Schema therapy for borderline personality disorder [Second ed.] 2020006598, 2020006599, 9781119101048, 9781119101062, 9781119101147, 9781119101178

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Schema Therapy for Borderline Personality Disorder

Schema Therapy for Borderline Personality Disorder Second Edition

ARNOUD ARNTZ Department of Clinical Psychology, University of Amsterdam, The Netherlands HANNIE VAN GENDEREN Maastricht, The Netherlands

This edition first published 2021 © 2021 John Wiley & Sons Ltd Edition History John Wiley & Sons, Ltd (1e, 2009) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Arnoud Arntz and Hannie van Genderen to be identified as the authors of the editorial material in this work has been asserted in accordance with law. Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 111 River Street, Hoboken, NJ 07030, USA For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging‐in‐Publication Data Names: Arntz, Arnoud, author. | Genderen, Hannie van, author. Title: Schema therapy for borderline personality disorder / edited by Arnoud Arntz, Hannie van Genderen. Other titles: Schematherapie bij borderline-persoonlijkheidsstoornis. English Description: Second edition. | Hoboken, NJ : Wiley-Blackwell, [2021] | Includes bibliographical references and index. Identifiers: LCCN 2020006598 (print) | LCCN 2020006599 (ebook) | ISBN 9781119101048 (cloth) | ISBN 9781119101062 (paperback) | ISBN 9781119101147 (adobe pdf) | ISBN 9781119101178 (epub) Subjects: LCSH: Borderline personality disorder–Treatment. | Schema-focused cognitive therapy. Classification: LCC RC569.5.B67 A76 2020 (print) | LCC RC569.5.B67 (ebook) | DDC 616.85/852–dc23 LC record available at https://lccn.loc.gov/2020006598 LC ebook record available at https://lccn.loc.gov/2020006599 Cover Design: Wiley Cover Image: © Ekely / Getty Images Set in 10.5/13pt Minion by SPi Global, Pondicherry, India 10 9 8 7 6 5 4 3 2 1

Contents

About the Authors

vii

Preface

ix

Acknowledgments

xi

Introduction

1

1 Borderline Personality Disorder

3

2 Schema Therapy for Borderline Personality Disorder

7

3 Treatment

31

4 The Therapeutic Relationship

49

5 Experiential Techniques

69

6 Cognitive Techniques

133

7 Behavioral Techniques

149

8 Specific Methods and Techniques

155

9 Methods per Mode

167

10 Schema Therapy in Other Settings and Modalities

201

11 Final Phase of Therapy

225

12 Conclusion

229

vi Contents Appendix A: Brochure for Patients: Schema Therapy for People with Borderline Personality Disorder

233

Appendix B: Cognitive Diary for Modes

239

Appendix C: Positive Logbook

241

Appendix D: Historical Testing

243

Appendix E: Experiments

245

Appendix F: Homework Form

247

Appendix G: Problem Solving

249

Appendix H: Changing Behavioral Patterns

251

Appendix I: Eighteen Schemas

253

Appendix J: Coping Strategies

259

Appendix K: Form for the Historical Role Play

261

References

263

Index

271

About the Authors

Between 1987 and 2014 Arnoud Arntz (Professor of Clinical Psychology and Experimental Psychopathology at Maastricht University and clinical psychologist) and Hannie van Genderen MPhil, (clinical psychologist, ­psychotherapist, and Supervisor of the International Society of Schema Therapy (ISST) and the Dutch Association for Behavioral and Cognitive Therapy) worked together at the Riagg Maastricht. They were involved there in numerous studies in the field of anxiety disorders and personality disorders. Arnoud Arntz was project leader of the Dutch multi‐center trial comparing schema therapy with transference‐focused psychotherapy. One of his main research interests is borderline personality disorder. Since 2014, Arnoud Arntz has been Professor of Clinical Psychology at the University of Amsterdam. He is, together with Joan Farrell, Principal Investigator of the international trial comparing two forms of group schema therapy for borderline to each other and to optimal treatment as usual. He practices as a clinical psychologist at the PsyQ mental health center in Amsterdam. Hannie van Genderen has worked since 2016 as a clinical psychologist in her own private practice. Since 2000 she has been the Director of “Schematherapieopeidingen” a Dutch Institute for Schema Therapy that organizes standard and advanced level international certification training programs in schema therapy (individual for adults, children and ­adolescents, and group therapy). In addition to training in schema therapy for ­borderline personality disorder, specialized training courses on Cluster C, workshops on Imagery Rescripting, Chairwork, Angry Modes, Depression, The Healthy Adult, and Narcissitic Personality Disorder are offered (see www. schematherapieopleidingen.nl).

Preface

Schema therapy is a relatively new integrative psychotherapy based on cognitive models and offers an effective treatment of borderline personality disorder (BPD). Several trials have now documented its effectiveness and cost‐effectiveness compared to psychodynamic treatment and treatment as usual. Moreover, dropout from treatment is consistently low, indicating that schema therapy is well accepted by patients. This book offers a practical guide for therapists to conduct schema therapy with BPD patients. Building upon Jeffrey Young’s schema mode model, Young’s schema therapy, and insights from Beckian cognitive therapy and experiential methods, it offers a conceptual model of BPD, a treatment model, and a wealth of methods and techniques for treating BPD patients. The treatment not only addresses the DSM BPD criteria‐related problems, but also the psychopathological personality features underlying the symptoms, like attachment problems, punitive conscience, inadequately processed childhood traumas and so on. Research has demonstrated that patients improve in all these aspects, including on the level of automatic information processing. The authors equate their treatment to blind simultaneous chess playing in a pinball machine, meaning that the therapist has to be actively aware of the abundance of quickly changing factors that play a role in the patient’s problems, and simultaneously has to address them. Though treatment of BPD is complicated, many therapists can learn this method. Experienced therapists with good stamina will feel supported and stimulated by the book’s practical explanations and examples. Central in the therapeutic relationship is the concept of “limited reparenting,” which forms the basis for a warm and ­collaborative relationship. A good therapeutic relationship is not enough, however. Therefore, numerous experiential, interpersonal, cognitive and behavioral methods and techniques are described that are specifically suited

x Preface for the treatment of BPD patients. Finally, the book offers specific methods to be used in the treatment of very difficult cases and helps the therapist to deal with the many pitfalls that can arise from the treatment of BPD. Since the publication of the first edition of this book in 2009 several important developments took place in schema therapy. Moreover, from teaching schema therapy we learned about bottlenecks that participants encountered in applying the treatment. We also realized that the general approach and the techniques change throughout the different stages of therapy. This necessitated a thorough revision. In this new edition we have revised the text so that new insights and methods are integrated. This revised approach leads to a speeding up of treatment, without loss of effectiveness. The new edition describes how techniques should be adapted to the phase of therapy. We also discuss new approaches related to the application of schema therapy in groups, couples, and youths. The latest research findings and their implications for clinical practice are discussed, and the theoretical underpinnings of the schema mode model are now more extensively covered. We treat more schema modes now, as many patients present with additional modes than covered by the basic mode model of BPD, and the clinician should know how to handle these. Lastly, we now refer to fragments of the audiovisual production “step by step” illustrating the different techniques.

Acknowledgments

The writing of a book combined with a busy job at the Maastricht Community Mental Health Centre demanded much time, which I managed to find thanks to the unconditional support of my late husband Leo Scheffer. He not only took over much of the care of the family but also helped me with reading and typing out the texts. I thank my children Sacha and Zoë for their patience as they heard “not now” many times during this period. I learned the treatment of patients with personality disorders thanks to the many training opportunities organized by Arnoud Arntz from Maastricht University, by inviting, among others, Tim Beck, Cory Newman, Jeffrey Young, Christine Padesky, Kathleen Mooney, Joan Farrell and Ida Shaw. However, I especially learned a great deal from Arnoud himself, through his enthusiasm and assertiveness in continuously discovering new ways to treat “untreatable” patients, just like the ones with borderline personality disorder. I would like to thank my colleagues from RIAGG Maastricht, particularly Arnoud Arntz, Tonny van Gisbergen and Wiesette Krol from the Borderline peer supervision group, for their collaboration and support while learning to treat patients with borderline personality disorder. Marjon Nadort, Marleen Rijkeboer and Remco van der Wijngaart I want to thank for years of collaboration: with them I have given the majority of courses and workshops. Together we have always found better ways to teach schema therapy to colleagues. I am also indebted to my colleagues Monique Wijers, Monique Auerbach, Ina Krijgsman and my brother‐in‐law Igor van de Wal as they have read the whole book, asked wise questions and suggested additions. The patients I have treated may have contributed most to this book. Examples in this book are (anonymously) taken from our conversations,

