self-harm
not be shared with the group, and it will be omitted here to honor her request.
Case Conceptualization
Based on the discussions with Debbie's therapist, it seemed that the diagnosis of borderline personality disorder was appropriate. She met six of the
nine criteria for borderline personality listed in DSM-IV. (Only five are required
for the diagnosis.) The specific criteria-focused data were gathered from her
therapist, Dr. John Smith, and from elucidation by Debbie in a pre-interview
meeting with the first author. The criteria met are as follows:
1. Unstable interpersonal relationships: Debbie has difficulty with coworkers
that often leads to her avoiding them, and to them excluding her from
social functions, and even ignoring her during the work day. The problems take the form of Debbie insulting them, being sarcastic, or angry
when others see no reason for her actions.
2. Self-mutilating behavior: Debbie has, for many years, self-mutilated.
3. Affective instability: Debbie reported that she can experience her moods
shifting almost instantly. She can go from calm to anger in what she de-

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scribed as "a flash." She also described having experienced many "moods"
in the course of a day.
4. Inappropriate, intense anger: Debbie reported that her anger responses
appear to others to "come out of the blue:' The level, content, focus, extent, and duration of the anger often surprises Debbie.
5. Chronic feelings of emptiness: By her own report, Debbie describes herself as "a nothing:' "without value;' "like an empty shell."
6. Dissociative symptoms: When "upset" she has, for many years, used the
technique of holding her breath until she becomes what she calls "dizzy"
She reports being able to see herself from a distance, sometimes looking
down from the ceiling of the room.
Given the above information, she likely had developed schema about the
world being a dangerous place: People, especially people in power, were not
to be trusted. Because sex was negative, and self-worth was based on sex, Debbie
valued herself negatively. Likely self-blaming for what had happened to her,
she hoped for support, and was disappointed when she could not find it. Displays of emotion were to be hidden, and she was both helpless and hopeless
about changing.
As therapist (AF), my goal was to use the available time to demonstrate how
a short-term cognitive behavioral therapy (CBT) model can be used with a
borderline patient. The intent was not to cure, but rather to treat. My goals
included the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

identify a problem area

reduce that area to a small enough piece for the single-session therapy
develop a conceptualization of the patient's problems
decide which parts of the conceptualization could be worked on in the
single session
decide what specific techniques would be useful
implement the technical therapy
evaluate the success of the interventions
make mid-course changes, as needed
get frequent feedback from the patient
leave time for appropriate closure and debriefing after the session

O f specific note is the use of the Socratic questioning throughout the session.
To enhance the rapport in this brief time, many of the questions are closedended questions that elicit an affirmative response. This assists in overcoming
the negative set many patients have about therapy.
There were several questions and issues that had to be kept in mind. These
included:
Issue #1. Did Debbie have the potential for verbal or physical violence? I
wanted to avoid this. It would not have been helpful to Debbie, and it might
have been seen by her as a failure and/or an embarrassment, and would, if

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physical, cause damage to me. Given her history, the therapist's response, and
my own estimation, there was little chance of this.
Issue #2. Were Debbie's social skills adequate and appropriate for her appearance in front of a group? The goal was to demonstrate a particular set
of interventions, not to put Debbie on display as an example of a diagnostic
category. Again, based on her history, Debbie had social skills, but often had
trouble using them. I could try to use her social skills by avoiding putting any
stress on Debbie.
Issue #3. Were Debbie's intelligence and verbal ability adequate for the task?
History and interview confirmed no problem in this area. Further, her intelligence and verbal ability were potential strengths to be used in the interview.
Issue//4. W h a t would be the effect of the audience on Debbie? Debbie's reaction to me and to the audience would be crucial. While she had agreed to
participate after several discussions with her therapist, it was not clear what
effect the audience would have. Would she use it as an opportunity to try to
embarrass and humiliate me (an authority figure and a male)? Would she use
it as an opportunity to get all of the audience feeling sorry for her as a way
of justifying her anger and upset?
Were there ways to minimize the effect of the audience? Ideally, the setting
for this would be a consultation room with video capability. This way, the audience could see and hear the session without being present in the room. However, as in life, the ideal is not always available. The second choice was to have
Debbie sit in front of the audience with her back to the group, which would
allow the therapist to face the audience and to keep his session notes on an
overhead projector. In this way, both the audience and Debbie could see the
session notes actually being written.
In terms of lighting and sound, the room was dimmed, with lights on the
stage, and, aside from some coughing, there were few sounds from the audience. O n several occasions Debbie's responses evoked supportive laughter from
the group.
Issue//5. W h a t was Debbie's frustration tolerance level? This would be the
key to the single session and to the treatment as a whole. It would be essential
to establish Debbie's flexibility and strength of boundaries. If her boundaries
were crossed, she would likely (and reasonably) retreat. IfDebbie's boundaries or
safety zone were not expanded, there would be minimal growth (Freeman &
Leaf, 1989).
If Debbie perceived a threat, she would withdraw. The best way to establish
her boundaries (or how far and fast she could be pushed) would be to test the
boundaries gingerly and gently. The therapist had to be prepared to immediately back off and, if needed, apologize quickly for the intrusion.
Schema about intrusion, boundary violations, lack of remorse by the offender,
lack of support, and victimization were all part of her life and had to be considered throughout the session.

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Overall, my concerns focused on the possible lability of the patient, possible

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

Session Transcript
Therapist: Hi, Debbie. I really appreciate your willingness to do this. We'll
talk for about forty minutes, is that all right?
Patient: Yes.
T: H o w are you feeling about doing this?
P: I'll be fine in about forty minutes.
T: About forty minutes. It feels okay now, but you'll feel better later?
P: Yeah.
T: Again, I'd like to thank you for doing this. l think that it's interesting that
you volunteered to do this because it says something about a level of courage.
It takes an awful lot of courage to come into a room of strangers, to talk
to a stranger about some very personal things. Given that we're going to
talk for about forty minutes, are there particular things that you would like
to try to address in the time we have?

