We describe an empirically supported treatment protocol for the treatment of Borderline Personality Disorder (BPD), a biosocial theoretical foundation of BPD and the philosophy behind dialectical behavior therapy (DBT)
DBT grew out of attempts to apply behavioral principles and cognitive therapy to suicidal behavior. It is a comprehensive principle-driven treatment designed to treat muli-problem, difficult to treat persons with emotion regulation dysfunction. Empirical literature supports DBT as an effective treatment for borderline personalty disorder.
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DSM-IV Diagnostic Criteria for Borderline Personality Disorder At least 5 of the Following A pattern of intense and unstable interpersonal relationships
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Conceptual Organization of Borderline Personality
-- Labile affect
-- Problems with anger
-- Chaotic relationships
-- Fears of abandonment
-- Parasuicidal behavior
-- Impulsive behavior
-- Substance use
-- Dissociative responses
-- Paranoid ideation
-- Identity disturbance/ difficulties with sense of self
-- Sense of emptiness
In consideration of the above parallel between DSM diagnostic criteria and a proposed conceptual taxonomy it is plausable to hyposize that Borderline personality disorder is a pervasive disorder of the emotion regulation system. Borderline criterion behaviours, it seems, function to regulate emotion or are a natural consequence of emotion dysregulation.
It is a well accepted tennant of the class of therapies called cognitive-behavioral that there is causal interaction among thoughts, behaviors, and emotions. (but see Angelette 2003 and, 2005) If we sucessfully effect change in one we can expect change in another.
In following subsections we will look at some standard cognitive-behavioral approaches to Borderline Personality Disorder and see how ARU can be utilized in each.
No single feature is invariably present in borderline personality disorder. Assessment and diagnosis of this disorder is more complex than with many other diagnostic categories. It is however noteworthy that researchers have found that borderline clients tend to score high on both the "neurotic" and Psychotic" scales of the MMPI, especially on scales 2,4,6,7 and 8. Other testing measures include the self-report questionaires of Bell, Qoiq, Edell, 1984 and Hurt, et. al. 1984 as well as the personality inventory by Millon 1982. According to Aaron T Beck and Arthur Freeman 1990, "It is particularly useful to be alert for six possible indications of BPD: (1) intense, unstable relationships; (2) a lack of a clear sense of identity (confusion or inconsistency regarding goals, priorities, and values) (3) episodes of intense, uncontrolled anger; (4)impulsive behavior; (5) chronic feelings of emptiness, boredom, or loneliness; and (6) "acting-out" behaviors. (p180)"
Given this constellation of indicators !ARU is expected to have impact by addressing especially (2), (3), and (4) above. !ARU directly addresses inconsistency of goals, priorities, and values. It may also serve to mitigate uncontroled emotions and impulsive behaviors. It should be clear, however, that !ARU is merely a clinical aid and not a panacea. It's efficacy will be limited not only by the limitations of the software but also by the skill of the clinician.
On the standard conceptualization of BPD, the borderline individual holds extreme, poorly intergrated views of relationships with early caregivers and, as a result, holds extreme, unrealistic expectancies regarding interpersonal relationships. Such expectancies shape both behavior and emotional responses which may be seen by the clinician as symptoms. Such early experiences form a schema or scaffolding through which current experiences are interpreted and acted upon. Traditionally, it has been supposed that uncovering early childhood experiences and realistically comparing them to the current concerns of the client over a period of long term psychotherapy offered an avenue of therapeautic change.
Connectionism is not at odds with this tradition. It is possible to reinterpret the tradition in connectionist terms using the neurodevelopmental model and proptype theory. On a connectionist verion of prototype theory, there is much plasticity in the neuronal organization of the infant brain. Early life experiences are encoded in various areas of the brain to produce vectorial representations of basic categories. We may supose that among these representation are such things as the maternal gaze during feeding for example. Relationships between prototypes from different categories may develop into more or less coherent organizational structures. These in turn influence the processing of new information through a process of cyclical brain growth.
