Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

of revenge. This, of course, is the extreme form of Angry Nora. A milder way in which Angry Nora may show the therapist her anger is by not attending sessions or stopping therapy all together.

      While the differences between the angry child and the angry protector are not always clear, they can usually be observed in how the anger is presented. The angry child is impulsive and unreasonable. She refers to issues that are completely unrelated and irrelevant. The angry protector is more controlled and more likely to be cynical than furious (see Chapter 9, “Treatment Methods for the angry/impulsive child,” for a sample dialogue).

      When Little Nora also has an undisciplined/impulsive mode (see ST step by step 5.04 and 5.05) she might also feel out of control and frustrated. She feels that her needs have to be satisfied immediately and she cannot tolerate discomfort (pain or conflict). This side looks more like a spoiled child but is in fact also a deprived child. The therapist should keep in mind that this behavior is due to emotional and pedagogical deprivation. Little Nora has not learned how to cope with difficulties.

The most important characteristic of this mode is the impulsive way BPD patients try to get their needs met. The patient may, for instance, have sexual contacts with people she doesn't really know, in an attempt to get a feeling of being of value and cared for. Other examples are impulsive buying, impulsive alcohol or drug use, and impulsive eating (Table 2.1). Such behaviors are related to this mode when they are impulsive (the patient did not really contemplate the long‐term risks), often motivated by a sort of rebelliousness against the punitive mode and have the aim of need satisfaction. Alcohol and benzodiazepine use, especially in combination, might lead to a loss of (the already problematic) inhibition of these kinds of impulses. The general aim of the treatment is that patients learn to acknowledge their needs (instead of trying to detach from them) and develop healthier ways of getting their needs met.

      The purpose of therapy is to teach the patient that she can be angry, but that there are other ways to express this emotion than the impulsive and extreme manner she currently adheres to.

Outbursts of rage are impulsive and unexpected. Should these take place during a session, the therapist should attempt to remain calm and tolerate the anger. He should only limit the display of anger when the patient threatens to damage persons or property, or when the expression of her anger is so humiliating that the therapist feels his limits are violated.

Table 2.1 Examples of impulsive behavior

Spending too much money Run up debts	Shopping without a plan. Buy too many or too expensive things in order to comfort yourself
Impulsive, unprotected sex	Having impulsive sexual contact with someone who is nice to you, while in fact you are looking for attention and love
Quit your job suddenly	When you have a problem at work and you feel treated unfair, you immediately conclude that this is not the right job
Alcohol and drugs abuse	Using too much alcohol and drugs too much because you don't care about the consequences
Get pregnant without a plan	Wanting a child to have company

      How to recognize the angry/impulsive child during a session

      The patient is very angry

      The patient acts impulsively

      The patient speaks in a louder voice and sometimes makes aggressive gestures

      The patient is angry about everything and everybody

      The patient doesn't listen to reasonable arguments

      The outburst of rage is often unexpected

      The outburst of rage can lead to physically damaging people

      The therapist can empathize with the patient when he sees the wrong that caused the anger

      The tone of voice is of a little angry child (harsh and screaming voice)

       The punitive parent

      The mode of the punitive parent usually also gets a name. When it is very clear which parent represents the punitive parent for the patient this mode can be given a name such as “your punitive mother [father]”or Mrs. or Mr. Johnson (which is the family name of the patient). Sometimes the patient may be unwilling or unable to actually give a name to the punitive parent out of a sense of (misplaced) loyalty toward that parent. When this is the case, the patient can refer to her “punitive side” or “the punisher.”

The punitive parent is taunting in her manner and has a tone of disapproval and humiliation (See ST step by step 5.20). She thinks that Nora is bad and deserves to be punished. The punitive parent states that Nora is showing off. When Nora fails, it is simply because she has not tried hard enough. Feelings are of little interest to the punitive parent and, according to this side, she uses them only to manipulate others. Should something go wrong, it is her own fault. In her mind, succeeding is dependent entirely upon her desire to succeed. If she really wants something, it will work out. If she fails or it does not work out, she obviously did not want it enough. Many BPD patients, perhaps even more than 50%, experience this mode as a voice, not (only) as thoughts. Often the voice is an echo of the caregiver that punished the child. Because there is usually no source misattribution (the patient is aware that it is her own mind producing the voice) we don't treat such a punitive voice as a form of psychosis. But according to some definitions, it can be considered a psychotic symptom. Because patients are often afraid of being considered “crazy” they are reluctant to tell therapists that they hear a voice when the punitive mode is activated. Therapists can therefore gently check how this mode is experienced, by explaining that many BPD patients experience this mode as a voice, others as thoughts, and many in both forms. As said, the way the mode is experienced has no direct treatment implications and therapists should not panic or start antipsychotic medication if their patients experience the messages of the punitive parent mode as a voice.

      Sample dialogue with a patient in the punitive parent mode

      T:

      How are you doing?

      P:

      (in an angry voice) Bad.

      T:

      Why is that, did something bad happen?

      P:

      No, I did something stupid and now everything is ruined.

      T:

      So, things are not going well with you?

      P:

      No, I'm hopeless and now I'm bothering you as well.

      When the punitive parent is present, Little Nora cowers away and is difficult to reach.

      While in this mode, the patient will punish herself by purposely denying herself enjoyable things or by ruining them. She will also punish herself by hurting herself or attempting to end her life. She provokes punishment everywhere, even from her therapist. She refuses to aid in her own recovery by spurning activities that would promote healthy improvement. This often results in a premature end to the therapy.

      When the patient is in this mode, the objective of the therapy involves extinguishing the unhealthy rules and behaviors and replacing them with more adequate rules and norms.

      How to recognize the punitive parent during a session