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

What is the patient's idiosyncratic meaning for her often-used terms such as "road"or "anger"?
The therapist can never assume idiosyncratic meanings.
P: I'm not m a d at the appropriate people, I take everything out on myself,
even if it's not my fault.
T: So, if someone does something, you'll take responsibility for it?
P: I tend to take a lot and then it starts oozing out in inappropriate ways.
T: C a n you give me an example, Debbie, of how this would show itself. Give
me a typical example.
P: If a situation occurs at work and it might have happened for the fifth time
that week, I would blow up at whatever person is in front of me, it had
nothing to do with that person, it was something underneath and they just
happened to get in the way.
T: Okay, so things have been happening, the anger builds up, builds up, and
then there's a trigger and then you explode?
P: Right.

This summary of the chain of events does two things. First, it indicates to the patient that
the therapist is listening, and, second, establishes a basis for further clarification.

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T: T h e other person is saying what to themselves?

P: "Where did that come from?"
T: W h e r e did that come from.

This reflective statement also encourages perspective-taking by asking Debbie what she guesses
the other person might be thinking.
P: A n d then I feel so guilty a b o u t laying s o m e b o d y out, but it's too m u c h to
deal with.
T: Do you feel guilty because you got a n g r y or do you feel guilty that you
got angry to such a high degree?

Guilty is too broad a concept. It is important to delineate her meaning, but also the nature
of the '~uilt" problem and any second-order problems attached to it.
P: T h e degree.
T: T h e degree? Is getting a n g r y okay.
P: No. Periodically, yes, it's good, I m e a n I know that I'm angry, but it's not
okay for any long time.
T: W h y not, why isn't anger okay?
P: I haven't h a d m u c h experience seeing a p p r o p r i a t e anger a n d I'm afraid that
that was exactly like what I grew up with.

This is a very broad invitation to explore issues of childhood experience, early learning,
parental interactions and reactions, and a general theme of the past. Given the parameter of
the setting and the single-session format, this will be left aside. The basic schema regarding
anger will have to be addressed as "here-and-now" issues.
T: Okay, so one thing we might be able to focus on in the time we have is
this issue of a p p r o p r i a t e anger or i n a p p r o p r i a t e anger, just kind of looking
at that.
P: Right.
T: A n y t h i n g else you might want to look at in the time we have, and then we
can see what would be reasonable for the limited time that we have?
P: I think anger pretty m u c h covers everything that I do.

This sets out an early problem list that would ideally be broad enough to fill the available
time, and Jbcused enough to allow use of the time.
T:
P:
T:
P:
T:
P:
T:
P:
T:

So anger is really something with a big capital 'N"?

Yeah.
A n d it's with you pretty m u c h all the time?
I feel like I'm j u s t boiling m a d and I take it out on myself a n d I'm trying
to find other ways . . .
A r e you boiling m a d right now?
No, I ' m scared to death right now.
Is that an alternative, either you're a n g r y or you're scared?
Yeah.
So we have two possibilities, you can be a n g r y or scared. Is scared a way
of not dealing with your anger?

Is this one method of coping? If it is, then it can be used us the start of a list of coping

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strategies. For many patients, the predominant idea is that they have r~ coping strategies and
are driven by the winds (chance or fate. By identifying any strategies, we can introduce the
idea that control is already part of their repertoire, and the therapeutic goal is to enhance and
build that list.
P: Well, I think I become angry when I'm really scared because I don't know
how to deal with being afraid, but at least anger leaves me someplace, I
feel paralyzed by the fear.
T: So being scared, you're stuck?

This is another summary statement that elicits a positive response. She knows the therapist
is listening.
P:
T:
P:
T:
P:
T:

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

This is the beginning of a cost-benefit analysis. The idea of this type of analysis will be
introduced here and expanded over the session. Just what is thefunction and value of anger in her life?
T: But the anger's also upsetting, is that what you're saying?
P: Because it's unpredictable and it oozes out and I don't always see it until
it's pointed out.
T: When you say it's u n p r e d i c t a b l e . . , i f . . . let me use an extreme example,
let's suppose someone from the audience comes up to you and kicks you
in the ankle, would that make you angry?

By constructing and introducing an extreme example, the therapist can see how Debbie responds to a scenario that is "here-and-now"rather than situations that are outside of the therapy
situation.
P:
T:
P:
T:

P:
T:
P:
T:
P:
T:

Yes.
Would you express your anger?
Probably in an instant.
So if someone comes up and kicks you in the ankle, you'd say, "You know
you have a helluva nerve doing that, who do you think you are, you shouldn't
do that?" You'd get pretty angry?
I probably wouldn't be that wordy.
Is that right? Would that be appropriate anger?
Off the top of my head, yes.
So if someone comes up to you and kicks you in the ankle and you got angry
at them, would you feel guilty afterwards for being angry?
Yeah.
Why? What would get you from being angry at what they did to you and
then feeling bad about being angry? Can you describe the process?