xii Acknowledgments and I have learned a lot from them. The diagnosis of borderline personality disorder is unfortunately not yet accepted to the extent that I could list their names here. But my heartfelt thanks to you. Hannie van Genderen Without my teachers, one of them the co‐author of this book, I should have never reached the point of treating people with borderline personality ­disorder. I am very grateful for this. I would like to give my special thanks to Tim Beck, Christine Padesky, Kathleen Mooney, Cory Newman, Joan Farrell, and Ida Shaw, and particularly Jeffrey Young for what they taught our team in their workshops. Jeffrey Young in particular deserves my thanks, as he developed a model that not only matched with my own early thinking about borderline personality disorder, but also developed a ­comprehensive treatment, which is the subject of this book. My therapist and research colleagues, among whom are my former PhD candidates Laura Dreessen, Anoek Weertman, Simkje Sieswerda, Joos Bloo, Thea van Asselt, Marjon Nadort, Lotte Bamelis and Jill Lobbestael, I also want to thank for the help they provided with developing the treatments and the research into borderline personality disorder. Moreover, I would like to thank the research assistants and interns who have conducted many s­ tudies, and especially the patients who have taken part in the treatment and the research, without whom we could not have gained insight into these ­complex problems and their treatment. Ultimately, this book could not have come about without the opportunities offered by the Maastricht Community Mental Health Centre to the academic project of the Research Institute of Experimental Psychopathology of the Maastricht University, as well as the grants from the Dutch National Fund for Mental Health and the Fund for Developmental Medicine by the College for Care Insurances. Their grants enabled the training of the therapists for the multi‐center trial into treatments of borderline personality disorder and the conducting of this study, which empirically tested the effectiveness and cost‐ effectiveness of the treatment outlined in this book. Thanks are due to Kyra Sendt and Jolijn Drost for their help with translating the original Dutch book into the first English edition. Arnoud Arntz

Introduction

Until recently, patients with borderline personality disorder (BPD) were known as particularly difficult patients. They were viewed as patients who either could not be helped by therapy or, in the best‐case scenario, showed low success rates to treatment. Meanwhile, their demands on both medical and mental health care are great and their dropout rates from treatment programs are high. In this book we describe a treatment for patients with BPD, which, in most cases, leads to recovery from this disorder or substantial clinical improvement. Schema therapy (ST) not only leads to a reduction in BPD symptoms, but also to lasting changes in the patient’s personality. In Chapter 1, BPD is defined and described, followed by a discussion of the development of this disorder. Chapter  2 gives an explanation of ST for BPD, developed by Jeffrey Young. The treatment is based on the schema mode model. The different schema modes for patients with BPD are described in this chapter. In Chapter 3 we explain the aims and different phases of the therapy. Chapters 4–8 discuss different treatment methods and techniques. Chapter 4 involves seeing the therapeutic relationship as an instrument of change. Also the essential concept of “limited reparenting,” a central point of ST, is discussed at length.

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

2

Schema Therapy for Borderline Personality Disorder

Chapter 5 describes experiential techniques that use experiencing to bring about change. These techniques are: imagery rescripting; role playing; the two‐or‐more‐chair technique; and experiencing and expressing feelings. The cognitive techniques used in this book are described and explained in Chapter 6. As there is a great deal of literature about these techniques, they are only briefly defined. This is also the case for the behavioral ­techniques described in Chapter 7. Chapter  8 deals with a number of specific therapeutic methods and techniques. While these are not relevant for all BPD patients, they can be important and useful for specific patients and applications. Chapter 9 explains which techniques are the most appropriate to each schema mode. The art of addressing different modes in a single session is also discussed in this chapter. The latest developments in the field of ST are explained in Chapter 10. In particular, Group‐ST, and ST with couples where one of the two partners has BPD, are discussed. We also briefly discuss the application of ST in day treatment and inpatient settings, the use of nonverbal therapies as adjunct to ST, and the application of ST for children and youths, and older people. Chapter 11 deals with the final phase of therapy during which the patient no longer has BPD, but perhaps retains some of the personality characteristics and/or coping strategies, which could stand in the way of further ­positive changes. Chapter 12 contains the summary and conclusion. Considering that a large percentage of BPD patients are female, the authors refer to the patient in the feminine form. Although many therapists are female, for the sake of clarity the authors refer to the therapist using the masculine form.

1

Borderline Personality Disorder

What Is Borderline Personality Disorder? Patients with borderline personality disorder (BPD) have problems with almost every aspect of their lives. They have problems with constantly changing moods, their relationships with others, unclear identities, and impulsive behaviors. Outbursts of rage and crises are commonplace. Despite the fact that many BPD patients are intelligent and creative, they seldom succeed in developing their talents. Often their education is incomplete, and they remain unemployed. If they work, it is often at a level far below their capabilities. They are at a great risk of self‐harm by means of self‐ injury and/or substance abuse. The suicide risk is high and approximately 10% die as a result of a suicide attempt (Paris, 1993). In this book, the DSM‐5 diagnostic criteria for BPD are used for the diagnosis of BPD and not the psychoanalytical definition of the borderline personality organization (Kernberg, 1976, 1996; Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989). The borderline personality organization includes a number of personality disorders and axis‐I disorders and is therefore far too extensive for the specific treatment for BPD that will be described here. According to the DSM‐5, patients must satisfy at least five of the nine criteria, as listed in Table 1.1, to obtain a diagnosis of BPD. The essential general feature of the DSM‐5 definition of BPD is instability and its influence on the areas of interpersonal relationships, self‐image, feelings, and impulsiveness. Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Schema Therapy for Borderline Personality Disorder

Table 1.1  DSM‐5 diagnostic criteria for borderline personality disorder A pervasive pattern of instability of interpersonal relationships, self‐image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self‐mutilating behavior covered in criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self‐image or sense of self. 4. Impulsivity in at least two areas that are potentially self‐damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self‐mutilating behavior as covered in criterion 5.) 5. Recurrent suicidal behavior, gestures or threats, or self‐mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress‐related paranoid suicidal ideation or severe dissociative symptoms. Source: After: American Psychiatric Association (APA, 2013) DSM‐5.

Prevalence and Comorbidity BPD is one of the most common mental disorders within the (outpatient and inpatient) clinical population. Prevalence in the general population is estimated at 1.1–2.5% and varies in clinical populations depending on the setting, from 10% of the outpatients up to 20–50% of inpatients. However, in many cases the diagnosis of BPD is made late or not given at all. This might be due to the high comorbidity and other problems associated with BPD, which complicate the diagnostic process. The comorbidity in this group of patients is high and diverse. On axis‐I, there is often depression, eating disorders, social phobia, PTSD, or relationship problems. In fact one can expect any or all of these disorders in stronger or weaker forms along with BPD. All of the personality disorders can be co‐morbid to BPD. A common combination is that of BPD along with avoidant, dependent, narcissistic, antisocial, histrionic, and paranoid disorders (Layden, Newman, Freeman, & Morse, 1993).



Borderline Personality Disorder

5

Reviews and studies by Dreessen and Arntz (1998), Mulder (2002), and Weertman, Arntz, Schouten, and Dreessen (2005) have shown that anxiety and mood disorders are treatable when the patient has a comorbidity with a personality disorder. However, in the case of BPD, one must be careful to only treat the axis‐I disorder. BPD is a serious disorder that results in permanent disturbance of the patient’s life with numerous crises and suicide attempts, which makes the usual treatment of axis‐I disorders burdensome. Axis‐I complaints and symptoms often change in nature and scope, making the diagnostic process even more difficult. This often results in the treating of BPD taking priority. Disorders that should take priority over BPD in treatment are described in “(Contra‐) Indications” (see Chapter 2).

Development of BPD The majority of patients with BPD have experienced sexual, physical, and/or emotional abuse, and emotional neglect in their childhood; sexual abuse in particular between the ages of 6 and 12 (Herman, Perry, & van der Kolk, 1989; Hernandez, Arntz, Gaviria, Labad, & Gutiérrez‐Zotes, 2012; Lobbestael, Arntz, & Bernstein, 2010; Ogata et al., 1990; Weaver & Clum, 1993). It is more problematic to identify emotional abuse and neglect in BPD patients than to identify sexual or physical abuse. Emotional abuse and neglect often remains hidden or not acknowledged by the BPD patient out of a sense of loyalty toward the parents or due to a lack of knowledge of what a normal, healthy childhood involves. These patients don’t know what they missed, because they never experienced feelings of being loved, accepted, and cared for. When someone tries to give them love and acceptance later in life, they sometimes react negatively toward that person (i.e., the therapist). These traumatic experiences in combination with temperament, i­ nsecure attachment, developmental stage of the child, as well as the social situation in which things took place, result in the development of dysfunctional interpretations of the patient’s self and others (Arntz, Weertman, & Salet, 2011; Zanarini, 2000). Patients with BPD have a disorganized attachment style. This is the result of the unsolvable situation they experienced as a child, in which their parent was both a menace or threat, as well as a potential safe haven (van IJzendoorn, Schuengel, & Bakermans‐Kranenburg, 1999). Translated into cognitive terms, a combination of dysfunctional schemas and coping strategies results in BPD (e.g., Arntz et al., 2011). Patients with BPD have a very serious and complex set of problems. Because the patient’s behavior is so unpredictable, it exhausts the sympathy

6

Schema Therapy for Borderline Personality Disorder

and endurance of family and friends. Life is not only difficult for the patients, but also for those around them. At times, life is so difficult that the patient gives up (suicide) or her support system gives up and breaks off contact with the patient. Treating BPD patients is often also fatiguing for the mental health care giver, especially in the absence of effective treatment methods. The good news is that effective treatments have been developed the last decades, and schema therapy is one of the most successful. Schema therapy offers BPD patients and therapists a treatment model in which the patient is helped to break through the dysfunctional patterns she has created and to achieve a healthier life. The model helps patients and therapists to understand how early childhood experiences are related to the present problems and offers grip on the otherwise overwhelming and difficult to understand problems. Treating BPD patients with schema therapy makes it relatively easy to comprehend the patient’s dysfunctional behavior and it gives the therapist many tools to treat the patient.

