The latest, the penultimate reiteration of cognitive therapy is of course the world famous cognitive behavior therapy or CBT.

There is a third wave of behavioral therapy. It’s a wave that combines CBT with other elements.

Number one, the primacy of the therapeutic relationship. The therapeutic relationship for the duration of the therapy becomes the main relationship of the patient, overriding even his intimate relationship, overriding his workplace, overriding anything. The therapeutic relationship becomes the main relationship because it is within the therapeutic relationship, the change is induced. Actually it’s the relationship itself that creates the change by having finally a healthy relationship with another adult who happens to be a therapist.

The personality disordered person experiences a monopoly of new experiences, so secure attachment. He feels safe. He can express negative affectivity and negative emotionality without being punished. He can be dysfunctional. The therapist will contain him and channel him and regulate him so he acquires regulation, etc.

The primary therapeutic relationship is a prototype for a healthy functional relationship, a prototype platform, a template that the patient can then take and apply to all his other relationships.

Remember we are talking about third wave of behavioral therapy, combining CBT with other elements. We’ll discuss a few of these therapies shortly.

The second principle in the third wave is learning, analyzing triggers, analyzing environmental cues, exploring schemas, we’ll discuss schemas a bit later, exploring emotions.

And then the third element is utilizing modeling, homework and imagery.

Now okay, all these principles are now abstract. I’m going to show you how they are manifested, how they are used in specific therapies.

And let’s start with my favorite by far, dialectical behavioral therapy.

Dialectical behavioral therapy was developed by Marshall Leibowitz in 1993. Recently, several elements were added to it, for example spirituality, mindfulness, not for me. I think it’s a contamination, a contamination of the original. The original was bright and brilliant. There was no need to combine it with new age in order to make it more marketable and to increase profits. So I regret this development, not only in DBT, dialectical behavioral therapy, but in numerous other, for example in Schema therapy, they also have mindfulness Schema therapy and so on. These are Indian gurus and mystics translated via Western gurus and one of the yogis who didn’t understand a word of the original Indian teaching, and it’s a bloody mess.

So I’m going to describe the original dialectical behavior theorem. Leibowitz developed it in 1993 to treat borderline personality disorders.

But gradually over the decades, the efficacy of DBT had been proven with other personality disorders and with disorders of mood, anxiety, eating disorders and substance abuse disorders. So it is widely, widely applied to a variety of disorders.

But the experience hitherto has been almost exclusively with female patients and in large part in inpatient or residential settings. In other words, in hospital settings, mental asylum settings to be less politically correct. People committed or hospitalized, women committed or hospitalized have undergone dialectical behavior therapy.

So at this stage, we have no proof that it would be useful or applicable to men or to children. I have just come up with a new diagnosis for men suggested diagnosis for men covert borderline. If I’m right, the covert borderline is a combination of antisocial narcissists and borderline, typical mostly to men, not to women. This would explain why DBT doesn’t work well with men or hasn’t been applied to men.

Because men gravitate more towards the primary psychopathy pole, while women gravitate more towards the secondary psychopathy pole. In other words, women borderline, women borderlines would tend to become secondary psychopaths under conditions of stress.

And men covert borderlines would tend to become primary psychopaths under the same conditions, for example, anticipating rejection, humiliation and abandonment or going through actual breakup or disintegration of an interpersonal meaningful interpersonal relationship.

So there is a substantial difference between the way a borderline personality disorder is expressed and manifested in men and the way it is expressed and manifested in women, which would explain why DBT is much more efficacious with women. DBT emphasizes emotional and affect regulation, not cognitions. It in this sense diverges from classic cognitive therapy and goes back, harkens back to the very beginning of behavioral therapy when it was combined with emotive therapy.

So it is concerned, DBT is concerned with how your shema, how the shemas of the patients were performed via dialectical conflicts. Shemas are simply combinations of beliefs, cognitions, emotions when you put them together in reaction to a set of specific circumstances or a relationship is a set of specific circumstances. And we have shemas that pertain, for example, to relationships.

We will deal with shemas at length a bit later, but DBT is asking the question, how did your shemas form? How is your affect? How were your emotions involved in generating these shemas?

DBT seeks to connect affect and need because every shema responds to a need and involves emotions. So we have shema, need, affect, emotions. And DBT tries to connect all of them. And DBT tries to demonstrate to the patient that there are processes of inference, deduction, analysis. There are belief systems which put together with the need and the affect had generated the shema.

So suddenly everything becomes clear. You had a need, you had a belief, you had a reasoning process or a logical or analytical process, deductive process, inductive process, you had some process of thinking, cognitive process. And when you put everything together, you came up with a solution. And this solution is a scheme or multiple solutions are shema.

So when these are reinterpreted, when you become self-aware of these background processes, this self-awareness begins to generate healing.