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How does Debbie process the event? By asking her to explicate and describe the process in
detail, possibly the thought-feeling-action connection can be elicited.
P: It would be because of my response, its like I would have to have a reason
why I did that, obviously I did something to them. It's because I'm the kind
of person that I am that they did that. This is what I deserved, and on and
on and on.
T: So if you were a better person, a nicer person, a sweeter person, a gentler
person, they wouldn't have kicked you in the ankle?
P: That's right.
There is an obvious segue in this example, the likelihood of Debbie's response being similar
to her response as a child where she was abused and hurt. It was then that she likely developed
the idea that if she were a better person, the abuse would not have occurred. As before, this
avenue is too much of a jump for the context or this brief contact. This is a rich avenue for
further and future therapy work.
On the other hand, it may be an area that has been covered much over years and has been
discussed with this and every other therapist, and is of little value at this point.
T: H m m . . .
P: I would be more angry that if you knew that about him why you wouldn't
try to defend me.
T: So you'd then get angry at me?
P: And then I'd be angry at you.
T: So that the anger is with you all the time?
P: Pretty much.
T: There are two ways to look at anger in my view, one is that people carry
around with them a kind of basket filled with anger and they keep pulling
from the basket and spreading the anger around the world, but if that were
t r u e then at some point the basket might be empty and you say, Whew,
I finally got rid of that last piece of anger. What you're describing though
is kind of a well that keeps being replenished from underneath so that you
always have this anger that keeps being there. Is that right?
P: Yeah.
T: Is that an accurate view on my part?
P: Yeah.
T: Have you thought about, either yourself or with John,* what generates the
anger, what keeps filling the well?
P: Alot oftimesit's situational, ifsomethinghappens andthere'slike, someone
could have spoken up for me or in some ways defended me and didn't.
[Patient's voice breaks and she gets teary.]
Here is the data to support the hypothesis of the anger, the lack of control, and the early
abuse. This lead is very compelling, but I have decided that it would not be in the patient's
best interest to explore it in this context.
T: Let me just stop, you're getting real upset right now. Can you tell me if
* References to '~lohn" refer to Dr. J o h n Smith, Debbie's therapist.

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you're comfortable in this setting, what is getting you upset right now? J o h n ,
if you have a box of tissues, can I have t h e m please? As you start talking
a b o u t "why haven't I been defended;' the tears come. W h a t ' s going on right
now that's generating those tears coming?

By immediately focusing on the emotional response, we can access the disturbing cognitions
(automatic thoughts). Once again, the focus has the effect of bringing the therapy work into
the here-and-now.
P: T h a t so m a n y things h a p p e n e d and that there was no one there for me . . . .
T: So what really gets upsetting is the idea that "I should have been defended
or helped or s u p p o r t e d "
P: Yes.
T: But I wonder. M a y b e the upsetting part is not that. W h a t it sounds like
is, "I should have been defended or helped or s u p p o r t e d andyou weren't."

This addresses the patient's rules about how others should have acted. Her rules or expectations are, of course, entirely reasonable.
We can p r o b a b l y all say "You know I should have been helped," "my teacher
should have been nicer" "my parents should have been kinder" "l shouldn't have
been h u r t " You know we can all think of that. But the thing that seems to be
most upsetting for you is m o r e this last piece, you needed to be supported,
to be helped, to be defended andyou weren't. A n d when you have that idea, I
should have been defended and I wasn't, how does that m a k e you feel?

The connection between the thoughts and feelings is important here. I have chosen not to
explore the broad or specific parts of the abase. It would be too revealing in the context of being
in front of an audience. The operative piece for her is, in my view, not the idea that being
hurt is the issue, but rather that she was not defended. This is also my clue as to how to use
the single session. I think that her issue is not being defended either externally or internally.
Does she defend herself against her negative cognitions. I think not.
P:
T:
P:
T:
P:
T:
P:
T:
P:

Well I wasn't. A n d I have . . . it's like I just lost it.

Well, does that make you happy?
No.
Does it make you sad?
It's just the way it was.
Does it m a k e you angry?
It's j u s t the way it was.
That's true, but as you look back on it, does it m a k e you angry?
I suppose.

She is either reluctant or unable to connect the thoughts or the emotions. She is also unable
or unwilling to labd the emotions. I use a true~false format to help her to identify and labd
her emotions.
T: I don't want to p u t words in your mouth.
P: I j u s t think that people are entitled to the basics.
T: You're right, I think we can take a vote a n d most of us would agree with
that. M a y b e some people wouldn't, but most of us would agree you're entitled to the basics a n d those basics include what?

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Having endorsed her idea of being entitled to basics, whatever that means, I seek the meaning
for Debbie.
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:

To be safe, to be protected, to be helped to survive.

Right, a n d that wasn't your experience?
No.
But that was a while ago, wasn't it? You still carry it in your head?
Like it was yesterday.
Like it was yesterday. But physically it wasn't yesterday, was it?
No.
But in your head it could have been this morning?
Right.
W h a t goes on here [I point to m y head] for you that keeps you upset all
this time?

The thought-feeling connection is very important. This is basic in the C B T model. She
has been in C B T with an experienced C B T therapist, so there is no need to offer a formal
description of the therapy. 73 emphasize the therapy, I chose to demonstrate throughout the session
the connections between thoughts, feelings, and behavior.
P: T h e noise in m y head that's very loud a n d critical, I can't do anything right.
T: T h e noise in your head, what does that noise sound like?
P: Sometimes it's a loud critical voice a n d sometimes there are so m a n y of
t h e m that it's like having an airplane that flies over your head, one after
another.
T: W h e n you h e a r the critical voices, what do the critical voices say to you?
P: T h a t I'm really bad, I'll never a m o u n t to anything, this is a joke, I'm k i d d i n g
myself if I think that things are going to be any better.

This is likely only a small sample of the internal negative dialogue. The initial hypothesis
of difftculty in accepting positives is clearer here. How can she see things as positive when there
are all of these negative voices. Having Debbie verbalize positive affrmations would not be useful
inasmuch as she would not believe them, no matter how often they were repeated. A goal of
therapy would be to work from the other end. 73 quiet the negative voices and allow some room
for the positive seems a better bet.
T:
P:
T:
P:
T:

As you h e a r the voice say those things, how does that make you feel?
Like I don't stand a chance.
You don't stand a chance?
No.
If any one of us h a d a b u n c h of people following us saying, "You'll never
a m o u n t to anything, you're worthless, you're a waste," what effect do you
think it would have on any one of us?
P: After a while, you'll begin to belieye it.

Here was an attempt at normalizing her experience.

