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techniques by, for example, compiling instructional manuals to help guide practitioners in conducting the specific treatment. In this way, it is hoped that the therapy is conducted consistently and equally effectively, irrespective of the practitioner. (An obvious, though perhaps crass, analogy may be made to a franchise food company, such as Starbucks or McDonald’s, which standardizes its ingredients so that its coffee or hamburgers taste the same regardless of where it is purchased.) Standardization also facilitates gathering evidence in controlled studies, which can support, or refute, the effectiveness of a particular psychotherapy approach.

The underlying theory of standardization is that, just as it would make little difference who physically gives the patient the Prozac (as long as he ingested it), it would make little difference who administered the psychotherapy, as long as the patient was in attendance. However, interpersonal interactions are surely different from taking and digesting a pill, so it is probably naive to presume that all psychotherapists following the same guidelines will produce the same results with patients. Indeed, John G. Gunderson, MD, a pioneer in the study of BPD, has pointed out that the original developers of these successful techniques are blessed with prominent charisma and confidence, which followers may not necessarily possess.2 Additionally, many therapists might find such a constrained approach too inflexible.3

Although the different psychotherapy strategies emphasize distinctions, they possess many commonalities. All attempt to establish clear goals with the patient. A primary early goal is to disrupt self-destructive and treatment-destructive behaviors. All of the formal, “manualized” therapies are intensive, requiring consistent contact usually one or more times per week. All of these therapies recognize the need for the therapist to be highly and specially trained and supported, and many require supervision and/or collaboration with other team members. Therapists are more vigorously interactive with patients than in traditional psychoanalysis. Because these therapies are time and labor intensive, usually expensive, and often not fully covered by insurance (e.g., insurance does not cover team meetings between therapists, as required in formal DBT—see page 179), most of the studies exploring their efficacy have been performed in university or grant-supported environments. Most community and private treatment protocols attempting to reproduce a particular approach are truncated modifications of the formal programs.

It is no longer simply a matter of “finding any shrink who can cure me” (though it is possible, of course, to get lucky this way). In our complex society, all sorts of factors are, and should be, considered by the patient: time and expense, therapist’s experience and specialization, and so on. Most important, the patient should be comfortable with the therapist and her specific approach to treatment. So the reader is advised to read the remainder of this chapter with an eye toward at least becoming familiar with specific approaches, as she will likely see them (and their acronyms) again at some point during the therapeutic process.

Cognitive and Behavioral Treatments

Cognitive-behavioral approaches focus on changing current thinking processes and repetitive behaviors that are disabling; this type of therapy is less concerned about the past than psychodynamic approaches (see page 183). Treatment is more problem-focused and often time-limited.

Cognitive-Behavioral Therapy (CBT)

A system of treatment developed by Aaron Beck, CBT focuses on identifying disruptive thoughts and behaviors and replacing them with more desirable beliefs and reactions.4 Active attempts to point out distorted thinking (“I’m a bad person”; “Everyone hates me”) and frustrating behaviors (“Maybe I can have just one drink”) are coupled with homework assignments designed to change these feelings and actions. Assertiveness training, anger-management classes, relaxation exercises, and desensitization