Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

relevant therapeutic techniques can be best applied for the different foci.

Whatever topic the patient focuses on and whatever pathway is tried, these techniques can only be successful once a certain level of trust and attachment to the therapist is formed (see “within therapy” in Table 3.1). Because of the importance of the relationship between patient and therapist, we will address the specifics of the therapeutic relationship in ST in Chapter 4 immediately after discussing treatment in this chapter. After the therapeutic relationship is addressed, we will move on to the techniques. First, we will discuss the change of implicit knowledge in Chapter 5 (Experiential Techniques), then thinking or explicit knowledge in Chapter 6 (Cognitive Techniques), and finally “doing” or changing operational representation in Chapter 7 (Behavioral Techniques). All of the subjects summarized in the matrix (Table 3.1) can be found in the following chapters. However, first we will examine the phases involved in the course of treating BPD with ST.

Table 3.1 Therapeutic techniques

Focus	Channel
Feeling	Thinking	Doing
Outside therapy	* Role‐play present situations* Imagining present situations* Practice feeling emotions* Exposure to showing emotions	* Socratic questioning* Formulating new healthy schemas and strengthening the Healthy Adult Mode* Schema dialogue* Flashcards* Positive logbook* Self‐monitoring Circle	* Behavioral experiments* Role playing skills* Problem solving* Trying out new behavior
Within therapy	* Limited reparenting* Empathic confrontation* Setting limits* Role switching therapist/patient	* Recognizing patient's schemas and modes in the therapeutic relationship* Pro's and con's Coping Modes* Challenging ideas about therapist* Self‐disclosure	* Behavioral experiments* Strengthening functional behavior* Training skills related to the therapeutic relationship* Modeling by therapist
Past	* Imagery rescripting* Role‐play past* Two‐or‐more‐ chair technique* Writing letters	* Reinterpretation of past events and integration into new schemas* Historical test	* Testing of new behaviors on key individuals from the past
Future	* Imagery or role‐play about situations in the near future* Two chair technique: dialogue between dysfunctional (old) modes and the Healthy Adult	* Developing new goals for the future, based on own needs, interests and talents* Anticipate on activation of schemas in difficult situations* Choose which situations, activities and people to engage in, and which not	* Testing of new behaviors on new contacts* Making new friends* Explore and try out new activities (e.g., education or work)

      Most of the techniques are also demonstrated in a recent audiovisual production Schema Therapy Step by Step, van der Wijngaart and van Genderen (2018). The purpose of this production is to familiarize therapists with all aspects of ST. When applicable, we will refer to relevant scenes.

Structure of Treatment

      Treatment begins with a comprehensive inventory of the problems as the patient experiences them. This is done in connection with a thorough explanation of the schema mode model. Also included in these beginning sessions is a discussion of practical matters such as the frequency of sessions (once or twice a week) and the expected duration of the therapy (one‐and‐a‐half years or longer if necessary).

      If the patient is not able to stay in therapy for such a long period for practical reasons (for instant she is going to move to another city far away) or doesn't want to participate in such a long therapy, it is advisable not to start with the therapy and refer the patient to another kind of treatment. The same applies to the therapist. If he is unable to work with the patient for a longer period, he should not start a ST with a patient with a BPD. If he stops therapy in the middle of the treatment, there is a big risk that the patient will feel abandoned and betrayed again and can have a serious relapse. When the therapist has to end therapy too early unexpectedly, it is very important that he takes enough time to discuss this with his patient and endures all the reactions of the patient without defending himself. He has to keep in mind that extreme reactions come from the modes and not from the healthy adult. So, he tries to adapt his reaction to the mode that comes to the fore. Of course, the therapist also does his utmost best to find another schema therapist and takes care of a good transfer, for instant by having at least one or two joint sessions.

      Another issue that has to be agreed upon is that the patient is willing to tell something about her past and her upbringing. If she refuses this completely it is better to refer her to a therapy that is more oriented at the present. This does not mean that you should not start with a patient who says that she has very few or no memories from her youth. There are several possibilities to help the patient to find relevant memories later in therapy (see Chapter 5).

The recording of therapeutic sessions is recommended. Most patients have a smartphone and use this for recording the session. The patient is asked to listen to it before the next session takes place. Listening to the recorded sessions strengthens the effect of the therapy. No one is capable of incorporating all the information involved in a single session. Therefore, it is a very beneficial tool for the patient to listen to the recorded session. Often it is only upon listening to the recording that a patient actually hears and comprehends what was said during the session. During the actual session the patient could be in a mode that is not conducive to listening or processing information. Modes can distort how tone and language are perceived and therefore strongly influence information processing. Because of this, listening or re‐listening, to recorded sessions not only reiterates the session itself, it also serves as proof of what was actually said and done during the session. However, the therapist does not try to force the patient to listen to the recordings, if the patient refuses. It is recommended that the reasons are explored and understood from the patient's mode model (which mode underlies the refusal?), and that priority is given to issues that are more important when it comes to change.

      Sample of listening to a recorded session

      Nora stated more and more often that she experienced my questions during sessions about something that had taken place as punishing. She thought that what I really wanted to say was that she had made a mistake and that the resulting consequences were her own fault. She was in the punitive parent mode. It was only when she later listened to the recording while in a young child mode or a healthy adult mode that she was able to actually hear my tone and realized that I was simply interested in how things were going and was not judging her.

Finally, it is important that agreements are made regarding the therapist's availability. The patient needs clear guidelines as to when she can (and cannot) contact the therapist outside of sessions. Often,