T: Right, have you ever tried to argue with those voices?
P: I m u s t have at some point.
T: You m u s t have . . .

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P: I'm sure . . .
T: H o w about in the last six months, have you tried to argue with those voices
recently?

My choice is to choose a proximal point. Six months is long ago, but still recent. 7b focus
on the more likely time frame of the last forty years would be far too upsetting. This introduces
the therapeutic notion of countering the automatic thoughts.
P:
T:
P:
T:

I argue with J o h n instead.

You argue with J o h n instead, well maybe we can do it for free here.
Okay.
Okay, there are some advantages, for example, tell me again what those
voices say, I want to write them down. W h a t are some typical things those
voices say?

Having elicited some of the negative cognitions, I have decided to help her try to challenge
them. This focus is far more reasonable than trying to modify the obvious schema.
P: That you're no good, you don't deserve goo d things.
T: Wait a minute, slow down, "you're no good," "you don't deserve good things"
I want to write them down. W h a t else? [At this point the thoughts are being
listed on the overhead.]

The thoughts run through her head like a runaway train. By directly slowing her down
and writing each one on my overhead, I want to highlight each and every thought.
P:
T:
P:
T:

You'll never amount to anything.

"You'll never amount to anything"
That I'm kidding myself if I believe that things could be better.
"You're kidding yourself to think that things ever will be better."
If we took anybody in this room and we attached a tape recorder to their
waist and there was a constant tape that ran "you're no good, you don't
deserve good things, you'll never a m o u n t to anything, you're kidding yourself to think you deserve any better" what effect do you think it would have,
say, on J o h n ? John's a pretty strong guy, I've known him for a long time.
W h a t effect do you think it would have on J o h n ?

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

After a while it weighs you down.

Yeah, after a while you start saying, Yeah, it's true.
U h huh.
Is that what you're saying now, Yeah, it's true?
U h huh.
You're agreeing with it.
U h huh.
W h a t do you think would happen, Debbie, if you challenged those voices
. . those ideas. W h a t effect do you think it would have on you?

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P: Hopefully it would change.

T: Okay, hopefully it would change? W h a t would be your guess if you could
answer these voices back, if you could, what would happen to the voices?
What's your prediction?
P: I'd . . . it would get louder and then go away.
T: You think it may" get louder and shout you down?
P: Initially.
T: Initially? I'd agree with that, I think initially the voices will get louder, but
then they'd probably . . . ideally, go away.
W h e n you hear these voices is there a particular person or voice attached
to it?
Here is thefamily-of-origin connection. It is not one that I want to emphasize, at this point.
Whatever the answer, I will not delve more deeply. This is for the ongoing therapy. The exploration would be more of a distraction in this context. It is a great lead that will be allowed to pass.
P: Sometimes it's my own, sometimes it's my stepfather's, sometimes it's my
grandmother's.
T: So there's specific people that you can hear saying these things?
P: U h huh.
T: Let me just explore something with you in terms of this, because what you're
saying is by believing these things you then say, "I should have been defended
and not have heard these things and I wasn't and that makes me really sad
and angry"
P: U h huh.
T: Is it true that you're no good?
Can she examine the evidence for goodness or badness?
P: I've had a good day now.
T: So you have a good day. W h a t would be a good day?
P: I don't really know, it's kind o f . . . like I guess . . . I haven't had one in
a very long time that I don't remember what it's like.
T: But if you were to have one of these infrequent good days you wouldn't easily
say you're no good, you would say what, maybe you're not so bad?
P: No, it would probably have more to do with the environment, with the sun
being out and going for a walk.
Debbie externalizes her good days. She has no control. This is a basic schematic element.
Rather than confronting and disputing the schema, I'll try to collect data to have her challenge
the absolutistic nature of this idea.
T: Okay. Do you believe you don't deserve good things?
P: Most of the time.
T: So you only deserve bad things?
P: Yeah, basically.
I will take an extreme position. Will Debbie take a more moderate one? I am not sure.
I'll try an extreme metaphor.
T: Do you go and buy torn clothing?

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

Debbie seems to be getting annoyed. I will try to gently push.

T:
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:
P:

W h y not? Those are pretty bad things.

Because I'm probably not tall enough to get in it, I don't know . . . .
Do you pull clothes out of the trash?
No!!
Do you sneak out to the Salvation A r m y dumpster at night?
No!!
W h y not, because if you don't deserve good things, so why not go out and
get bad and torn things?
Because I have enough to wear.
Is that the only reason?
I never thought about it.
Think about it.
I don't want to think about it!!
W h y you don't deserve nice clothes, clean clothes?
It's not a big deal.

Debbie's annoyance with this line of therapy is clear and emphatic. 73 continue in this vein
is to risk harming whatever therapeutic alliance we have developed. I'll back off and come at
the problem another way. My goal was to ask Debbie to operationalize her meaning of being
uruteserving of good things. My hope was to use it to help her examine evidencefor her belief.
I'll go back to safer ground.
T: Okay, if you could quiet these voices, there's a chance that you might feel better, all right. Do you ever try to argue with the voices, to challenge these ideas?
P: Yeah.
T: A n d the result of that?
P: The noise gets louder and I begin to hurt myself.
T: I'm not clear, if you try to answer the voices the noise gets louder and then
you hurt yourself.
P: It's part of a chain of events, its just so loud, it wins.
T: A n d when it wins, its reward is that you hurt yourself?.
P: Yes, I know it doesn't make sense, but . . .
T: Help me understand it, Debbie, I'm trying to understand the sequence.
The voice says, for example, "Debbie, you're no good," and you say, "Yes
I a m " then the voice says "Forget it, no you're not," and you say "Okay, you're
right, no I'm not" and then you do what, you hurt yourself?.
P: I start getting more and more agitated and it pretty much plays into the
noise, but, yeah you're right, ! say, "This is the truth, you are a worthless
piece of crap."

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T: . . . and, and what, you're a worthless piece of crap and . . . .

