Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

       Response from a self‐aggrandizer:

      P:

      I am not angry at all. I am only irritated because you have planned your holiday at the wrong time. Exactly before my holidays. Can't you postpone your holiday?

      T:

      No, I'm not going to do that. Which side of you thinks I should adapt to you?

      P:

      Should I explain ST to you? I thought that limited reparenting was the core of your therapy. If you really think that I am important you would postpone your holiday.

       Response from punitive parent:

      P:

      I don't know which “side” of me this is. I only know that I must have been a complete idiot to trust you and that is one mistake I won't make again. It doesn't matter anyway; I'll never get better and I don't deserve to get better.

      T:

      I think I hear the voice of your punitive parent mode. Maybe that side says that you make a fool of yourself by having sad or angry feelings.

      P:

      That's not my punitive parent mode, but a fact. It is childish behavior when you only have 1 week holiday.

      In the beginning of the therapy, the subtle differences between the angry protector or bully and attack mode and the angry child can also be difficult to distinguish. The differences are primarily evident in the level of anger that is paired with the reaction (see the section “angry/impulsive child”), and in the intention underlying the anger. Whereas, with the angry protector, the intention is to keep others away to protect oneself for being abused, rejected, or abandoned, with the angry child the intention is to protest against maltreatment by others and to get recognition for one's (interpersonal) needs.

      These examples involve the protector expressing herself in an active manner. The completely opposite form in which the protector may express herself is by exhibiting tired or sleepy behavior. In this case the therapist must assess whether or not the patient is actually tired or whether she is in the protector mode.

      There is the risk that while in the protector mode, the patient may avoid therapy and not work on her problems with a serious chance of her stopping therapy all together. The patient can also have problems with dissociative symptoms, self‐injury, addiction to numbing substances (e.g., drugs or alcohol), or may attempt suicide. Because of this, it is important to identify when the protector mode is present and bypass it. This will give the patient an opportunity to work on her actual problems.

      How to recognize a detached protector mode during a session

      The patient is not making real contact with the therapist

      The patient doesn't show emotions, even if she talks about emotional experiences

The patient doesn't want to talk about her problems

      The patient is rationalizing

      The patient is angry or arrogant in a controlled way in order to keep you at a distance

      The patient talks a lot about nothing

      The patient is complaining about physical problems extensively

      The patient whines (seems to cry, but the therapist doesn't feel empathy)

      The patient is completely worn‐out without a clear cause

      The patient always wants to talk about actual problems and expects an immediate solution

      The tone of voice is flat

       The abandoned/abused child

      The abandoned/abused child is often referred to as “Little …” (= the name of the patient). In our examples, we refer to the patient as Nora. Therefore, when in this mode she becomes “Little Nora.”

      Little Nora is sad, desperate, inconsolable and often in complete panic (See ST step by step 5.01). When in this mode the patient's voice itself often changes to that of a child. Her thoughts and behavior become that of a four‐ to six‐year‐old. She feels alone in the world and is convinced that no one cares about her. The basic belief in this mode is that she can trust no one. Everyone will reject, abuse, or eventually abandon her. The world is a threatening, dangerous place that holds no future for her.

      Little Nora thinks in terms of black and white. She demands constant and immediate reassurance and solutions to her problems. She is incapable of helping herself. There is a great chance that during the first phase of the therapy, the therapist will face Little Nora mainly in situations of crisis. In the early stage of the therapeutic process, it is unlikely the patient will show her abandoned child side at other moments (for a sample dialogue, see Chapter 9, “Treatment Methods for the Abandoned and Abused Child”).

When the patient is in this mode, she latches onto the therapist in the hope that he holds the solutions to all of her problems. She expects complete and constant comfort and compassion from him. During this mode the therapist often feels overwhelmed by the patient's expectations of him. In an attempt to address her cries for help, he can have the tendency to look for practical solutions far too quickly. On the other hand, he may also attempt to rid himself of the patient by referring her to a crisis center too quickly. When Nora is in a panic, all practical solutions appear unfeasible. Little Nora cannot comprehend that the crisis will ever come to an end.

      Nora's feelings of desperation and the therapist's feelings of incompetence will only become greater if the therapist continues to advise practical solutions. Should she be referred on too quickly, Little Nora becomes even more desperate as she feels misunderstood, abandoned, and rejected.

      The therapist must allow Little Nora's presence in these sessions. He must be supportive of her, validate her feelings, offer a safe haven, encourage her to bond with him as a therapist, and address her past abuse. In short, he must offer her what she was most likely denied during her childhood.

      How to recognize the abandoned/abused child during a session

      The patient is overwhelmed by sad or anxious emotions

      The patient is helpless

      The patient acts as if she is totally dependent on the therapist

      The patient wants the therapist to solve her problems

      The therapist empathizes a lot with the patient

      The tone of voice is of a little child (sad or panicky)

      The therapist experiences a strong emotional appeal to solve the emotional pain of the patient and to not abandon her.

       The angry/impulsive child

      The other child mode in BPD is that of the “angry/impulsive child.” The beginning of therapy is often overshadowed by desperation (Little Nora) and shame (punitive parent). Because of this, one does not often see the angry/impulsive child in the beginning of the therapy.

      Angry Nora is a furious, frustrated, and impatient young child (approximately 4 years of age) who has no regard or consideration for others (See ST step by step 5.02). When in this mode, the patient is often verbally and, at times, physically aggressive and acrimonious toward others including her therapist. She is incensed that her needs are not met, and her rights go unacknowledged.

Angry Nora is convinced it is better to take all you can, or you will end up with nothing at all. She is convinced she will be taken advantage of. She is not only furious, but also wants everyone to see just how badly she has been treated. She does this by attacking others (verbally or physically), hurting herself, attempting to kill herself,