2

Schema Therapy for Borderline Personality Disorder

The Development of Schema Therapy for Borderline Personality Disorder Before the development of specialized psychotherapies for BPD, such as schema therapy (ST), BPD was treated primarily from a psychoanalytical perspective. This started to change in the late 1980s when cognitive behaviorists began to study the treatment of personality disorders with cognitive behavioral therapy, and psychodynamic therapists started to develop variants of psychodynamic therapy that were specifically adapted to BPD. The most important early developments in specialized psychotherapies for BPD that emerged in this era were the formulation and empirical validation of Dialectical Behavior Therapy (DBT; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, 1993), the development of Transference‐Focused Psychotherapy (TFP) (Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989), the development of Mentalization Based Treatment (MBT, Bateman & Fonagy, 2004), and the development of cognitive therapy for personality disorders. The use of cognitive therapy for treating personality disorders was first introduced by Aaron Beck, Arthur Freeman, and colleagues in their work Cognitive Therapy of Personality Disorders (1990). In that same year, Jeffrey Young introduced a new form of cognitive ­therapy, which he referred to as “Schema‐Focused Therapy,” later “Schema Therapy” (Young, 1990, 1994). He later expanded upon this therapeutic model with the introduction Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Schema Therapy for Borderline Personality Disorder

of schema modes (Young, Klosko, & Weishaar, 2003). His theory is based upon a combination of insights derived from cognitive, behavioral, psychodynamic, humanistic, and developmental (including attachment) theories. The actual treatment is mainly based on cognitive behavioral therapy and techniques derived from experiential therapies. There is a strong emphasis on the therapeutic relationship which is used as a means to bring about change, as well as on the emotional processing of traumatic experiences. To date, ST appears to be a good method to achieve substantial personality improvements in BPD patients.

Research Results Research on traditional psychoanalytical forms of treatment showed high dropout percentages (46–67%) and a relatively high percentage of suicide. Across four longitudinal studies, approximately 10% of the patients died during treatment or within 15 years following treatment due to suicide (Paris, 1993). This percentage is comparable to that of nonpsychotherapeutically treated BPD patients (8–9%: as reported by Adams, Bernat, & Luscher, 2001). The first controlled study of cognitive behavioral treatment for BPD was realized by Linehan et al. (1991). The DBT they introduced had lower dropout rates, fewer hospitalizations, and a greater reduction in self‐injury and suicidal behavior in comparison with usual treatment. On other measurements of psychopathology, there were no significant differences when compared with usual treatment. Uncontrolled studies as to the effectiveness of Beck’s cognitive therapy also showed a reduction in suicide risk and depressive symptoms, as well as a decrease in the number of BPD symptoms (Arntz, 1999; Beck, 2002; Brown, Newman, Charlesworth, Crits‐Christoph, & Beck, 2004). Moreover, the dropout rates during the first year were lower than normal (about 9%). The first controlled study testing ST as developed by Young was conducted in the Netherlands, where ST was compared to TFP, a psychodynamic method from Kernberg and co‐workers (Giesen‐Bloo et al., 2006). This study started in 2000 and involved 3 years of treatment. ST showed more positive results than TFP in reduction of BPD symptoms, as well as other aspects of psychopathology and quality of life. In the follow‐up study, 4 years after the start of the treatment, 52% of the patients who started ST recovered from BPD, compared to 29% in TFP, while more than two‐thirds of ST participants showed



Schema Therapy for Borderline Personality Disorder

9

clinically significant improvement in reducing BPD symptoms, compared to 52% in TFP. These percentages are impressive given that dropouts (even those due to somatic illness) were included in the study. One of the most compelling results from this first randomized clinical trial (RCT) was that all BPD problems were reduced and not only conspicuous symptoms such as self‐harm. For instance, the patient’s quality of life as a whole and her feeling of self‐esteem improved significantly. Thus, as a result of ST, all psychopathological characteristics of BPD, whether symptomatic or personality related, significantly improved. Similar results were found in a Norwegian series of case studies. When patients were measured post‐treatment, 50% no longer met the criteria for BPD and 80% appeared to have notably profited from the treatment (Nordahl & Nysæter, 2005). Despite the high treatment costs, this first RCT on ST also demonstrated that ST is cost‐effective, as evidenced by a cost‐effectiveness analysis showing that ST is not only superior to TFP in effects, but also less costly. Moreover, compared with baseline, ST leads to a reduction of societal costs for BPD patients, so that the net effect was a reduction of costs, despite the costs involved in delivery of ST (van Asselt et al., 2008). The question whether ST has similar effects when implemented in ­clinical practice was addressed in a study by Nadort et al. (2009). Results indicated that effectiveness and treatment retention were similar to those of the Giesen‐Bloo et al. (2006) trial. The study also addressed the issue whether therapists should provide a phone number that patients could use when in crisis outside office hours, as was originally prescribed by the protocol. As the results did not yield any evidence for a positive effect of this, providing such a phone contactability was deleted from the protocol. As will be seen, giving patients an email address that they can use to share experiences with their therapist outside office hours, without any obligation of therapists to respond immediately, has replaced the phone contactability. There have been several studies completed now on ST for BPD (see Jacob & Arntz, 2013 and Sempertegui, Karreman, Arntz, & Bekker, 2013, for reviews), including studies on group‐ST (Farrell, Shaw, & Webber, 2009), the combination of individual and group‐ST (Dickhaut & Arntz, 2014; Fassbinder et al., 2016), and inpatient ST (Reiss, Lieb, Arntz, Shaw, & Farrell, 2014). Taken together, these studies indicate low dropout from treatment and high effectiveness of ST, that is not limited to BPD‐­symptom reduction, but includes better social and societal functioning, better ­quality of life, and increased happiness. When dropout from ST for BPD is compared to other treatments, a multilevel survival meta‐analysis i­ ndicated

10

Schema Therapy for Borderline Personality Disorder

that the dropout percentages reported so far in ST studies are remarkably smaller than those from other treatments (Arntz et  al., 2020). The ­effectiveness of ST on measures of BPD‐severity and specific BPD‐traits is also high and the effect sizes tend to be significantly higher than in other treatments (Rameckers et al., 2020). However, so far only one larger RCT has been published that compared ST to another treatment (Giesen‐Bloo et  al., 2006). It is necessary that more RCTs compare ST to other treatments, including treatment as usual and other specialized psychotherapies. One large international study comparing the combination of individual and group‐ST, group‐ST, and (optimal) treatment as usual for BPD was just completed when this book was finalized. The preliminary results indicated that ST was superior to treatment as usual in primary and secondary outcomes, and that especially the combined individual–group format was effective and associated with the highest treatment retention (Wetzelaer et al., 2014; Arntz et al., 2019). Another study that is currently underway is a German study comparing the combination of individual and group‐ST to DBT as treatments for BPD (Fassbinder et al., 2018). Both RCTs include not only focus on effectiveness, but also study cost‐effectiveness and experiences of patients. What makes ST so acceptable for patients and what might explain its effectiveness? Qualitative studies into the views of patients and therapists have yielded some suggestions (de Klerk, Abma, Bamelis, & Arntz, 2017; Tan et al., 2018). First, the schema mode model is often mentioned as very helpful, offering both patients and therapists an easy to understand model of the patient’s problems. This offers a meta‐cognitive understanding to patients and helps therapists to choose the right technique. Second, the therapeutic relationship, more specifically limited reparenting, is mentioned as particularly helpful. Third, experiential techniques are mentioned as ­particularly powerful. Fourth, on a more general level, the ST approach that focuses on deeper levels than symptoms and skills, linking developmental experiences and life‐long patterns to problems in the present, and addressing the historical roots of the patient’s problems, is appreciated. Lastly, patients don’t mention specific issues that are not focused on enough in ST, this in contrast to the findings by Katsakou et al. (2012), who concluded that patients found the focus of DBT and MBT too limited. However, some patients criticized that the newer ST models start to reduce session frequency in year 2, and stop treatment after 2 years, which is often viewed as too early. As to the comparison of group‐ST to the combination of individual and group‐ST, patients and therapists tend to favor the latter (from the results of



Schema Therapy for Borderline Personality Disorder

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the quantitative analysis of the international RCT we will learn whether this tendency is supported by treatment retention and effectiveness results). To summarize, the results of empirical studies indicated that ST is a highly acceptable and effective treatment, which is cost‐effective despite its relative high intensity.

