Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

patient talks about herself in a very negative way

      The aggression is directed at herself

      The content of the messages is black and white

      The patient seems not to hear what the therapist says

      The patient repeats the negative message over and over again

      The tone of voice in which the patient talks with the therapist is harsh, but not loud (like an adult voice)

      The patients feel shame or guilt

      The patient's self‐talk is characterized by words like “stupid,” “foolish,” “dumb,” and so on

      The patient engages in counterfactual thinking, as if she knew beforehand how things would end

      The patient attributes negative experiences as if she intended them and does not show understanding of the concept of bad luck. Thus, she seems to live in a world where everything happens intentionally, with the source of the bad intentions being her.

       The healthy adult

      It may seem odd to have a “healthy adult” mode when dealing with BPD, but it is exactly this mode that the patient needs to cultivate and eventually let dominate. Due to absence of a normal, healthy childhood, as well as due to uncontrollable events during this period, the healthy adult mode is seldom strongly present during the initial stages of the therapy. Research shows that BPD patients are on average characterized by very weak presence of this mode.

The patient's lack of healthy development in areas such as bonding with others, autonomy, self‐expression, self‐value, misfortune, emotions and emotional needs, and the lack of experience in dealing with realistic limitations, requires the therapist to serve as a representative of the “healthy side” particularly in the beginning of the therapy.

      However, it is the healthy adult who initially ensures that the patient seeks out and remains in therapy. At later stages of therapy this mode helps the patient to achieve healthy goals. These therapeutic goals such as relationships with others, looking for educational or work opportunities, and other such activities that the patient will enjoy and be capable of completing, are necessary for successful completion of the therapeutic process. While in this mode the patient not only dares to show her feelings, but also shows she is capable of controlling their expression, a necessary skill for the BPD patient to accomplish (See ST step by step5.23).

      As previously stated, in the beginning of the therapy, it is the therapist who serves as a representative of the so‐called healthy side. By the end of the therapy, the healthy adult is so evolved that she can take this role over from the therapist and the therapy can be concluded in a healthy, appropriate manner.

      How to recognize the healthy adult during a session

      The patient can see an issue from different perspectives

      The patient asks for help in an adequate way

      The patient is able to express anger in a controlled way

      The patient shows adequate assertiveness

      The patient understands other people have different views and needs than hers and can deal with that

      The patient is able to enjoy pleasant activities

      The tone of voice is modulating with the feelings

       The happy child

      The Happy Child mode, or Happy Nora, is very weak in the beginning of therapy, because this part was always criticized or even forbidden by the punitive parent mode. Self‐expression was always suppressed and punished.

      Happy Nora feels happy, relaxed, accepted, loved, and playful. She is satisfied with her life (See ST step by step 5.06).

She believes that she can trust other people and feels attached to them. She thinks that the serious things in life, like work and housekeeping, must alternate with relaxing and doing things you like.

      When in this mode she does things that are funny and pleasant, like playing with friends or children, visiting theme parks, or going to the cinema. She is curious to experience new things.

      The purpose in therapy is to intensify activities to bring up Happy Nora. Most BPD patients have no idea how to trigger their Happy Child mode, because they never were allowed to make fun. In the beginning of therapy, it is difficult to feel good and relaxed because of the detached protector and the punitive parent. When she is in the detached protector, the patient doesn't feel anything at all. If you suppress your bad feelings, you also suppress all good feelings. It is important to explain this to your patients in order to ask the detached protector to diminish. If the punitive parent is activated, making fun or playing is seen as ridiculous and silly or even seen as a proof of being worthless and stupid. If this happens the therapist should fight the punitive parent first in order to make space for the happy child.

      How to recognize the happy child during a session?

      The patient is laughing

      The patient is enthusiastically telling about things that went well

      The patient tells about doing nice things with others

      The patient looks relaxed or happy

      The patient feels attached to the therapist

Summary

      There is a saying that necessity is the mother of invention. ST was developed out of necessity. It was necessary to expand upon cognitive techniques, as these therapies were not helpful enough in treating personality problems. By adjusting techniques from other therapy schools and fitting them into a cognitive framework, a new form of integrated therapy was created: “Schema Therapy.”

Research results prove that patients can recover from BPD with ST or have clinically relevant improvement. ST not only leads to symptomatic change, many patients feel that their personality changed, that they are better capable of dealing with intimate as well as professional relationships, and that their quality of life and their level of happiness improved considerably. Important is also that this treatment is cost effective. Moreover, ST is highly acceptable for most patients, and patients feel ST is comprehensive, addressing what they are looking for in treatment.

      The schema mode model attempts to give insight as to why patients with BPD have such strong mood changes and erratic behaviors. We will now continue with a description of the different phases of therapy (Chapter 3), and the most important techniques (Chapters 5–8). We will then return to schema modes in Chapter 9, to explain how different techniques can be applied for the different modes in the different phases of treatment.

3 Treatment

      The process of change in ST for BPD takes place along three distinct channels: feeling, thinking, and doing. These channels correspond to the three levels of knowledge representation that are present in the schemas: explicit knowledge (thinking), implicit “felt” knowledge (including emotional representations or feeling) and operational representations (doing).

In addition to these three channels, we can also distinguish four different foci, which can be addressed by these channels. These foci are life outside of therapy, experiences in therapy, past experiences, and future life. The channels and foci are presented in a matrix in Table 3.1