Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

Figure 2.2).

In clinical practice we advise to make a more extensive case conceptualization in which the origins of the schemas and modes in the youth and the current problems are described. In each mode the specific schema's that give “color” to the mode of your individual patient are added (see Figure 2.3 for an example).

      We must strongly emphasize that this heuristic model does not infer that BPD is a multiple personality disorder. Giving names to the different modes is a means of helping the patient to better understand and identify with the mode and does not have any reference to identities or persons.

      The following are descriptions of the different modes most prominent in BPD. The modes are also demonstrated in a recent audiovisual production (ST step by step, van der Wijngaart & van Genderen, 2018). Chapter 9 further describes treatment and how therapists can best address the different modes.

Figure 2.2 Borderline personality disorder: six modes

       The detached protector

      When the patient is in the detached protector mode, the patient seems relatively mature and calm (See ST step by step 5.08). A therapist could assume the patient is doing well. In fact, the patient uses this protective mode in order to avoid experiencing or revealing her feelings of fear (abandoned/abused child), inferiority (punitive parent), or anger (angry/impulsive child).

The patient also doesn't look happy or relaxed (happy child). Underlying assumptions that play important roles here are those of: it is dangerous to show your feelings and/or desires and to express your opinion. The patient fears losing control of her feelings. She attempts to protect herself from the alleged abuse or abandonment. This becomes particularly evident as she becomes attached to others. The protector keeps other people at a distance either by not engaging in contact or by pushing them away (the detached protector can become an angry protector (see ST step by step 5.11) or a bully and attack mode (see ST step by step 5.13 and 5.14)) or belittle them by denigrating them (self‐aggrandizer see ST step by step 5.12)). Should others discover her weaknesses, the patient would face potential rejection, punishment, and/or abandonment. Moreover, if the patient would allow to fully feel emotions and emotional needs, the dysfunctional modes to the right of the “wall” in Figure 2.2 might get activated, which is a frightening prospect for the patient, as she does not know well how to deal with that. Therefore, it is better to not feel anything at all and keep others from getting too close to her, and to prevent emotions to be felt.

Figure 2.3 Borderline personality disorder: an example of a case conceptualization linking modes with the origins in youth, schemas, and current problems

The therapist should try to find a special name for the detached protector of Nora. A lot of patients call their protector a wall or a shield. This helps to make clear what the function of this mode is.

      Sample dialogue with a patient in the protector mode

      (In this example and following dialogues, “T” is therapist and “P” is patient.)

      T:

      How are you doing?

      P:

      (with no emotion) Good.

      T:

      How was your week, did anything happen that you would like to talk about?

      P:

      (looks away and yawns) No, not really.

      T:

      So, everything's OK?

      P:

      Yeah, everything's OK. Maybe we could have a short session today?

      Should simple methods of avoiding painful emotions prove ineffective, she may attempt other manners of escape, such as substance abuse (such actively soothing emotional pain is called a self‐soother mode), self‐injury (physical pain can sometimes numb psychological pain), staying in bed, dissociation or attempting to end her life. BPD patients often describe this mode as an empty space or a cold feeling. They report feeling distanced from all experiences while in this mode, including therapy.

      If the patient is not successful at keeping people at a distance, she can become angry and cynical in an attempt to keep people away from her. It is important for the therapist to recognize these behaviors as forms of protection and not be put off by them. If this angry–cynical state is very pronounced, it can be distinguished as a separate “angry protector” mode. The patient could even attack the therapist (the bully and attack mode) or she can disagree with the therapist in a condescending way (the self‐aggrandizer).

It is sometimes difficult to distinguish the angry protector or bully and attack mode from the punitive parent, especially during the initial stages of the therapy. One manner of distinction is to observe the direction of the patient's anger. While the angry protector's anger is directed toward the therapist (or someone else), the punitive parent's anger is directed toward the patient herself. If the therapist is unsure of the mode he is presented with, he can simply ask the patient if she is able to disclose which “side” of her personality is currently active.

      Sample dialogue with patient in the angry protector, the bully and attack mode, the self‐aggrandizer, and the punitive parent mode (See ST step by step 5.11, 5.12, 5.13, 5.14, and 5.20)

      T:

      When I told you that I have the next week off, your reaction was pretty angry. What mode do you think that reaction came from?

       Response from angry protector:

      P:

      Oh No! We're going to have another lecture about that stupid borderline model of yours? You couldn't wait, could you? Can't think of anything, better can you?

      T:

      I think your angry protector mode is activated because you feel to be left alone the next week.

      P:

      Do you really think you're that important for me? I do not need anybody.

       Response from a bully and attack mode:

      P:

      I see that you do not really know what you're talking about. You only pretend to be a good schema therapist.

      T:

      (he has a tendency to defend himself) I really think I know which side of you is this.

      P:

      O you are such a loser if you talk like that.

      T:

      I do not like it when you talk to me like that.

      P:

      (laughing) Now you are insulted