Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

a connection outside therapy sessions, but therapists need to make clear how often they approximately read emails and how fast (and how often) they approximately will respond. The patient needs to know what courses of action to take when a crisis is approaching and to whom she can turn when the therapist is unavailable (see Chapter 4, “‘Limited Reparenting”). Normally there is another member of the peer supervision group who is involved in the therapy from the side lines. He can temporarily replace the therapist if needed, for example, in case of holidays or illness.

Phases in Treatment

      ST for BPD patients does not have a fixed protocol that describes per session which issues need to be addressed. After all, this is a therapy that covers more than a year. There are, however, a number of distinguishable phases in the therapy, which will be described later. It is important to the protocol of ST that the therapist is aware of how best to react toward the different modes. Because of the importance of this we have chosen, after describing the separate therapeutic techniques (Chapters 5–8), to devote a chapter on how the therapist can deal with each mode during different phases of the therapy (Chapter 9). In Chapter 10 we will give separate attention to the final phase of the therapy.

      While there is no set order to these phases, there are four distinctive and distinguishable periods of therapy. Some phases may be omitted while others may recur at a later stage of therapy. These phases are:

      1 starting phase and case conceptualization;

      2 crisis management;

      3 treatment phase: therapeutic interventions with schema modes;

      4 final phase of therapy.

       Preliminary: treating comorbid disorders

Any disorder that needs immediate attention and that cannot be viewed as a consequence of BPD that will disappear with proper treatment of BPD, should first get attention, before a treatment of BPD is considered. This should already be clear from the diagnostic phase, as such disorders should be the primary disorder (thus, BPD a secondary disorder). There are a few disorders that specifically require attention before ST can begin. As described in the section on contraindications (Chapter 2), this involves a limited number of disorders. In all other cases, treatment of disorders other than BPD before ST can start may be omitted. It is possible that symptoms of such disorders will arise, or return, at a later stage of therapy. In that case, it might be necessary to return to a specialized treatment of these disorders, which can sometimes be done in parallel to ST, whereas in other cases ST has to be interrupted temporarily (e.g., in case of clinical detoxification). The treatment of these specific disorders is not discussed in this book as their treatment does not differ for patients without BPD and can be found adequately explained in other works.

      As comorbidity is the rule, we don't recommend excluding patients from ST because of comorbidity. We have successfully treated patients with for instance seven comorbid disorders. What is recommended, is to integrate the comorbidity in the case conceptualization. In other words, the schema mode model should also explain how the comorbid disorders relate to the modes. By understanding what the function of the comorbid problems are, or how they result from the modes, the therapist can integrate them in the patient's mode model. The focus of ST is primarily on the modes, and not on symptoms or disorders. Only when a specific symptom or disorder doesn't change despite successfully addressing the mode that is associated with it, specific techniques (or medication) for these remaining problems should be considered.

       Starting phase and case conceptualization

      Information about Nora

      Nora is a 25‐year‐old woman presented with anxiety, escalating quarrels with her boyfriend, self‐harm, mood swings, and depressive episodes. She is living by herself and has a limited social network with only one meaningful friend.

      Her boyfriend has no regular work. He uses drugs and alcohol. Nora cleans people's homes about 24 hr a week.

      Nora has a very low self‐image with doubts about her abilities. She didn't complete any higher education despite the fact that she is quite intelligent. Because of her insecurity she avoids social activities which makes her feel lonely and depressed. If she cannot avoid social contact, she behaves tougher than she is with the result that she gets exhausted.

      Nora grew up in a family with two brothers and one sister. Her father was a dominant, aggressive man who drank too much out of insecurity. Without alcohol he was only verbally aggressive, but when he got drunk, he also became physically aggressive. Mother is a gentle, kind but also anxious and submissive woman. For fear of her husband she kept her mouth shut and didn't protect the children. After father's outbursts she always tried to hush up the abuse. Her statement was “Ah you know him” and “you better stay quiet because saying something will only make things worse.”

      If it all became too much for mother, she would sometimes go to her family for a few days. That was very frightening for Nora because she never knew if and when mother would return. Mother could not handle the family and often called on Nora to help her.

      Nora has always felt lonely and different in relation to peers. Her family was considered to be different and people were afraid of her father. She did well at school because she has an above‐average intelligence, but due to her problems at home she just managed to complete lower level education.

      Diagnostically there is a recurrent depressive disorder in partial remission, a generalized social anxiety disorder, and a borderline personality disorder with dependent and avoidant features.

      The initial phase of the therapy involves approximately five sessions during which a case conceptualization is made. The therapist uses three pathways to gather the information that is needed to make a comprehensive overview of the actual problems, the (origin of) the schemas and modes and the connection between these parts. That means that he tries to gather information via cognitive, behavioral, and experiential channels.

      The different ways to gather information are:

       Cognitive:A diagnostic interview (information from former therapies)The downward arrow techniqueQuestionnaires

       Behavioral:Information from therapeutic relationshipBehavioral patterns reported by patient (and by referral and/or family members, if seen)

       Experiential:Imagery and two chair technique historical role play

       Diagnostic interview

      In the first place a complete diagnostic interview takes place. During this interview, all information relevant to the patient's problems and complaints is described in detail by the patient. A comprehensive anamnestic interview is conducted, and the therapist begins to search for the relationship with parents/caregivers and possible events that are relevant to the formation of dysfunctional schemas. Information from former therapies can also be very relevant (see ST step by step 1.01). This is a more cognitive pathway.

      In the diagnostic interview, the therapist also looks into contraindications before continuing with treatment (see Chapter 2, “(Contra‐) Indications”) as well as measuring the patient's level of functioning and BPD symptoms. If the therapist works in a mental health center, contraindications have usually already been checked, but as there is often a waiting list, therapists are recommended to check them again for