Individuals with Borderline Personality Disorder sometimes engage in self-harming behavior, such as cutting. They often experience their self-harm as "automatic" and out of their control. It is useful to ask clients to describe, in detail, a recent episode of self-harm. Careful questioning can elicit the precise sequence of situations, automatic thoughts, and reactions (emotional, behavioral, and physiological). Therapists can record the sequence in writing and then indicate to clients all the points along the way at which they can learn to intervene. This helps clients feel more hopeful that they can stop self-injurious behavior that they themselves often label as "abnormal" or "crazy."
MC, a 23 year old sales clerk, came to treatment for her "mood swings." She had been cutting herself between once a week and once a month for several years. When asked about a recent episode, she reported, "I don't know what happened, really. I just know I got so mad when my boss called to say that I had to come to work on Saturday-which meant I'd have to cancel my plans. I was so upset that I went in the kitchen and cut myself."
Through questioning, MC was able to identify the following sequence: She received the upsetting phone call (Situation), and thought, "This is so unfair. I have to say yes or he'll fire me," (Automatic Thoughts), which then led her to feel angry (Emotion) and to experience hot flushes, tension in her upper body, and knots in her stomach (Physiological Response). The meaning to her was, "I'm trapped. There's nothing I can do about this," (Underlying Belief). MC then noticed how tense and angry she felt (Situation) and thought, "I can't stand feeling like this," (Automatic Thought).The meaning to her was that she was weak and vulnerable to negative emotion. She then had a memory from the previous week in which she ended up cutting herself as soon as she arrived home, following an encounter with her boss during which he had been quite critical of her (Automatic Thought in Imaginal Form). These thoughts led her to feel quite anxious (Emotion). The tension in her body and warmth in her face and throat increased, and she noticed that her heart started to race (Physiological Response). She again focused on her physical sensations (Situation) and thought, "I can't stand feeling like this!" (Automatic Thought). She felt even more anxious (Emotion) and her physical sensations continued to increase (Physiological Response). She continued to focus on her body and her emotional state (Situation) and thought, "I have to make this go away. I know I shouldn't, but I'm going to cut myself," (Permission Giving Automatic Thoughts). She then immediately started to feel a little relief (Emotion) and her sensations started to decline (Physiological Response). She then started to think, "I should go get the razor blade," (Automatic Thought) and she found the razor blade and cut herself (Behavior). She thought, "That's good," (Automatic Thought) and immediately experienced more relief (Emotion). But a few minutes later, when she realized she had again engaged in this self-injurious behavior (Situation), she thought, "I can't believe I did that. I'm really crazy. If anyone knew about this... [they'd reject me]," (Automatic Thoughts) and she felt embarrassed and hopeless (Emotions). The episode fortified her ideas that she is crazy, weak, and out of control (Core Beliefs).
MC's therapist then went through the written scenario with her client and showed, at each point, how MC could learn to intervene through problem-solving, responding to her automatic thoughts and beliefs, changing the focus of her attention, decreasing her physiological response, reaching out for support, and eventually, tolerating the discomfort of negative emotion.