(Contra‐) Indications There are certain disorders that can complicate the diagnosis of BPD, in particular bipolar disorder, psychosis (this refers to psychotic disorder, not a short‐term and reactive psychotic episode, which often occurs in BPD patients), and ADHD. The presence of these disorders complicates not only the diagnosis but might also interfere with treating BPD. However, if these disorders are very prominent, they will be the primary diagnosis, and BPD will be usually viewed as a secondary comorbidity. Usually these disorders have to be addressed first, before it is possible to focus on treating BPD. Specific comorbid disorders, even if they are not viewed as primary, must be addressed before ST can be considered for BPD. These include very severe major depression, severe substance dependency in need of clinical detoxification, and anorexia nervosa. In addition, developmental disorders such as autism spectrum disorders require adaptation of ST. Recently therapists who work with these patients reported that they do have success with treating personality disorders with modified ST in this group when the autistic problems are not too severe. Research on ST for people with the combination of an autism spectrum disorder and a personality disorder has been conducted (Vuijk & Arntz, 2017). It should be stressed that the aim of such applications of ST is not to treat the autism spectrum disorder, but rather the personality disorder problems. In the study by Giesen‐Bloo et al. (2006), antisocial personality disorder was also excluded. This was insisted upon by the TFP experts. However, pilot studies using ST with antisocial personality disorder have shown positive results, as an RCT comparing ST to treatment as usual in high security forensic hospitals, indicating ST can be an effective treatment for these patients (Bernstein, Arntz, & de Vos, 2007; Bernstein et al., 2020). However, for group application of ST for BPD, the inclusion of patients with specific comorbid antisocial personality traits might constitute a risk, if these patients cannot control their aggressive impulsive and act out in unpredictable ways to other group members. Thus, a history of recent lack of control

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over interpersonal physical aggression might be a contraindication for group‐ST for BPD. Similarly, specific narcissistic traits, manifested as poorly controlled denigrating others, are a risk for group‐ST.

Rationale of Treatment/Theories Supporting Treatment ST as described by Young states that everyone develops schemas during childhood. A schema is an organized knowledge structure, which develops during childhood and manifests in certain behaviors, feelings, and thoughts (Arntz, 2018; Arntz & Lobbestael, 2018). While a schema is not directly measurable, it can be gauged by analyzing the patient’s life history and observing the manner in which she deals with her temperament and talents. This becomes more evident and observable as the patient shares more details about her behavior in various social situations and the life rules and strategies to which she adheres. Healthy schemas develop when the basic needs of a child are met. This enables children to develop positive images about other individuals, themselves, and the world as a whole. The basic needs of children include: Safety – Children must be able to depend on a reliable adult for care and a safe place to live, develop, and grow. Connection to others – Children must feel that they are connected to others and are able to share their experiences, thoughts, and feelings with others. Autonomy – Children must have a safe and secure environment from where they can explore and learn about the world. The ultimate goal of maturing to adulthood is for them to eventually stand on their own two feet. Caregivers must slowly but surely allow children to separate from them in order to grow into autonomous adults. Self‐appreciation – Children must have an adequate sense of appreciation. In order to develop a strong sense of self‐esteem, they must be appreciated for who they are as people and what they are capable of doing. Self‐expression – The expression of one’s opinions and feelings must be learned and stimulated without being held back by strict or oppressive rules. Realistic limits – In order to live in a society with others, it is necessary for children to learn certain rules. They must understand when to subdue their autonomy or self‐expression when dealing with others and be



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c­ apable of doing so. Children also have to learn to tolerate and adequately deal with frustrations (Young & Klosko, 1994; Young et al., 2003). When these needs are not met, whether solely due to shortcomings in the child’s environment, or in combination with traumatic events (such as emotional, physical, or sexual abuse, or being bullied), this can form—in interaction with the temperament of the child—dysfunctional schemas and coping strategies (see Figure 2.1). The dysfunctional schemas that are formed during childhood development are called “early maladaptive schemas.” Given the circumstances in which the child grew up, they are usually understandable (e.g., a child growing up in an environment where there is a lot of threat of abandonment has an increased risk to develop an abandonment schema). Young describes 18 different early maladaptive schemas (see Appendix I) and three groups of coping strategies (see Appendix J) (Young et al., 2003). The schemas and coping styles form a sort of alternative for the personality disorder diagnostic system in the DSM‐5 (American Psychiatric Association [APA], 2013). For BPD, so many schemas have been found that a treatment based solely on a schema conceptualization would be very complex. Moreover, the 18 schemas and three coping styles lead to 54 possible combinations, further complicating the task to understand the patient’s problems with this model. Parental influence

Temperament

Traumatic experiences

Basic needs are not fulfilled

Disfunctional schemas Complaints and problems Disfunctional coping styles

Figure 2.1  The development of dysfunctional schemas

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Schema Modes Patients with BPD often have so many different schemas present at the same time that both patient and therapist cannot see the wood for the trees. Because shifts in behavior and feelings take place so quickly, it is difficult for the patient herself, let alone for those around her, to understand what is taking place. This further exacerbates an already complex problem. These sudden shifts in patterns of feeling, thinking and behavior, which are so common in BPD, have inspired the development of the concept of a “schema mode” (also called “mode” or “schema state”) (McGinn & Young, 1996). A schema mode is a set of schemas and processes, which, in certain situations, determine the thoughts, feelings, and actions of the patient at the cost of other schemas. In other words, when the BPD patient is relatively relaxed and comfortable, one sees a totally different side of her personality as opposed to when she feels threatened. Under normal circumstances, one sees a relatively quiet patient who appears to have few emotions. However, when, for example, the threat of abandonment by an important figure is posed, one sees a “young child” being very upset and completely inconsolable. A patient with BPD can switch from one strong mood or emotion to another in a very short period of time. According to the schema mode model, this is due to the patient’s continual and uncontrolled shifts from one mode to the other. It is important to understand that schema modes are related to schema’s, and that there is no fundamental difference between schema theory and schema mode theory. The schema model as formulated by Young et  al. (2003) states that when an early maladaptive schema is triggered, or is threatened to be triggered, people use specific ways of coping to deal with this activation, as the activation is usually experienced as highly unpleasant and signaling threat. The ways of coping are grouped in three coping styles: overcompensation, avoidance, and surrender—analogous to the primitive coping under high stress common to mammals (fight, flight, freeze). The combination of a schema that is (threatened to be) triggered and a coping response is a schema mode. In other words: Schema → Coping → Schema Mode. Two studies have actually supported this model, in that they demonstrated that coping indeed determines how modes are related to schemas (in statistical terms: the coping style mediates the relationship between



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schemas and modes) (Rijkeboer & Lobbestael, 2012; van Wijk‐Herbrink et al., 2018). The last study even went one step further, demonstrating that the very same early maladaptive schemas can underlie internalizing as well as externalizing psychopathology, and that it depends on the type of coping, hence the schema modes, whether a (threatened) schema activation results in internalizing or externalizing psychopathology: Schema → Coping → Schema Mode → Psychopathological Symptom(s). Thus, in the phase of case conceptualization (see Chapter  3) it is ­ eaningful to combine the mode model as described below with the m ­specific schemas that give “color” to the mode of your individual patient. When patient A is in the abandoned/abused child mode she might feel ­stupid (schema defectiveness/shame) and distrustful (schema mistrust/ abuse) while patient B might feel abandoned (schema abandonment/­ instability) and dependent (schema dependence/incompetence). Young suggested that the following five modes are characteristic of BPD: the detached protector, the abandoned/abused child, the angry/impulsive child, the punitive parent, and the healthy adult (actually, a weak healthy adult mode). Recently an extra important mode has been added to the model: the happy child mode, which is also weak in BPD. In some cases, we also see an undisciplined or impulsive child, which we will describe in ­combination with the angry child. These modes can be renamed to make them more applicable to the patient’s situation (see Figure 2.2). In clinical practice we advise to make a more extensive case conceptualization in which the origins of the schemas and modes in the youth and the current problems are described. In each mode the specific schema’s that give “color” to the mode of your individual patient are added (see Figure 2.3 for an example). We must strongly emphasize that this heuristic model does not infer that BPD is a multiple personality disorder. Giving names to the different modes is a means of helping the patient to better understand and identify with the mode and does not have any reference to identities or persons. The following are descriptions of the different modes most prominent in BPD. The modes are also demonstrated in a recent audiovisual production (ST step by step, van der Wijngaart & van Genderen, 2018). Chapter  9 further describes treatment and how therapists can best address the ­ ­different modes.