P: Yeah.
T: If the result is that you h u r t yourself then you then say you're a worthless
piece of t r a p and you want to do something to prove it?
P: No, I just know it j u s t happens.
T: W h a t just happens, you h u r t i n g yourself?.

The "it" externalizes the problem. "It happens without M Y doing anything."
P:
T:
P:
T:
P:
T:
P:

T:
P:

Yeah, sometimes the pressure feels so big it's like sometimes it eases . . .
H u r t i n g yourself?.
Yeah.
Have you ever kind of tried to tough it out and let the noise build and build
a n d not h u r t yourself?.
I have a contract.
A n d what h a p p e n s then?
First I try to deal with it. A n d then, and if it hasn't gone away, I'll call J o h n
or Dr. White. [N.B.: Dr. W h i t e is a colleague of John's and works in the
same practice. T h e y will cover for each other's patients as needed.]
Okay, and what h a p p e n s then?
Usually in talking 5 minutes on the phone it's enough to work it through
a n d it might not be totally gone, but at least its better and I don't have
to hurt myself.

This is great news. Debbie can be, and is, able to take control-- at this point, with the
therapist. The ultimate treatment goal is for her to internalize it. (Linehan, 1994).
T: It's not up here? [Therapist points to his head.]
P: Right.
T: Okay, why when you talk about it does it then release some of that pressure?
What's most helpful?
P: W h e n I'm experiencing a lot of pain I tend to hold m y b r e a t h and sort of
black out. I have to go to someplace else that eases the pain so what I'm
working on is trying to b r i n g it out so that it won't stay stuck inside.
T: A n d then you don't dissociate?
P: I do, but I can come down from being up in the ceiling and I can h e a r
the voices and be able to work it through.

Another great leadfor therapy work, but one that I will choose to not take, given this context.
T: Okay, what do you think would h a p p e n , Debbie, if you could answer these
voices back as soon as you h e a r them? W h a t do you think the result of that
would be?

Would direct disputation work? I want to try it out.

P: T h e way to go is that I could talk back to the voices, I could be louder and
m a k e myself heard.
T: A n d what do you think would be the result of that?
P: T h a t I could feel better.
T: A n d what would be the result of that?

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P:
T:
P:
T:
P:
T:
P:

T h a t I wouldn't have to hurt myself anymore.

A n d what would be the result of that?
I wouldn't see J o h n anymore.
A n d what would be the result of that?
I would be very sad.
That you wouldn't see him?
Yeah, even though it would hurt sometimes . . . .
The downward arrow technique has Debbie looking at each successive level of belief(Freeman,
Pretzer, Fleming, & Simon, 1990).
T: Sometimes. If you're able to not hurt yourself, if you're able to feel better
about yourself, if you can answer all of these negative voices, then you wouldn't
need therapy and you would lose J o h n as a support.
P: By that time I wouldn't need it.
T: You're not so sure about that?
P: Well definitely no, I've really taken a long time to be able to talk with him.
T: Yeah, one of the things that I said to you when we just started talking, Debbie,
is the fact that you're just doing what you're doing with me shows a great
deal of courage. C a n you see it that way, do you see yourself as courageous?
W h a t do you think when I say to you I think that you're courageous and
that most people in this room would not have the strength to do what you're
doing?
I want to come back to the initial hypothesis. What will she do with the positive statement.
It is not meant to simply pat her on the back. I truly believe that very few of the 100 or so
people in the audience would have the courage to do what she is doing. She keeps dismissing
the positive to avoid the voices and hurting herself. Avoidance has become one of Debbie's major

coping tools.
P:
T:
P:
T:
P:
T:

P:
T:
P:
T:
P:
T:

It's not a big deal.

It's not a big deal?
No.
So if you do something really positive, really in effect very powerful, you
dismiss it how?
I don't know, it's that I'm doing this and just keep on doing it.
So it doesn't require any strength or courage on your part? W h a t do you
think they're [pointing to the audience] thinking, do you think they consider it courageous?
I don't know.
M a y b e we can check later.
I have planted a seed. There is no reason to follow that lead now. I'll come back to it later.
It's a very negative thing right now and I'd beat myself up, because it's just
too much.
So if everyone here comes up and says, Debbie, boy you did a great job?
I wouldn't know what to say.
You could just say, T h a n k you . . .

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199

Well, I know that . . .

Inside what would you say?
It's not a b i g deal.
So you kind of dismiss the positive?
U h huh.
A n d emphasize what you don't do or what you see as a negative? H m m m .
W o u l d you be willing to try a little e x p e r i m e n t with me? I'll tell you what
it is, don't agree to it until I tell you what it is.
P: Okay.
T: W h a t i f . . . you've gone to school, have you ever been in a debate at school?
P: No.
T: Never in a debate?
P: No.
T: Have you ever seen a debate?
P: Yeah.
T: W h a t ' s your u n d e r s t a n d i n g of a debate?
P: You do your best to be the most convincing.
T: Right. W h a t if you and I were to have a debate, I would like to be this
really negative voice a n d what I want you to do is debate with me. I want
to see if you can quiet me down. Would you be willing to try that?
The session is about half gone. I have made a clinical decision. By externalizing the negative
voices I think that several points can be made. First, I can demonstrate the technique to the
audience. Second, we can see exactly how Debb# copes with the negative voices. Third, Debbie
can see just how she copes. Finally, we can use the data from the experience to try to help
her to respond in a more adaptive fashion.
P: Yeah.
T: Okay, so I'm going to be the negative voice and you're going to debate with
me. You're going to try to quiet me. Got it?
P: Yeah.
T: Okay, in fact, one of the things we can do here that we can't otherwise do,
I'd like to stack the deck. D o you m i n d if I do that? In your favor, of course.
C a n we do that? All right, J o h n , I'd like to invite you to j o i n us. I would
like you to sit next to D e b b i e a n d if she starts having trouble I would like
you to help her out. Okay? Would that be all right with you?
P: Yeah.
T: Okay. [To John] So you don't have to say a word until she gets into trouble.
[To Debbie] You in trouble yet?
P: No.
T: No? Okay. So this is you and me.
P: Okay.
T: But if you need help, we've got the enforcer [pointing to John]. Okay? All
right. You know, you're really no good, you're really a worthless person.
P: You're right.