DBT identifies fixation or perseveration, example, rumination, caused by early developmental deprivation and by protective inattentional constriction. So as a child would be deprived, for example, of maternal love in case you had a dead mother and you have learned gradually as a borderline personality disorder patient, you had learned gradually to react to this deprivation by kind of mentally insisting, by getting fixated, by being unable to move on until the issue is resolved, until your needs are met.

We all know these insistent children who keep nagging and nagging until they get what they want because they feel deprived.

Similarly, you develop protective attentional constriction. You filter out a lot of data and information because they’re too painful. They’re too hurtful. They threaten your inner precarious balance because you’re emotionally dysregulated. You’re very vulnerable. You don’t have an outer protective armor or shield or skin.

DBT examines the effects of negative reinforcement through emotional avoidance or in other ways and also studies inadequate coping skills. DBT claims that negative reinforcement, emotional avoidance, inadequate coping skills, they are actually rewarded. There’s something called partial reinforcement effect. I will not go to it right now, but they’re actually gratifying things while in healthy people, emotional avoidance, inadequate coping skill is cause for distress. Healthy people don’t like it. Borderlines actually do like it and not only borderlines. We’re talking about class the big, but mostly borderlines.

Now, DBT, dialectical behavioral therapy, which is used mostly for borderline, involves individual therapy, group skills training, reskilling, you acquire new skills, phone contact to show you over in between sessions and therapist consult, consultation, which is not for you. It’s for your therapist.

Exactly like in psychoanalysis, your therapist consults other therapies.

Actually, a typical DBT process involves as a minimum two therapies. One supervises the other, so to speak, consults the other.

DBT focuses on using validation and problem solving to counter severe behavioral discontol, issues of quiet desperation, problems of life, of living, and to reduce the borderlines perception, self-perception, as incomplete, incapable of experiencing happiness and joy, for example, missing, broken, damaged goods. This is DBT.

DBBT is an exceedingly successful therapy. It has immediate effects on borderline patients.

Well over 50% of borderline patients within the first year of DBT lose the diagnosis. The borderline can no longer be diagnosed with these people.

The next therapy I would like to discuss is cognitive behavioral analysis system of psychotherapy or CBAST. It was developed by Nicola and adopted by Sperry. It is not to be used with DBT. It’s dangerous.

Exactly like cold therapy that we’re going to discuss at the end, this is a therapy which is dangerous for borderline patients.

The clients of CBAST plan to analyze life situations and manage daily stressful events. They evaluate which thoughts, which behaviors prevent them from accomplishing desired outcomes.

So it’s a very, very pragmatic kind of therapy, more like I would say management consultancy.

There are two processes, two stages. One is called elicitation and the other is called remediation.

In the elicitation phase, the therapist asks the patient questions about the situation, the client’s role and functioning within the situation and the desired outcome.

And then the therapist demonstrates to the client that his behaviors, even his cognitions, are counterproductive, prevented him from accomplishing the desired outcome. And this leads to a revision of these self-defeating behaviors and cognition.

Of course, there’s an underlying assumption that every client and every patient is not masochistic, is not self-defeating, is not self-destructive by nature, is not self-tracting, that every person seeks his own best interests. That’s not always true with cluster B personalities.

At any rate, one thing the therapy does for sure is it replaces emotional reasoning with consequential, logical, analytical reasoning.

And that’s a major achievement because many cluster B personalities engage in emotional reasoning.

The next therapy is mindfulness-based cognitive therapy, MBCT. It was developed by Tisdale. It fosters awareness, focus on thoughts, feelings, and experiences in the present with an attitude of acceptance and without analysis, even without judgment, but without analysis.

Now, MBCT had become, as I said earlier, had become a module, if you wish. Some of its techniques became integrated into dialectical behavior therapy, EMDR, schema therapy, and so.

Next therapy is pattern-focused psychotherapy. It was developed by Sperry himself. Sperry defined pattern as a predictable, consistent, self-perpetuating style of thinking, feeling, acting, coping, and self-defense. A pattern can be adaptive and encourage you to be competent, to be self-efficacious, to leverage your agency, to secure favorable outcomes from your environment.

But the pattern can be maladaptive. It could be inflexible, ineffective, inappropriate. And if it is maladaptive, it causes symptoms. It impairs your functioning in a variety of settings, including interpersonal relationships. And it reduces your satisfaction with yourself and with your life, a state called dysphoria. It generates dysphoria.

The pattern-focused therapy consists of replacing hurtful, painful, maladaptive patterns with helpful, adaptive patterns. And this is done by interpreting situations and behaviors in a certain way so as to throw light, shed lights suddenly on how maladaptive the pattern is.

You see, there’s a commonality between all these. All these therapies assume that early on in childhood, we had become malformed. And this malformation, this wrong molding, wrong sculpting of who we are, I mean, there is a tendency to regard the newborn as a kind of raw material. And the parents mold and sculpt this raw material, kind of plastic art of parenting. And they produce an objet d’art. They produce an artwork.