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Healthy adult

Punitive parent

Happy child

Detached protector Angry-impulsive child Abandoned/abused child

Figure 2.2  Borderline personality disorder: six modes

The detached protector When the patient is in the detached protector mode, the patient seems relatively mature and calm (See ST step by step 5.08). A therapist could assume the patient is doing well. In fact, the patient uses this protective mode in order to avoid experiencing or revealing her feelings of fear (abandoned/abused child), inferiority (punitive parent), or anger (angry/ impulsive child). The patient also doesn’t look happy or relaxed (happy child). Underlying assumptions that play important roles here are those of: it is dangerous to show your feelings and/or desires and to express your opinion. The patient fears losing control of her feelings. She attempts to protect herself from the alleged abuse or abandonment. This becomes particularly evident as she becomes attached to others. The protector keeps other people at a distance either by not engaging in contact or by pushing them away (the detached



Schema Therapy for Borderline Personality Disorder Positive figures: Aunt and grandmother

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Healthy adult

Happy child Behaviour father: Aggressive alcoholic

Peers: Bullied and excluded

Detached protector (schemas) (e.g. Subjugation. emotional inhibition)

Family rule: Don’t show your feelings or opinions

Behaviour mother: Anxious, submissive abandons family

Punitive parent (schemas) (e.g. Mistrust/abuse, emotional deprivation) You are worthless You deserve to be punished You don’t deserve any help or attention

Feels almost nothing,

Angry/impulsive child (schemas) (e.g. Mistrust/abuse) Abandoned/abused child (schemas) (e.g. Mistrust/abuse, abandonment, emotional deprivation) I am stupid, helpless, unattractive, and lonely

Current problem lonely and depressed

Current problem difficult relationship

Temperament of the child: Intelligent sensitive

Current problem anxiety

Figure 2.3  Borderline personality disorder: an example of a case conceptualization linking modes with the origins in youth, schemas, and current problems

protector can become an angry protector (see ST step by step 5.11) or a bully and attack mode (see ST step by step 5.13 and 5.14)) or belittle them by denigrating them (self‐aggrandizer see ST step by step 5.12)). Should others discover her weaknesses, the patient would face potential rejection, punishment, and/or abandonment. Moreover, if the patient would allow to fully feel emotions and emotional needs, the dysfunctional modes to the right of the “wall” in Figure 2.2 might get activated, which is a frightening prospect for the patient, as she does not know well how to deal with that. Therefore, it is better to not feel anything at all and keep others from getting too close to her, and to prevent emotions to be felt.

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The therapist should try to find a special name for the detached p ­ rotector of Nora. A lot of patients call their protector a wall or a shield. This helps to make clear what the function of this mode is.

Sample dialogue with a patient in the protector mode (In this example and following dialogues, “T” is therapist and “P” is patient.) T: How are you doing? P: (with no emotion) Good. T: How was your week, did anything happen that you would like to talk about? P: (looks away and yawns) No, not really. T: So, everything’s OK? P: Yeah, everything’s OK. Maybe we could have a short session today?

Should simple methods of avoiding painful emotions prove ineffective, she may attempt other manners of escape, such as substance abuse (such actively soothing emotional pain is called a self‐soother mode), self‐injury (physical pain can sometimes numb psychological pain), staying in bed, dissociation or attempting to end her life. BPD patients often describe this mode as an empty space or a cold feeling. They report feeling distanced from all experiences while in this mode, including therapy. If the patient is not successful at keeping people at a distance, she can become angry and cynical in an attempt to keep people away from her. It is important for the therapist to recognize these behaviors as forms of protection and not be put off by them. If this angry–cynical state is very pronounced, it can be distinguished as a separate “angry protector” mode. The patient could even attack the therapist (the bully and attack mode) or she can disagree with the therapist in a condescending way (the self‐aggrandizer). It is sometimes difficult to distinguish the angry protector or bully and attack mode from the punitive parent, especially during the initial stages of the therapy. One manner of distinction is to observe the direction of the patient’s anger. While the angry protector’s anger is directed toward the therapist (or someone else), the punitive parent’s anger is directed toward the patient herself. If the therapist is unsure of the mode he is presented with, he can simply ask the patient if she is able to disclose which “side” of her personality is currently active.



Schema Therapy for Borderline Personality Disorder

Sample dialogue with patient in the angry protector, the bully and attack mode, the self‐aggrandizer, and the punitive parent mode (See ST step by step 5.11, 5.12, 5.13, 5.14, and 5.20) T: When I told you that I have the next week off, your reaction was pretty angry. What mode do you think that reaction came from? Response from angry protector: P: Oh No! We’re going to have another lecture about that stupid borderline model of yours? You couldn’t wait, could you? Can’t think of anything, better can you? T: I think your angry protector mode is activated because you feel to be left alone the next week. P: Do you really think you’re that important for me? I do not need anybody. Response from a bully and attack mode: P: I see that you do not really know what you’re talking about. You only pretend to be a good schema therapist. T: (he has a tendency to defend himself) I really think I know which side of you is this. P: O you are such a loser if you talk like that. T: I do not like it when you talk to me like that. ­ rofessional P: (laughing) Now you are insulted huh? That is not very p behavior. Response from a self‐aggrandizer: P: I am not angry at all. I am only irritated because you have planned your holiday at the wrong time. Exactly before my holidays. Can’t you postpone your holiday? T: No, I’m not going to do that. Which side of you thinks I should adapt to you? P: Should I explain ST to you? I thought that limited reparenting was the core of your therapy. If you really think that I am important you would postpone your holiday.

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Schema Therapy for Borderline Personality Disorder Response from punitive parent: P: I don’t know which “side” of me this is. I only know that I must have been a complete idiot to trust you and that is one mistake I won’t make again. It doesn’t matter anyway; I’ll never get better and I don’t deserve to get better. T: I think I hear the voice of your punitive parent mode. Maybe that side says that you make a fool of yourself by having sad or angry feelings. P: That’s not my punitive parent mode, but a fact. It is childish behavior when you only have 1 week holiday.

In the beginning of the therapy, the subtle differences between the angry protector or bully and attack mode and the angry child can also be difficult to distinguish. The differences are primarily evident in the level of anger that is paired with the reaction (see the section “angry/impulsive child”), and in the intention underlying the anger. Whereas, with the angry protector, the intention is to keep others away to protect oneself for being abused, rejected, or abandoned, with the angry child the intention is to protest against maltreatment by others and to get recognition for one’s (interpersonal) needs. These examples involve the protector expressing herself in an active manner. The completely opposite form in which the protector may express herself is by exhibiting tired or sleepy behavior. In this case the therapist must assess whether or not the patient is actually tired or whether she is in the protector mode. There is the risk that while in the protector mode, the patient may avoid therapy and not work on her problems with a serious chance of her s­ topping therapy all together. The patient can also have problems with ­dissociative symptoms, self‐injury, addiction to numbing substances (e.g., drugs or alcohol), or may attempt suicide. Because of this, it is important to identify when the protector mode is present and bypass it. This will give the patient an opportunity to work on her actual problems. How to recognize a detached protector mode during a session The patient is not making real contact with the therapist The patient doesn’t show emotions, even if she talks about emotional experiences



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The patient doesn’t want to talk about her problems The patient is rationalizing The patient is angry or arrogant in a controlled way in order to keep you at a distance The patient talks a lot about nothing The patient is complaining about physical problems extensively The patient whines (seems to cry, but the therapist doesn’t feel empathy) The patient is completely worn‐out without a clear cause The patient always wants to talk about actual problems and expects an immediate solution The tone of voice is flat

The abandoned/abused child The abandoned/abused child is often referred to as “Little …” (= the name of the patient). In our examples, we refer to the patient as Nora. Therefore, when in this mode she becomes “Little Nora.” Little Nora is sad, desperate, inconsolable and often in complete panic (See ST step by step 5.01). When in this mode the patient’s voice itself often changes to that of a child. Her thoughts and behavior become that of a four‐ to six‐year‐old. She feels alone in the world and is convinced that no one cares about her. The basic belief in this mode is that she can trust no one. Everyone will reject, abuse, or eventually abandon her. The world is a threatening, dangerous place that holds no future for her. Little Nora thinks in terms of black and white. She demands constant and immediate reassurance and solutions to her problems. She is incapable of helping herself. There is a great chance that during the first phase of the therapy, the therapist will face Little Nora mainly in situations of crisis. In the early stage of the therapeutic process, it is unlikely the patient will show her abandoned child side at other moments (for a sample dialogue, see Chapter 9, “Treatment Methods for the Abandoned and Abused Child”). When the patient is in this mode, she latches onto the therapist in the hope that he holds the solutions to all of her problems. She expects complete and constant comfort and compassion from him. During this mode the therapist often feels overwhelmed by the patient’s expectations of him. In an attempt to address her cries for help, he can have the tendency to look for practical solutions far too quickly. On the other hand, he may also attempt to rid himself of the patient by referring her to a crisis center too

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quickly. When Nora is in a panic, all practical solutions appear unfeasible. Little Nora cannot comprehend that the crisis will ever come to an end. Nora’s feelings of desperation and the therapist’s feelings of incompetence will only become greater if the therapist continues to advise practical solutions. Should she be referred on too quickly, Little Nora becomes even more desperate as she feels misunderstood, abandoned, and rejected. The therapist must allow Little Nora’s presence in these sessions. He must be supportive of her, validate her feelings, offer a safe haven, encourage her to bond with him as a therapist, and address her past abuse. In short, he must offer her what she was most likely denied during her childhood. How to recognize the abandoned/abused child during a session The patient is overwhelmed by sad or anxious emotions The patient is helpless The patient acts as if she is totally dependent on the therapist The patient wants the therapist to solve her problems The therapist empathizes a lot with the patient The tone of voice is of a little child (sad or panicky) The therapist experiences a strong emotional appeal to solve the ­emotional pain of the patient and to not abandon her.