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That was fast. She immediately agrees with the negative voice.
T: Wait a minute, wait a minute. W h a t kind of a debate is that?
[John says something to her. She moves back into role.]
P: W h y would you say that?
T: Oh, no reason, I just think it.
P: O f course you need a reason.
T: No, I just think you're a worthless person, you're just, you're a bad person.
P: Nobody's listening.
T: Except you. You're no good and you don't deserve anything good happening
to you.
P: That's not true.
T: It is true. [Stopping.] What's happening?
P: All I hear are negative voices, it's like I'm lying to you.
T: That's right. So we have a problem with this debate because you hear the
negative idea and the voice inside you says "True, you're right." If you could
say the things that would quiet me, that might be a beginning and you don't
have to believe it. At first you have to practice saying it. You okay? What
I'd like to do is switch roles. Okay?
P: U h huh.
T: I would like for you to be the negative voice and I want to see i f I can model
for you a way of responding. Okay? C a n you be the negative voice that
beats you up?
P: No problem.
Certainly she has no problem being the negative voice. I want to model a strong and adaptive
voice that is not afraid of the negative voice, but is assertive and reasonable. A voice too unreasonable will be rejected by Debbie, and a voice too positive will be rejected as "cheerleading."
I have to model some level of adaptive response.
T: No problem? Do it.
P: You really aren't worth a piece of crap.
T: Says who?
P: Says me.
T: W h o the hell are you to tell me that I'm no good?
P: I know it all.
T: I think you know very little, you have no right to make judgments on anyone.
P: It's not just anyone, I'm talking to you.
T: Oh, it's me and you have no right to make judgments about me. I'm not
worthless and I don't have to listen to this garbage from you. If you weren't
so d a m n stupid you wouldn't even say something like that. Just who in the
hell do you think you are talking to me like that? I'm sick and tired of hearing
it.
[Debbie sits back in her seat, shakes her head, and smiles.]
Where's that negative voice, Debbie? Where is it?
P: You're being a pain in the butt.

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T: I m a y be a p a i n in the butt, but I ' m tired of feeling bad, I ' m tired of h u r t i n g

myself, I ' m tired of b l a m i n g myself for everything, a n d it's your fault and
I want to h e a r no m o r e of it. Where's the negative voice?
P: I don't h e a r it.
T: Wait, let's back up. W h e r e did the negative voice go?
P: I j u s t feel like I'm sinking.
T: You're sinking right now? T h e negative voice is sinking, or you're sinking?
P: I'm sinking.
T: W h y ? W h y are you sinking?
P: Because I can't keep up with you . . . .

She interprets this as a failure, and feels like she is sinking. She may believe that I have
overwhelmed her and "won." Maybe I have. I'll back off.
T:
P:
T:
P:
T:

Okay, what do you say to yourself that's m a k i n g you sink?

I'm just g o n n a be loud, I feel fine now when I'm loud.
Does it feel better or worse when that negative voice is quiet?
Better.
W h e n I was really doing a j o b on that negative voice you were smiling. Why?

I wanted to do two things here. First to understand why Debbie was smiling, and second
to give her some breathing space.
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:

Well, you're quite powerful.

Yeah. W h y were you smiling?
C a u s e it was kind of funny.
It's funny? You weren't laughing, you were smiling.
Well I guess I never stood up to myself in that way.
A n d you were smiling because of what?
Because of how you were saying it.
A r e those things you could say?
Today? Yeah. O n l y one thing . . .
I have a hunch, let m e share m y hunch with you, Debbie. W h a t I . . . m y
experience over the years has been that very often people c a r r y voices that
they give great power to. T h a t the voices are kind of l i k e - - D i d you ever
see the film The Wizard of Oz? T h e p a r t where they are in the Wizard's castle
and want to talk to the wizard, a n d they see this fearsome image on a screen
saying, "I'm the great and powerful O z " R e m e m b e r that scene?
P: U h huh.

I decide to use a metaphor that has great power. If the image has no meaning for Debbie
it would not be worth explaining. I would try to 3~nd another image.
T: W h a t was he? Was he a great wizard? W h a t was he?
P: A sorry old man.
T: U s i n g all kinds of tricks to m a k e himself look bigger a n d sound bigger. I
w o n d e r . . . a n d I'd j u s t like to present that for your consideration . . .
is it possible that this negative voice is like the W i z a r d of Oz? Because if
we could shut that voice up so easily that it's a lot of bluster a n d a lot of