In addition to atypical, invalidating, early life experiences contributing to incoherent organizational structures it is hypothesized that individuals with BPD have a biological predisposition to more frequent and intense emotion. This leads to emotion vulnerability. High sensitivity together with slower return to affective baseline increases the likelyhood of immediate reactions to stimulus which translates to more incoherent cognitive processes.
An invalidating environment punishes or ignores behavior or the internal experience of the person independent of actual validity or importance. Typical invalidating environments include trauma, emotional abuse and neglect, sexual abuse, and lack of emotion regulation skills in parents. In consequence the environment does not teach the individual to label private experiences consistent with social norms, effectively regulate emotions, or trust experience. Instead the individual learned self-invalidation and searches the social environment for cues about how to respond. !ARU exploits this disposition by placing an anamated and interactive representation of the clients own internal organization before them.
Intervention using!ARU is adjunctive to a multi-disiplinary approach to therapy that may include psychotherapy, medication, hypnosis, or other modality. It is important that all participants and stakeholders have an oportunity to communicate and agree on expectancies and limitation of the intervention. There are risks associated with any change in clients' environmental interactions and there should be a plan in place to address these with clear lines of action and responsibility.
!ARU appeals to the disposition of persons with BPD to search the environment for clues to self identity by providing an environment that mirrors the internal coherence state of that individual. This strategy is implemented interactively with the client providing information about their conflicting, beliefs, goals, desires.
A working relationship between client and facilitator does not happen accidentally. It must be carefully thought out and implemented with the greatest care and authenticity. The facilitator must remain clear particularly with the borderline client. Dicotomous thinking and acting out pervade the borderline's way of being in the world. The facilitator and !ARU will constantly be targets of these processes. This may, however, work to the advantage of therapeautic progress. Often, the client will take the introduction of a new method or technique either as black or white. When the later the client will exhibit with an exagerated hopefulness and idealize the facilitator and !ARU: The danger is of course that the client will untimately be disapointed when unrealistic expectation are not realize. The prospect for progress may depend upon how the primary therapist presents the prospect of the clients interaction with !ARU.
Take time to develop a personal history of the client. Develop standards of personal boundaries and interaction expectancies prior to introducing the software.Long before the introduction of !ARU the client must have progressed in therapy at least to the point that they are not actively psychotic.
However, labial moods may be present persistantly. While it is anticipated that !ARU will have effect on mood, it is not the job of the facilitator to modulate clients moods. This may, however, be a mistaken impression of the client and an invitation for transference and counter transference. While transference and counter-transference may be grist for the psychotheripuatic mill these matters are beyond the domain of the !ARU intervention and should merely be noted by the facilitator and refered to the attention of the primary thearapist. No progress can be made if either the facilitator or client mistake or over reach their roles. Gently redirect attention towards the primary task of building and re-building !ARU models
!ARU is a complex program and may easily overwhelm or confuse the novice user. It is important to present aspects of !ARU in a stepwise and engaging manner. Do not move to a more complex use of !ARU before the user is completely comfortable with prior uses.
The user must understand and trust the outcomes of their interactions. To this end, it may be useful to aquaint the user with other cognitive decision making uses to which !ARU has been put. A library of models and results may be found here Others may respond better to simple models created on the fly in session.
Beck, Aaron T and Freeman, Arthur (1990) Guilford Press New York
Lineham, MM (1993) Cognitive behavioral thearpy of borderline personality disorder. New York: Guilford Press
Lineham, MM (1993) Skills training manual for treating borderline personality disorder New York: Guilford Press
Lineham MM et al. (1991) Arch Gen Psych 48(12): 1060-1064
Lineham MM et al. (1993) Arch Gen Psych 50(12): 971-974
Lineham MM et al. (2002) Drug Alcohol Depend 67(1): 13-26
Masterson, James (1976) Psychotherapy of the Borderline Adult, Brunner/Mazel, Publishers, New York
Verheul R et al. (2003) Br J Psychiatry 182:135-140
Van den Bosch LMC et al. (2005) Behav Res Ther 43(9): 123`-1241
Turner RM (2000), Cognitive Behavioral Practice 7:413-419
= = = = = = = = = = = = = ABOUT THE MODEL = = = = = = = = = = = = = = |
This model provides the user with the ability to rationally assess competing ideas on the basis of coherence using a connectionist formula to update the activation of interconnected nodes. The network is also a (PDP) Parallel Distributive Processing Model in the sense that each node acts independently and simultaneously* to update its activation with information about only those nodes with which it is immediately connected.
