Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

mode and invites her to guess which mode he was playing. Be aware that the patient doesn't get the impression that you intend to make fun of her. This exercise has the advantage that not only the tone of voice but also the nonverbal signals become clearer. After the demonstration they discuss how this mode can be recognized. After this the therapist can also invite the patient to play one of her modes. In this way the patient gets a better understanding of her modes. This is not to say that it is unnecessary to occasionally return to this point for a short “refresher course” in the mode model at a later stage of treatment. However, at a certain point (after about six sessions) the therapist must stop gathering information and giving explanations and move on to schema mode work. Many therapists find this an uncomfortable point in the therapy. One could describe this moment as similar to the fear of diving off the deep end, particularly when starting with a new technique (e.g., the experiential techniques). Do not hesitate but simply jump in! Of course, one can always turn to the peer supervision group and ask for advice.

       Structure of sessions during active treatment

When the phase of case conceptualization is rounded off, the therapist starts with working with the modes. In order to discover which mode is most active at the beginning of a session he starts with a general question like “how was your week?”, “how have you been doing since we last met?” or “what do you want to discuss with me today?”. Don't talk too long about what happened (roughly 5 min) and try to find out which mode is active. The therapist can form an idea of the mode that is “talking” from the tone of voice of the patient in combination with the content of the story (Table 3.2) (see ST step by step 2.17 and 5. Examples of modes).

      When the therapist is pretty sure which mode is talking, he states which mode he thinks is active. So, don't ask the patient to tell which mode is active, because in the first phase of treatment the patient is usually not able to tell you which mode, she is in. She is convinced that there is no mode and she answers “I am telling this.”

The following step is that the therapist uses a technique appropriate for that mode. This can be all kind of techniques (see Chapter 9). Be aware that there can be a lot of mode flipping during the session, so you have to adapt your strategy a few times. The ultimate goal of each session is to reach the vulnerable child. As soon as the vulnerable child appears the therapist does everything to support and comfort the vulnerable child and provides psychoeducation about needs. Try to help the vulnerable child to grow emotionally by fulfilling unmet needs in such a way that this matches with the phase of growth the patient is in. The therapist must be aware of the fact that practical solutions mostly are not the best way to support the vulnerable child in the beginning of therapy, because the patient is not able to perform the suggested actions. Only when the vulnerable child feels comforted enough for the moment the therapist can give some psychoeducation about possibilities to solve the problem or accepting that things cannot be changed immediately. In a later phase of therapy, he can stimulate the patient to find her own solutions by learning her problem solving. Working with the mode(s) takes between 15 and 30 min.

Table 3.2 Different reactions possible in the first moments of the session. Question: “How was your week?”

Tone of voice	Content	Mode
Flat without emotion	I am okay. No nothing special happened. I think we can have a short session today.	Detached protector
Harsh, negative	I had a bloody awful week, everything went wrong. I am such a fool.	Punitive parent
Sad, anxious, panicky with a childlike tone	I had a terrible week. I felt sad and lonely. I am afraid that my friend is going to leave me.	Abandoned/abused child
Angry, loud, incoherent	Everything goes wrong. Everybody is against me. Starts mentioning a lot of examples of negative experiences in which he/she was treated unfair.	Angry child
Calm, shows emotions in an appropriate way	Some things went well and some things went wrong. I would like to talk about the situation that made me sad. I want to find out why this happened.	Healthy adult

      It is strongly recommended to not postpone experiential techniques to later phases of therapy. The idea that it is contraindicated to use for instance empty chair techniques or imagery rescripting of aversive childhood memories early in treatment has been proven wrong. By using such techniques, the detached protector mode is bypassed, the abandoned/abused child mode is supported and healed, and the punitive parent mode weakened. Thus, the current treatment model states that almost every session of this central phase should contain experiential work, and that one should start within a few minutes with this, to prevent that one avoids emotional work and runs out of time. Talking and understanding can be done at the end of the session.

      Be sure to reserve around 5–10 min at the end of each session to draw conclusions on schema and mode change and to strengthen the healthy adult.

       Final phase of therapy

      In the final phase of therapy, the emphasis is shifted from processing the past to changing behavioral patterns. The experiential techniques change in nature because the patient now increasingly takes on the role of the healthy adult. The exercises will be more focused on future situations. In the final phase it will also be possible to use more cognitive techniques that the patient can use outside of sessions. In the following chapters, each technique will be discussed in more detail with the shift of emphasis from child mode to healthy mode

       Changing behavioral patterns

      Young, Klosko, and Weishaar (2003) referred to this phase of promoting more autonomy and changing behavior, as crucial (see Chapter 11, “Behavioral Pattern‐Breaking”). Even when the patient is no longer ruled by constantly changing modes and the healthy adult has been developed, enacting upon these new behaviors is not always easy. The patient starts to apply what she learned in therapy outside the safe environment of the therapy and is able to do more complicated homework assignments. In most cases this phase starts in the second year of treatment with less frequent sessions and a more coaching attitude of the therapist to acquire new, healthier behavior.

       Ending therapy

      According to Young, ending therapy is considered when the patient no longer meets the criteria for a diagnosis of BPD and has built up a relatively stable social network and has found a meaningful way of filling her days. So originally, ST for BPD was open‐ended: treatment finished when patient and therapist agreed it to be complete. However, recent experiences demonstrate that a time‐limited ST for BPD is in general as successful as open‐ended ST (see Chapter 11, “Ending Therapy”). When there is no progress at all after at least one year of ST, it is also recommended to seriously consider stopping treatment, as research indicates that there is little chance that improvement will be accomplished later.

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