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noise and lot of smoke, but it's not as powerful as it makes out to be. Is
that possible?
At this point I am addressing her beliefs that people in power are indeed as powerful as
they make themselves out to be. I am fully aware that the image of the "pathetic old man" may
well be the stepfather who was viewed as very powerful. Again, given the context and the
limit of our contact, I will plant the seed for her therapist to harvest.
P: It feels like it.
T: Right now it feels like it? Okay. So what I'd like to do, if that's true, I'm
going to be the negative voice again and I'd like you to really be tough.
No messing around, and John's there to help you. I want y o u - - don't just
be gentle -- I want you to really quiet me cause I'm not doing you any good.
I'm not your friend. I make you feel bad, you get angry, you hurt yourself.
Okay?
Having offered the metaphor that the voice may not be that powerful after all, we need to
try the debate again. Can she be helped to feel powerful?
"You know, Debbie, you're no good. You're worthless."
P: That's not true.
T: "Yeah it is. Yeah it's true. You're no good, you'll never amount to anything."
C o m e on, that's it.
P: [John offers a response. Debbie gulps and then repeats it.] W h o the hell
are you?
T: I'm the negative voice, I've been here a long time. A n d don't you talk to
me that way.
P: Okay. [audience laughs.]
T: O h boy! In that one time when you said what J o h n did, how did you feel?
P: It was great.
I wanted Debbie to identify what she was feeling at that moment, and to offer her feedback
about her response.
T: Again, I wish you could see yourself, if we had a mirror to see you weren't
smiling, you were grinning, you gulped once and then said, "Who do you
think you are anyway?" But it felt good?
P: U h huh.
T: Let's do it again.
"You're a worthless individual, you don't deserve anything good to happen
to you"
P: That's not true.
T: "It's been true for years, Debbie, lets just face it--you're a worthless piece
of crap."
P: W h o the hell are you?
T: "I am just your voice, I've been with you a long time; that gives me great
longevity and seniority and I know you're worthless."
P: Things can change.

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T: Oh, yeah, yeah, sure, the oceans can all dry up. You know you're worthless
and you'll be that way forever.
P: [John whispers to her.] You're just like the character in the Wizard of Oz.
T: "You know you're just kidding yourself if you think that things will ever
get better. You'll always be . . . you know . . . no good, worthless, a loser,
a piece of crap"
P: You don't know that.
T: "Well, I'm inside your head, I know everything. I'm the smartest thing going"
P: W h o says so? You don't know everything.
T: "Well, I know, I may not know everything but I know you're no good."
P: You're a disturbed pathetic old man. [Debbie starts giggling.]
T: Let me stop. You look, you've gone from smiling, to grinning, to being almost
giggly. Why?
The here-and-now focus invites her response.
P: I guess it's all the things he's [pointing to John] saying about you.
T: He's not saying it. You're saying it. I'm running out of things to say.
P: It's the same stuff, you'll run out of them.
T: Exactly. B u t . . . "yeah says you." How does it feel for you right here, right
now, to say those things?
P: It's like you're talking about somebody else.
T: So if you practice and then they get to be yours. How does it make you
feel when you start getting giddy and start giggling? W h a t are you feeling?
Here we can focus on the need for practice via homework.
P: A lot lighter.
T: Lighter? Does it make you want to go out and hurt yourself?.
P: No, not at the moment.
T: So when you're able to answer that voice back, to be really tough, do you
feel guilty for quieting that voice down?
P: Not yet.
T: But you might.
P: U h huh.
T: Okay. A n d that's something else that you're going to work on with John.
Right here, right now, you've gone from smiling to grinning, to giggly, just
answering this negative voice back. Debbie, what's been going on inside
your head?
P: Well I haven't been thinking about the voice.
T: Okay. Having someone nearby is real helpful.
P: Yeah.
T: Okay. Well let me recommend something that might be a good exercise,
some good homework for you. Was this little exercise painful?
P: In the beginning, I was afraid I wouldn't have the right answer.
T: And then . . .
P: I would fail.

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A n d then what happened?

I get really nervous in front of all these people.
That's right, but what happened instead of that?
I'm still here, I didn't move.
Are you embarrassed in front of all these people?
Not yet.
Not yet? Okay, let me suggest something that can maybe be helpful. Do
you have a cassette recorder at home?
P: Yes.
T: Okay. I would like to r e c o m m e n d something, and again this is something
I'll recommend for J o h n and you to work on. I don't think your negative
voice is that terribly clever. Okay? I don't think it's terribly smart. I think
it's kind of a J o h n n y O n e Note. It has just the same things over, you're no
good, you know, same kind of crap over and over again. First thing that
I'd like to recommend is that you write those thoughts down. Try to identify
all of the thoughts, those negative thoughts that this really insistent negative
voice annoys you with. T h e n what I'd recommend you do is to record them
on a tape recorder in the following way: You're no good, You're a worthless
piece of c r a p - and give yourself about ten seconds between each negative
statement -You'll never amount to anything in your life-- 10 seconds--You're
just a piece of crap, no one even c a r e s a b o u t you. A n d then, I'd like to recommend ....
Do you understand what I'm asking so far, to work with
John, cause John's a good helper on this, you just saw what he d i d - - t o come
up with responses that you can write down.
So what I'd like for you to do is that you're going to go home and you're
going to put on your cassette recorder and a voice is going to say "You're
no good." A n d you're going to practice, "You know you're full of shit, I don't
have to take that from you, you're a worthless jerk, you're a stupid, stupid
voice, I don't have to agree with you any longer"
"Nothing's going to ever work out for you" Well, that's not true, something is working out right now, I'm shutting you up. Write those down and
practice them a couple of times a week. So you're going to become your
own negative voice on the tape and John's going to help you respond. Does
that make sense?
P: Yup.
T: W h a t do you hear me asking you to do?
I want to be sure that Debbie and I are talking about the same thing. By having her repeat
the homework, I can monitor and change, if necessary.
P: Change the way it is.
T: Is this something you think you'd be able to manage to do?
P: Yeah.
T: You can practice it in the office and then you can work on it at home. John,

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is that something you'd be willing to work with D e b b i e on? [John agrees.]