The angry/impulsive child The other child mode in BPD is that of the “angry/impulsive child.” The beginning of therapy is often overshadowed by desperation (Little Nora) and shame (punitive parent). Because of this, one does not often see the angry/impulsive child in the beginning of the therapy. Angry Nora is a furious, frustrated, and impatient young child (approximately 4 years of age) who has no regard or consideration for others (See ST step by step 5.02). When in this mode, the patient is often verbally and, at times, physically aggressive and acrimonious toward others including her therapist. She is incensed that her needs are not met, and her rights go unacknowledged. Angry Nora is convinced it is better to take all you can, or you will end up with nothing at all. She is convinced she will be taken advantage of. She is not only furious, but also wants everyone to see just how badly she has been treated. She does this by attacking others (verbally or physically), hurting



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herself, attempting to kill herself, or even others, as a form 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 b ­ uying, 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.

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Table 2.1  Examples of impulsive behavior Spending too much money Run up debts Impulsive, unprotected sex Quit your job suddenly Alcohol and drugs abuse Get pregnant without a plan

Shopping without a plan. Buy too many or too expensive things in order to comfort yourself Having impulsive sexual contact with someone who is nice to you, while in fact you are looking for attention and love When you have a problem at work and you feel treated unfair, you immediately conclude that this is not the right job Using too much alcohol and drugs too much because you don’t care about the consequences 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.”



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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: P: T: P: T: P:

How are you doing? (in an angry voice) Bad. Why is that, did something bad happen? No, I did something stupid and now everything is ruined. So, things are not going well with you? No, I’m hopeless and now I’m bothering you as well.

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Schema Therapy for Borderline Personality Disorder

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 The 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.



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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).

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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 ­ etter change, many patients feel that their personality changed, that they are b capable of dealing with intimate as well as professional relationships, and



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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 c­ hannels: 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 so that it is clear which 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

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Schema Therapy for Borderline Personality Disorder

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

* Behavioral experiments * Role playing skills * Problem solving * Trying out new behavior

Within therapy

* Limited reparenting * Empathic confrontation * Setting limits * Role switching therapist/patient

* Socratic questioning * Formulating new healthy schemas and strengthening the Healthy Adult Mode * Schema dialogue * Flashcards * Positive logbook * Self‐monitoring Circle * Recognizing patient’s schemas and modes in the therapeutic relationship * Pro’s and con’s Coping Modes * Challenging ideas about therapist * Self‐disclosure

Past

* Imagery rescripting * Role‐play past * Two‐or‐more‐ chair technique * Writing letters * Imagery or role‐play about situations in the near future * Two chair technique: dialogue between dysfunctional (old) modes and the Healthy Adult

Future

* Reinterpretation of past events and integration into new schemas * Historical test * 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

* Behavioral experiments * Strengthening functional behavior * Training skills related to the therapeutic relationship * Modeling by therapist * Testing of new behaviors on key individuals from the past * Testing of new behaviors on new contacts * Making new friends * Explore and try out new activities (e.g., education or work)

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33

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. 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

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Schema Therapy for Borderline Personality Disorder

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, email is a good option for both to maintain 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,

Treatment

35

“‘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 2 3 4

starting phase and case conceptualization; crisis management; treatment phase: therapeutic interventions with schema modes; 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,

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Schema Therapy for Borderline Personality Disorder

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,

Treatment

37

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 technique Questionnaires

Behavioral:

• •

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

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Schema Therapy for Borderline Personality Disorder

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 possible changes. Downward arrow technique  A cognitive technique that helps to gather more information about the schemas of the patient is the downward arrow technique which is extensively described in the literature on Cognitive Therapy. Therefore, this technique is only briefly summarized here. When a patient formulates thoughts about themes that seem very important to explain the problems, the therapist can ask questions about the meaning of this thought. So, he doesn’t start to explore or evaluate the evidence for this thought, but he asks, “what does this mean to you?” If the answer is not clear he repeats this question a few times. Most of the time the patient is not able to identify the underlying schema instantly, so the therapist can ask some more questions to reveal this. At first, he explains to the patient that he empathizes with her negative thoughts and feelings, but he also explains that he has some more questions to understand the problem of the patient even better. He could use the following questions:

• • • •

if this is really true so what? What’s so bad about …? What’s the worst part about …? What does that mean about you (others)?

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39

The therapist can stop with this downward arrow technique when he discovers an important core belief on schema level and/or the patient shows a negative shift in affect. Questionnaires  To assess the patient’s schemas and modes, the Young Schema Questionnaire (YSQ; Young, 1999), the Schema Mode Inventory (SMI; Lobbestael, van Vreeswijk & Arntz, 2008) and other questionnaires are completed by the patient along the first few sessions. The results are discussed with the patient. The Young Parenting Inventory can be helpful in clarifying factors that have influenced the development of the modes. The Borderline Personality Disorder Severity Index (BPDSI) is a structured interview that assesses the seriousness and frequency of BPD symptoms and expressions that meet DSM‐IV criteria and have been experienced within the previous three‐month period (Arntz et  al., 2003; Giesen‐Bloo et al., 2006; Giesen‐Bloo, Wachters, Schouten, & Arntz, 2010). With the help of the BPD checklist the patient can indicate to what extent her BPD symptoms have been a burden to her in the past month (Bloo, Arntz, & Schouten, 2017). The Personality Disorder Beliefs Questionnaire (PDBQ) includes a subscale with statements specifically relating to BPD (Arntz, Dreessen, Schouten, & Weertman, 2004). From the Personality Beliefs Questionnaire (PBQ) a series of items specific to BPD have been derived (Butler, Brown, Beck, & Grisham, 2002). When the patient has a high score in the YSQ or SMI, you can be sure that this is an important problem. But be aware of the fact that questionnaires can give incomplete or biased information. Because of the personality problems, patients might be unwilling to reveal specific information, might present a too good picture of themselves to be true, or might over‐ report problems. Patients might not be aware of specific modes or schemas, they might misinterpret items, or respond in a way they think is desirable. Patients with strong overcompensating modes usually don’t report an abandoned/abused child mode (or any vulnerable child mode), which is actually predicted by schema mode theory, as overcompensating modes have the function to make the patient believe that he or she is the opposite (Bamelis, Renner, Heidkamp, & Arntz, 2011). Fortunately, questionnaires are not the only way to gather information about the schemas and modes of the patient. Thus, the therapist is recommended to use all kinds of information in the collaborative formulation of the mode model, including the patient’s request for help, her description of current and past problems, current and past relationships, study/work history, her

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Schema Therapy for Borderline Personality Disorder

developmental history, file information, including from past treatments, and the patient’s behavior during the sessions. A schema or a mode might also appear during experiential techniques such as imagery, or when there is a “decompensation,” when the situational triggers are so strong that they cannot be avoided or overcompensated anymore. If an exceptionally large number of modes (or schemas) is reported by the patient, the therapist should try, in collaboration with the patient, to pick the most important ones, so that the mode model remains surveyable. Another possibility is to combine two modes that have a similar function into one mode. The “abandoned/abused child mode” and the “angry/impulsive child mode” are actually examples of such mergers (see Figure 3.1). The feedback of the results of the questionnaires can best be integrated in the conversation about the complaints and experiences. By delving into an experience of the patient, the discussion of a schema or mode is more involving. Discussing the schemas must encompass more than just stating the names of the schemas or modes and the scores. Educating the patient on how an activated schema or mode feels, helps the patient to recognize the relevant schema or mode and she experiences that the therapist understands her (ST step by step 1.02 and 6.06).

Adult Nora

Happy Nora Punitive parent The wall

Angry Nora Little Nora

Figure 3.1  Case conceptualization Nora

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41

Information from the therapeutic relationship  In order to make the patient feel safe and understood from the very first session, the therapist takes a friendly, open, and not distanced position (see Chapter  4, “Limited Reparenting”). He spends a lot of time with the current problems of the patient and empathizes with her feelings. He examines, in conjunction with the patient, which situations trigger intense emotions. Further, he also looks at how she usually deals with her problems and in how far this is helpful in solving them. He informs himself about the patient’s expectations toward the therapy and the therapist and asks for previous experiences with therapy. Often the patient has already had experience with a number of different therapies, which produced limited results or even a damaging effect, for instance broken trust (sometimes even sexual abuse) of the patient by the therapist. Therefore, the therapist must be aware that the patient might distrust him in advance. He explains how far the patient’s expectations can be met in the therapy and what the general rules are (see discussion in Chapter 4). The therapist is very attentive to the way the patient treats him. From the behavior of the patient he can gather information about the schemas, modes and the coping strategies of the patient. The process of treating a BPD patient seldom begins with a calm conversation of information collection and case conceptualization. One should not be surprised when this process of information gathering is more of a rollercoaster as opposed to a quiet drive in the country. Often from day one it is clear that the patient is not comfortable or in a state to embark on a constructive relationship with the therapist. The development of a therapeutic relationship and the gathering of information will be discussed in the next chapter. Experiential techniques  The patient’s personal history is mapped and put into relation with the emergence of the schema modes. The therapist analyses which experiences in the past have contributed to the current problems. This is often not easy to find out in a more cognitive way. Here, it is recommended to use a short imagery exercise to examine the link between the past and the present (see Chapter 5) or a two chair technique (see Chapter 6). We recommend using imagery at least one or two times in the phase of case conceptualization. In this way the patient can discover links between her present problems and her schema modes or between her past and her schema modes (See ST step by step 1.03) If the patient is unable to imagine unpleasant events from the past, the therapist can also suggest an imagery with her father and/or mother. The instruction is that it doesn’t have to be an