But if they don’t know how to do it or if they have their own problems, the dead mother, Andrei Green’s dead mother, then the objet d’art is deformed, malformed, and is likely to behave in ways which will not be conducive to health, happiness, good, satisfactory relationships, attainment of goals, etc.

They all make these assumptions. This is the underlying assumption of modern psychotherapies in plural, which leads me to Schema therapy.

Schema therapy was developed by Jung. Schema therapy changes these maladaptive patterns, which in Schema therapy, they’re called schemas. They’re 18 schemas.

These are enduring and self-defeating ways of regarding oneself and others. And the 18 schemas are arranged in five domains.

Schemas are perpetuated through coping styles. There is schema maintenance, schemas avoidance, and schemas compensation.

And you can work with these schemas. You can reconstruct them, which is very difficult. It takes a lot of time and investment. But you can also modify them, which is a bit easier. You can interpret them in sight. It’s supposed to generate internal dynamics of change.

Or you can camouflage them, disguise them so that they are no longer able to operate. Very similar, by the way, to how viruses behave with the immune system. Just an apropos.

I’m going to read to you a list of all the schemas because it’s a wonderful summary or summation of everything that’s wrong with cluster B personality disorders.

So here are the schemas, maladaptive schemas and schema domains.

Schema domain number one, disconnection and rejection. One, abandonment, instability, the belief that significant others will not or cannot provide reliable and stable support.

Number two, mistrust, abuse, the belief that others will abuse, humiliate, cheat, lie, manipulate, or take advantage of you.

Number three, emotional deprivation, the belief that one’s desire for emotional support will not be made by others.

Number next one, defectiveness, shame, the belief that one is defective, bad, unwanted, or inferior in important aspects.

Social isolation, alienation, the belief that one is alienated, different from others, or not part of any group, impaired autonomy and performance is the next domain.

And within this domain, we have the following schemas, dependence and competence, the belief that one is unable to competently meet everyday responsibilities without considerable help from others.

Vulnerability to harm or illness, the exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it, catastrophizing.

Next scheme, enmeshment, undeveloped self, the belief that one must be emotionally close with others at the expense of full individuation or normal social development.

Next scheme, failure, the belief that one will inevitably fail or is fundamentally inadequate in achieving one’s goals.

Next domain, impaired limits or boundaries.

Scheme number one, entitlement, grandiosity, the belief that one is superior to others and not bound by the rules and norms that govern normal social interaction.

Number two, insufficient self-control, self-discipline, the belief that one is incapable of self-control and frustration, tolerance.

Next domain, other directness at other people, subjugation, the belief that one’s desires, needs and feelings must be suppressed in order to meet the needs of others and avoid retaliation or criticism.

Next, self-sacrifice, the belief that one must meet the needs of others at the expense of one’s own gratification.

Next, approval seeking, recognition seeking, the belief that one must constantly seek to belong and be accepted at the expense of developing a true sense of self.

And then we have the domain of over-vigilance, hyper-vigilance and inhibition.

Scheme number one, negativity, pessimism, a pervasive lifelong focus on the negative aspects of life while minimizing the positive and optimistic aspects.

Next, emotional inhibition, the excessive inhibition of spontaneous action, feeling or communication, usually in order to avoid disapproval by others, feelings of shame or losing control of one’s impulses.

Next, unrelenting standards, hyper-criticalness, the belief that striving to meet unrealistically high standards of performance is essential in order to be accepted and to avoid criticism.

And finally, punitiveness, the belief that others should be harshly punished for making errors.

Chema therapy is a very powerful therapy and very intelligent, if I may add.

Next, Kerenberg, who else? Still active in his 80s, amazing men, the father of the field, together a bit later with Theodore Miller.

Transference focused, psychotherapy developed by Kerenberg.

Kerenberg said that infants form internal representations of self and internal representations of others, of objects. And the infant connects these internal representations of self and others via emotions or more precisely affect.

A personality disorder occurs when positive representations and negative representations fail to integrate later in life, echoes of melanin decline.

Such splitting between all negative, all positive representations of self and of others, such splitting affects, of course, relationships, including the therapeutic relationship, including therapy.

So, Kerenberg, very similar to cold therapy, I’m doing this in cold therapy as well, Kerenberg encourages transference to the therapist because he believes that when the patient engages in transference, when the patient projects his innards, so to speak, his internal objects onto the therapist, the patient exposes these internal objects to scrutiny.

The patient delineates the faulty relationship template by engaging in a faulty relationship with a therapist via transference.

And if the therapist is empathic, the therapist can correct this faulty template via empathy and support and so insight, empathy and insight, these are the two pillars.

So identity integration is accomplished as the patient experiences negative emotions, but in a safe accepting environment.

Beautiful.

If you are an adherent of object relations, as I am, this is simply beautiful.