Okay. If you could quiet that negative voice, what would the result be?
P: I wouldn't need to h u r t myself.
T: Would that be good or bad?
P: Good.
T: Okay. We're r u n n i n g close on our time. Let me ask you, as our time is almost up, what are you going to take h o m e from today's session? W h a t have
you learned?
I wanted Debbie to review the session work for herself,for me, and also to have the audience
hear what she was taking home.
P: W h a t I did.
T: W i t h what?
P: Change.
T: Yeah and . . .
P: Q u i e t i n g the voice.
T: Yeah, what else?
P: T h a t I have a way now of trying to use the m e c h a n i s m s I have . . . .
T: Okay. H o w . . . W h a t word do I want? H o w likely do you think it is you'll
be able to do this?
P: Well, I want to be realistic because you suggested a n d it seemed like a pretty
good idea, it's not like its gonna change right away like today.
T: You're right. You know maybe it wouldn't change your behavior at all. M a y b e
it won't change things one bit. H o w are you going to find out.
P: I'd have to try it.
T: Okay. Sounds like a good idea. I n closing, Debbie, how do you feel about
what we've done in the last 45 minutes?
P: I ' m m o r e relaxed t h a n in the beginning.
T: M o r e relaxed than in the beginning?
P: U h huh.
T: D i d I say a n y t h i n g that upset you or hurt you?
P: No.
T: D i d I say anything that you found obnoxious or difficult to deal with?
P: No.
T: Okay. W h a t ' s your overall impression of the 45 minutes we spent?
P: I was on the hot seat.
T: You certainly were. Okay. H o w do you think you did on the H o t Seat?
P: Well, I'm still talking.
T: You survived?
P: Yeah.
T: O n a scale of zero to one h u n d r e d , where zero equals total failure, one hund r e d equals really positive. H o w do you think you did today?
P: Sixty.
T : Better than half. You know I ' m going to ask t h e m [the audience] the same

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question, they're listening to us of course, and I'm going to see what their
view is. Once again, if what you said is accurate, that you underestimate
your value, so you're giving yourself a sixty which is still pretty good, would
you be interested in hearing what they think? Or would you rather not hear it?
P: Okay.
T: Okay, we're going to stop and what we're going to do, they're going to have
a chance to ask me questions. Would you like to stay, and maybe they'll
have some questions for you, and if you feel comfortable maybe you can
answer them.
P: Okay.
At this point the session ended. Debbie stayed for a brief question session
and then left. She was debriefed by her therapist at that time and reported
feeling quite positive. She told her therapist that she hoped I didn't take her
statements about being a pathetic old man personally. He assured her that I
did not.
Discussion
Debbie's schema provides the instructions that guide the direction and quality
of her daily life (Young, 1990). The products are largely conscious and accessible to consciousness. H e r dysfunctional feelings and conduct are largely due
to the function of certain schemas that tend to produce consistently biased judgments and a concomitant consistent tendency to make cognitive errors in certain types of situations. What is clear in this interview is that the schematic
errors, not unconsciousness or defensiveness per se, are the source of her difficulties. Given the long-term nature of Debbie's characterological problems, her
general difficulty in relating to others, and her emotional lability, the diagnosis
of borderline seems appropriate. It is interesting to note that in some ways Debbie
differs from the typical, stereotyped Axis II patient who is referred through
family pressure or legal remand, who generally avoids psychotherapy, presenting
with poor motivation and a seeming reluctance or inability to change. Debbie,
on the other hand, comes to therapy and works hard. Also, she did not seek
out therapy because of an Axis II disorder. She came, as is typical, with Axis
I complaints of depression and anxiety. The reported problems may be separate
and apart from the Axis II patterns or derived and fueled by her Axis II personality disorder.
Debbie sees the difficulties that she encounters in dealing with other people
or tasks as often outside of her self or her control. She does, however, see her
role in the interactions. H e r problem is how to take and maintain control. Another difference between Debbie and many Axis II patients is that she has an
idea of why she is the way she is, how she got that way, what she would like
to do, and how to do it. The problem is more how to build tolerance for the

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ongoing frustration and to increase her threshold for the frustrations that lead
to emotional outbursts.
The degree to which Debbie's schemas are on the continuum from active
to inactive, as well as the degree to which they are on the continuum from unchangeable to changeable, is an essential dimension in conceptualizing her problems (Beck, Freeman, & Associates, 1990; Freeman et al., 1990). Her active
schemas relating to trust and dependence are central (Young, 1990), and govern
her integration of information from her environment. Debbie's inactive schemas
exist outside of awareness and become active when under stress, serving to govern
behavior. Of course, when the anxiogenic situation is no longer present, the
inactive schemas recede to their previous state of dormancy. It was important,
therefore, that the stress of the interview be kept low, and that the therapist
back away from any confrontation.
Debbie's cognitive distortions served as signposts that suggested schema. The
goal of the therapy session was to help her to identify some of the different
rules that she lives by and to work on schematic modification (Freeman et al.,
1990). This involved asking her to make some changes to her basic manner
of responding to her internal world.

Summary
Debbie, a patient in ongoing therapy, volunteered to assist in a workshop
by participating in an interview. The goals of the session were to identify some
small, discrete problem that could he worked on in the limited time available,
and to demonstrate how a short-term treatment can be used.
The issues considered revolved around Debbie's schema. Her early abuse
set several schemas that have directed Debbie's life. The goals of the therapy
would be to help modify those rules. The single session was a microcosm of
a longer-term therapy. Overall, from the reports of the patient and her therapist, on follow-up, she was able to do the homework with the therapist's assistance and found that it was helpful in countering the negative thoughts. This
led to a lifting of the concomitant depression and a diminution in the self-injurious
behavior.
Many sessions would be needed to reinforce and strengthen the exercise started
in this session. Overall, I would see this session as both a successful treatment
session and a demonstration of how identifying discrete, proximal goals can
benefit patients with long-standing Axis II problems. The hypotheses and questions led to data gathering and hypothesis testing. Throughout the session, it
was essential to be aware of the likely schemas so that some could be used in
the session, while others were clearly avoided. By developing a conceptualization or model of the problem(s), a set of interventions could be mobilized within
the session and as homework between sessions. By working toward a coping
model of treatment rather than attempting to cure long-standing problems,
brief cognitive behavioral interventions can be successful.

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To maintain the authenticity and flow of the session, the grammatical errors or dysfluencies of
therapist and patient were left unedited with few emendations.
RECEIVED: August 5, 1996
ACCEPTED: August 12, 1996