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Schema Therapy for Borderline Personality Disorder

uncomfortable situation but can be a neutral or typical situation. Usually this imagery can also give relevant information for the case conceptualization. Case conceptualization  Together the therapist and patient create a case conceptualization based upon the mode model (see Chapter  2). The different modes are described to the patient in terms she can understand and identify with (see Figure 3.1). They link the different modes with relevant experiences from the past and current complaints (see ST step by step 1.04 and 1.05) It is recommended to link the relevant schemas to each mode in order to understand which schemas are triggered when a mode is active. Especially when the abandoned/ abused child is triggered it is relevant to know that in patient X the mistrust/abuse schema is most prominent and in patient Y defectiveness/shame is the central issue. This gives the therapist extra information about the content of the limited reparenting. It is important that the most important problems and BPD‐traits of the patient can be understood as manifestations of the modes. There is no one‐ to‐one relationship of specific BPD symptoms to modes. The therapist and the patient should collaborate in finding out what the function of the symptom is, before the symptom can be linked to a mode. For instance, self‐ injury or a suicide attempt can have different functions, for example:

• • • •

to punish oneself for a certain behavior or for having an emotional need (then it is a manifestation of the punitive parent mode) to distract from emotional pain (then it is a manifestation of the detached protector mode) to signal despair and alarm others that they should take care of the patient—a cry for help (then it is manifestation of the abandoned/ abused child mode) to make others feel guilty about how they treated the patient—as an act of revenge (then it is a manifestation of the angry child mode).

Even in the same patient, the same symptom may have different functions, depending on the triggers and the context, and should therefore be linked to different modes. Apart from symptoms and other problems having a function, symptoms and problems can also be consequences. For example, a low mood may be the consequence of being so often in the detached ­protector mode that there are too few positive experiences in the patient’s life, in which case the low mood should be connected to the detached ­protector mode.

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43

BPD patients usually have many problems and symptoms, therefore the therapist should not strive for completeness. It suffices to place the most important problems and symptoms in the mode model, keeping the ­problems that the patient experiences as most debilitating in mind. The therapist creates a mode model together with Nora, with names for the modes that best suit the patient’s experience, (Figure 3.1). They ­gradually expand this model with the relevant schemas and the elements from her childhood that are the cause of the problems (Figure 3.2). Explaining the  treatment rationale  Once a diagnosis of BPD has been established, the therapist begins to explain the rationale behind the therapy by means of the BPD model and its modes (see ST step by step 1.06). He explains how the patient’s current problems are connected to schemas and Grandmother caring and loving

Healthy adult

Happy child Family rule: We don’t talk about feelings

Bullied at school

Father agressive Punitive parent You are worthless (defectiveness shame) If you don’t obey you will be punished (Mistrust abuse) If you fail it is your own fault (Failure)

The wall (Detached protector) It is dangerous to show your feelings (Emotional inhibition) Do not connect to people because finally they will leave you or hurt you (abandonment)

Problems with intimate relations

Mother is passive doesn’t protect the children

Angry nora Angry about the abuse and deprivation Little nora I am worthless and incompetent (Defectiveness and failure) Nobody loves meand I will always stayalone (Emotional deprivation abandonment)

Problems with work

Anxious in contact with other people

Figure 3.2  Mode model with schemas and historical roots Nora

Sensitive and intelligent child

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Schema Therapy for Borderline Personality Disorder

modes. He further explains how each schema mode brings along with its certain feelings, thoughts, and behaviors (see Appendix A: ST for patients). For a more in‐depth explanation, the patient can refer to a number of relevant chapters in Breaking Negative Thinking Patterns (Jacob, van Genderen, & Seebauer, 2015) or Reinventing Your Life (Young & Klosko, 1994). Most BPD patients find the experience of learning about the borderline model enlightening. It offers a clear explanation as to why they experience sudden mood swings and have so little control over their behavior (see Chapter 9, “A Simultaneous Chess Play in a Pinball Machine”). It also offers them the hope that change is possible and that they are not doomed to a life filled with uncontrolled behavior and mood swings. If the patient finds that this model is not appropriate to her situation, there are usually three possibilities: one is that the individual simply does not have BPD. The second one is that important modes are overlooked, in which case these have to be added to the patient’s mode conceptualization. The last possibility is that despite the person having BPD, there is also a very strong protector mode at work. Because of this protector, everything the therapist says is considered to be dubious and unreliable. A variant of this is when the patient recognizes parts of the model, but denies other parts, for example, the punitive parent mode, as acknowledging that mode is yet too frightening. If the latter is the case, the therapist must take more time in building a trusting relationship with the patient and not dwell upon attempting to convince the patient of the schema model.

Crisis management Crisis management can be skipped when there is no crisis present at the beginning of the therapy. However, for BPD patients it is recommended to make a crisis management plan together with the patient and to relate this to the modes. Different modes can be active in different crises and might need different actions. The (short‐term) risks of a crisis should be discussed with the patient. The actual handling of a crisis is returned to later in the therapy in case it occurs. Should a crisis be present, it indeed requires the highest attention (see Chapter 8, “Crisis”).

Treatment phase: therapeutic interventions with schema modes This is the central phase of therapy and has a duration of about a year (see Chapters 5–10). The general goals of this stage are

Treatment

• • • • • • •

45

Learn to recognize when one of the modes is active Reassure, and gradually replace, the Detached Protector Empathize with and protect the Abandoned/Abused Child, to help the Abandoned/Abused Child to receive love, and to help this mode to emotionally process the memories of abuse, neglect, and abandonment Fight against, and expunge, the Punitive Parent Re‐channel the Angry and Impulsive Child to express emotions and needs appropriately and reaffirm child’s basic rights Encourage the Happy Child to spend more time on enjoyable things Help patient to incorporate the Healthy Adult mode, modeled after the therapist

The first phase of therapy aims at teaching patients to recognize their modes. One can also teach the patient to recognize her modes by a “mode guessing game” (see ST step by step 1.07). The therapist explains that he will play how the patient behaves when she is in a specific 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

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Schema Therapy for Borderline Personality Disorder

the mode that is “talking” from the tone of voice of the patient in c­ ombination 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 vulnerTable 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 Harsh, negative

I am okay. No nothing special happened. I think we can have a short session today. I had a bloody awful week, everything went wrong. I am such a fool. I had a terrible week. I felt sad and lonely. I am afraid that my friend is going to leave me.

Detached protector Punitive parent Abandoned/ abused child

Everything goes wrong. Everybody is against me. Starts mentioning a lot of examples of negative experiences in which he/she was treated unfair. 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.

Angry child

Sad, anxious, panicky with a childlike tone Angry, loud, incoherent Calm, shows emotions in an appropriate way

Healthy adult

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47

able 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. 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.

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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.

Frequently Asked Questions About Treatment Should I use a mode model, or can I also use a schema model? Given that most borderline patients sore high on almost all schemas we advise to use a mode model. You can add the information about the schemas by explaining which schema is present in each mode (see Figure 3.2). How much time do you spend creating a case conceptualization? Creating a case conceptualization usually takes around five sessions. In exceptional cases, especially if the patient is very distrustful, it can take more time. If there is a strong angry protector who rejects working with a mode model, it can also take more time to make a case conceptualization. It may be necessary to gain the patient’s trust first. Or it may be helpful to explain to the patient that her behavior is a survival strategy that hinders working on the problems. A role play with role reversal can sometimes be very enlightening. You must realize that the case conceptualization is always a working model. If new relevant information emerges during therapy, the case conceptualization can be adjusted. What can I do when the patient is still in panic or desperate at the end of the session? You can offer the patient some support outside the session like calling her later that day or letting her sit in the waiting room. An interesting observation is that most patients automatically go into their detached protector when they leave the room of the therapist at the end of a session in order to stop the bad feelings.

4

The Therapeutic Relationship

Creating a safe, trusting relationship will take a lot of time, energy, and commitment from the therapist as most BPD patients have a long history of relationships in which neglect, abuse, and exploitation took place. It is sad to say but some of these negative experiences are regrettably with therapists or other health care professionals. Because of this, therapists must spend a great deal of time and energy in creating a safe, trusting therapeutic relationship with their patients. In addition, many patients have experienced relationships with therapists that were, though not abusive, not good or that came to a premature end. It is important for the therapist to have a great deal of patience as well as the support of a good peer supervision group. In comparison with other forms of psychotherapy, this treatment demands a great deal of both time and involvement. Therapists must, on the one hand, be unusually involved with their patients while at the same time maintaining the ability to set their own boundaries and in doing so protecting those of their patients. Therefore, therapists have to be aware of their own (dysfunctional) schemas and coping styles and must be able to deal with them in a healthy way. In the following paragraphs we illustrate important elements of the therapeutic relationship between the BPD patient and the therapist.