As activation of a node increases, the node size increases. As activation decreases, the node size decreases. Below activation 0.0 the node changes from a circle to a triangle representing rejection. Some models may have nodes that include a valence in addition to an activation. Changes in valence are indicated by color changes of the nodes.
With the exception of orange special nodes set at 1, the default activation of a node is 0.01. Changes of activation and valences is achieved via links between the nodes. Positive links, colored green, are created with a default weight of 0.04 while negative links, colored red, have a default weight of -0.06. The activation and valence of unconnected nodes will decay at a rate of 0.05 per cycle.
* the model mimics simultaneous updating by first updating each node in a network and then beginning it's next cycle.
======================== AFFECT ======================= |
This particular example models a coherence network with the influence of affect shown as a star.
======================== REASON ======================= |
The theory of explanatory coherence can be summarised in the following principles (Thagard 1992. Conceptual revolutions. Princeton, NJ: Princeton University Press, 2000. Coherence in thought and action. Cambridge, MA: MIT Press.)
======================== UTILITY ======================= |
Thagard (2000) offers the following principles to be considered in the design of PDP models of utility and which principles may be applied to !ARU:
"Principle L1: Symmetry Coherence and incoherence are semmetrical relations: if factor (action or goal) F1, coheres with factor F2, then F2 coheres with F1.
Principle L2: Facilitation Consider actions Ai, . . . , An that together facilitate the accomplishment of goal G. Then
(a) each Ai coheres with G,
(b) each Ai coheres with each other Ai, and
(c) the greater the number of actions required, the less the coherence among the actions and goals.[we may imagine this to be a way to interpert work ]
Principle L3: Incompatibility
(a) If two factors cannot both be performed or achieved, then they are strongly incoherent.
(b) If two factors are difficult to perform or achieve together, then they are weakly incoherent.
Principle L4: Goal priority Some goals are desirable for intrinsic or other noncoherence reasons.
Principle L5: Judgment Facilitation and competition relations can depend on coherence with judgments about the acceptability of factual beliefs.
Principle L6: Decision Decisions are made on the basis of an assessment of the overall coherence of a set of actions and goals (p. 128)."
Actions like hypotheses are evaluated with respect to their coherence with each other and with goals. In addition goals get a degreee of priority since they will connect directly with specials or else Vspecials via a valence node.
======================================================================== = = = = = = = = = = = = = USING THE INTERFACE = = = = = = == = = = = = = |
Buttons and sliders along the top of the interface provide the user with the ability to load and run the default model and to modify its operation.
Buttons and sliders along the left allow the user to add and remove components of the model.
Networks are displayed in the large center square.
Information about the status of the network is displayed on demand in the white rectangle below screen.
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================TO RUN THE DEFAULT MODEL========================================================================================= |
Click the button labeled Make Blank
click the button near the top left labeled Observationsa window will pop up. enter in brief discription of what you've observed.
A node will be created. click Observations again to enter another observation. Continue in this manner until you've input all the observations you think relevant to the current problem.
Next, click the button labeled Beliefs. A window will pop up. Enter a discription of the belief you have as a consequence of some observations you've already input. When you click OK another box will pop up asking you if your belief is explained by something.
If your belief is supported by some observations you've already input,Click OK
If you find the belief is unsuported or is supported by something you have not already input, click the down arrow and select NO and then click OK.
Supposing you have indicated that your belief is explained by somthing, a new input box appears asking how many observations you consider to be responsible for your belief. Look over your observation nodes and note which ones account for this particular belief. Put the sum into the blank and click ok.
This will bring up a series of new popups, as many as will be needed. Look at the observatin nodes. Notice that each node has a number at its center. Type into the input popup the number of a node that accounts for your belief and click OK. This will bring up yet another input box asking you to name the theory to which the belief belongs. Enter the name of the theory and click OK (Use a short name such as T1 or T2 as any mistype will cause an error) Continue in this way until you've identified all the observations that account for this belief.
When windows stop topping up you know you're done with this belief and it's time to connect the dots. Look in the left column for the control button labeled click+linking-nodes. Now click on the belief node you've just created and then click on the observation you've related it to. A green link line should appear. Continue in this way to connect your belief with each observation withwhich it is related.
Now think of another belief that you have about what you've observed, click on the Beliefs button and continue as before.
You may find that you will need more than one Theory to account for your experiences and sometimes there will be competition between the beliefs. It is important to note these competitions by placing negative constraints between them. This is accomplished using the click--linking-nodes button
Now it's time to take note of how many theories it takes to account for your experience. Move the number of theories slider to the number of theories you've created. (note: number of theories and number of beliefs are not the same thing.)
Click on the "balance weights" thenAs activation of a node increases, the node size increases. As activation decreases, the node size decreases. Below activation 0.0 the node changes from a circle to a triangle representing rejection. If "valence off" is not selected, color changes will represent the flow of valence through the network.
Click the button at the top right labeled display output to see display of the current status of each node.
========================================================================== = = = = = = = = = TO RUN ADDITIONAL PRE-SCRIPTED NETWORKS = = = = = =
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========================================================================== = = = = = = = = = = = = TO MAKE CHANGES TO A NETWORK = = = = = = = = = = = |
Click the control labeled "leison nodes"
Using your mouse, click on each node to delete. All links to the node will be deleted as well.
Click the "leison nodes" control again after having deleted all nodes you selected.
Several types of nodes may be created with default settings and user interpretations. NOTE: Any nodes that are added by the user can only operate correctly if the network is reset to it's initial conditions before making additions and "Accounts" of new relationships among nodes must be done only after all new nodes have been added. To run your newly revised network, click reset, then balance weights, then go.
Look in the left hand column of buttons.
Click the button labeled "AddObervation" to add nodes representing the interface between the world and how our senses interpret observation. A user input box appears allowing you to enter a brief descriptive label of the observation to be interpreted, e.g. "the wind turns me on". ARU will then create a new node of activation 0.01 with your discriptive label and identify the number of the node, the fact that it is to be regarded as evidence, and link it to a special node. At a later stage in developing your network you can use the mouse to link your new node to others.
Click the button labeled "AddHypothesis" to add nodes representing concepts that may account for some bits of evidence. A user input box appears allowing you to enter a brief descriptive label of your hypothesis, e.g., "Because the wind is high" Another box appears allowing you to assign your hypothesis to a collection of nodes representing hypotheses that give a collective name, e.g., "T1". ARU will then create a new node of activation 0.01 with your descriptive label, identify the number of the node, and tag it as a hypothesis. At a later stage in developing your network you can use the mouse to link your new node to nodes representing supporting evidence and other concepts withwhich it may cohere or in-cohere.
Once you have created and linked all addtional nodes you can click the ACCOUNTS button to begin updating any new explanitory relations among nodes. Next, click a node you've newly created that is explained by another node or combination of nodes. An input box will appear which asks "Is this being explained by anything" Click the drop down arrow if the node has no explaination and pick "no" other wise click "OK" and a new box asks "How many other nodes will this node be explained by?" Using the AFFECT REASON UTILITY principles as your guide, count how many other nodes this node is explained by and enter the numeral in the blank provided. A new input box will now appear that asks you to provide a node number of each explaining node. Each time you enter a node number of an explaining node and click ok another input box will appear asking for the next node number until you have entered all of the node numbers that explain the node you at first clicked.
when the explainations are exhausted for the current clicked node no more input boxes will appear and you can click on the next node in need of explaination. When you're done exploring explanations click the ACCOUNTSbutton again to turn it off.
Click the control labeled "leison links"
Using your mouse point to the midpoint of the link to be deleted, click on each link to delete.
Click the "leison links" control again after having deleted all nodes you selected.
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=======================SCRIPTING RULES==================== |
go here
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