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Limited Reparenting Limited reparenting can be viewed as a form of restricted parenthood in which the therapist’s demeanor forms the basis for the therapeutic process. In other words, the therapist goes into this relationship as if he were a parent figure for the patient. Please take note of the words “as if.” It is not the intention of this therapy for the therapist to become the parent but rather help model appropriate parental behaviors and reactions. The therapist starts therapy with the understanding that he is prepared to invest two years (or more if necessary) in working with the patient. At times the therapist might have to invest extra time in the treatment of the patient, for example, when there is a crisis. When treating BPD patients, we recommend that the therapist remains easily accessible to the patient. If the therapist is able to help the patient himself during a crisis, not only will this help to alleviate the crisis in a timely fashion, but it will also strengthen the relationship with the therapist. We no longer recommend telephone accessibility outside office hours, as research didn’t demonstrate a large enough effect of this to maintain it in the protocol. Email is a good alternative, as patients often feel connected to the therapist when writing and sharing their problems. It is not a good idea to check your email 24 hr a day, and you should explain this to the patient, including that when there is a crisis that needs professional intervention, and you cannot be reached (e.g., it is outside office hours), the patient should use the usual crisis facilities. Upon completion of her therapy, Nora stated that simply knowing she was able to contact her therapist in the event of a crisis was very important to her. It gave her the feeling that she was valued and cared about. During her 2 years of therapy, Nora called her therapist 10 times during office hours; 8 of these 10 times were during the first year. By providing a patient with a telephone number to use in the event of a crisis or suicide attempt, the therapist is not providing 24‐hr care for his patient. The therapist is making himself available by means of, for example, his voicemail or an email address on which the patient can leave a message describing the seriousness of her situation. In this manner the therapist is on the one hand temporarily unavailable (e.g., at a concert/theater, sleeping, or away for the weekend), but on the other hand the message system provides the patient with experiencing an immediate connection with her therapist. For some patients simply hearing the therapist’s voice on the voicemail offers enough reassurance to help them through whatever crisis is at hand. If there is an acute crisis requiring immediate attention and the therapist is not available,



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the patient can follow the protocol discussed during the first sessions. This will require her to turn to others for help such as her general practitioner or a crisis center. Limited (re)parenting implies that the therapist fosters the neglected components of the patient’s past. He offers direction when the patient is incapable of addressing a problem and sets limits when necessary. The therapist will work with her in developing and improving her abilities and encouraging her to develop her autonomy and responsibility. In the last phase of therapy, when the patient has to become more autonomous, the role of the therapist has to change from a parent of a small child to a parent of an adolescent. So, his attitude changes from fulfilling the needs of the patient in a very caring way, to a more coaching attitude. As a coach he encourages the patient more and more to find her own solutions and bring in her own healthy adult. In time, the patient will internalize the role the therapist plays by building healthier schemas and strengthening the healthy adult mode, which will in turn help her to build a new life. The different elements that are involved in limited reparenting are described in the following paragraphs.

Good care The therapist must be able to offer more than the average amount of involvement when dealing with a BPD patient. Good care means connecting with the patient’s experience. It also means that the therapist talks to the patient in a warm, reassuring manner. If the patient is in the vulnerable child mode, the therapist must realize that on an emotional level the patient is still a child. The patient is overwhelmed by emotions that have to do with experiences from her past. It helps if the therapist considers what he would say if he was actually facing a child who is panicking or sad. You do not immediately come up with practical solutions, but you give recognition for the feeling and experience of the patient. If the patient has calmed down, you can possibly make connections with past experiences and, if necessary, think along about more practical matters (see Schema Therapy Step by Step 2.01). The therapist must be prepared to continue this care for a long period of time. As with every parent–child relationship, this will not always be easy or pleasant for the patient nor for the therapist. This is often further exasperated by the expectations of the patient. Because her basic needs were not met during her childhood, BPD patients tend to have high expectations of their therapists. Therefore, the therapist must have a clear idea as to what he

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will and will not do for the patient and he must communicate these limits in a clear way (see the section “Setting limits”). The manner in which this is done differs between therapists and is a regular subject during peer supervision meetings. Therapists who have this above‐average willingness to make the extra effort with this rather demanding therapy, often have the tendency to exceed their own limitations (or allow their limits to be broken) too long before setting limits. At these moments there is an increased risk of burnout or boundary‐exceeding behavior like starting a nontherapeutic relationship with the patient. The therapist must remain very alert and aware that this is very damaging to the already severely damaged patient, as it repeats the pattern of abandonment and abuse. When the therapist comes to the conclusion that he either cannot or is unwilling to do something for the patient, he must tell the patient in a personal manner and not hide behind the rules and regulations of the institute or practice where he works (see the section “Empathic confrontation”). The frustrations that are hereby elicited during therapy are simply a normal part of the therapeutic process, just as frustrations are a normal part of the childrearing process. The therapist can help the patient deal with these frustrations in an appropriate manner (see Chapter 9, “Treatment Methods for the Angry Child,” “Treatment Methods for the Undisciplined/Impulsive Child”).

Giving direction Just as a parent gives advice and counsel to his children, the therapist also gives advice and opinions to encourage healthy development of the patient. He also intervenes when he believes that the patient’s behavior could be damaging. This can take place when the patient engages in behaviors that interfere with therapy (e.g., missing many sessions) or when the patient refuses to talk about relevant topics during sessions. The therapist can make the patient aware of these behaviors and help to link the behaviors with the schema modes that are responsible for them. Further, he can attempt to motivate the patient to change these behaviors. Damaging behaviors outside of therapy must also be addressed or one runs the risk of these behaviors interfering with any positive development in the sessions. Examples of damaging behaviors are substance abuse, unhealthy or irregular eating, or continued involvement with friends/partners who are abusive. The therapist must be aware of the fact that his advice will not lead to immediate change in reality. But nevertheless, he must go on with explaining to the patient how she can organize that her needs will be met in a better way (see Schema Therapy Step by Step 2.02). If the patient is involved in life‐threatening behaviors or behaviors that threaten others, these must take priority. The therapist explains which



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mode leads to this behavior and how the patient can stop it. If necessary, he can help the patient to think of alternative behaviors. Should these actions not lead to an acceptable reduction in these behaviors, the therapist can refer back to limit setting (see “Setting limits”). Once the damaging behavior is identified and stopped, the therapist should continue to ask the patient about this damaging behavior (e.g., How is she doing? Is she still “clean”?) until he is absolutely certain that the problem is no longer an issue. When a patient has problems with her relationships, the therapist should first attempt to get an idea of the other person involved. He can ask, for example, that she brings her partner to a session. If the patient does not want to involve her partner in therapy or her partner does not want to participate in therapy, the therapist must respect this choice and rely on information obtained from the patient in order to get an idea of the partner and the situation. If the therapist thinks that the partner has a good influence on the patient, he can help them solve their relationship problems and use psychoeducation about BPD. By educating the patient’s partner about BPD, the therapist can help him better understand what is going on during difficult periods. Together they can discuss what to do to help prevent conflicts from escalating and how they can work together to solve crises. If necessary, the partner can come regularly and participate in discussions about the dysfunctional schemas. However, sometimes it is clear that the partner does not have the patient’s best interests at heart and is actually trying to hurt the patient. This is particularly evident when abuse and/or mistreatment is taking place. This results in the patient continuously re‐experiencing the painful issues of her past and the therapist must help protect the patient and advise her to leave her partner.

Empathic confrontation The therapeutic relationship is not only a safe haven for the patient but must also serve as a source of change. Once a safe, close relationship has been developed between therapist and patient, the therapist can begin to confront the patient with the consequences of her behavior. When doing this it is important that the therapist addresses his own feelings that the patient evokes in him by her behavior during the sessions or by her descriptions of her behavior outside of therapy toward others. Firstly, he explores whether his reaction is based on the patient’s behavior or that his own dysfunctional schemas are the underlying cause for his reaction (see the sections, “Therapists’ Schemas” and “Self‐Disclosure”). After making sure that his own dysfunctional schemas are not interfering with his reaction, he must confront the patient in a friendly, personal but very clear manner. He is careful that it is the behavior that he rejects, without rejecting the patient as a

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person. He should not hide behind abstract rules or norms (e.g., r­ egulations of the institution where he works or a professional code of ethics), but rather deliver this message in a very honest and personal manner.

Sample dialogue: empathic confrontation t: Nora, I notice that you are asking me to support you in the way you behaved last week toward the woman whose house you are cleaning. But I get the feeling that you want to force me into supporting you and that you will not allow me to have an opinion that differs from yours. This is very annoying for me. It makes me not say what I’m really thinking, but at the same time I know that when I do that, I’m not helping you. p: (angry) Oh great, so you think I dealt with that woman wrong too? Now you also think I’m an idiot! t: No, that’s not what I’m trying to tell you. I meant that because of the manner in which you try to force me into agreeing with your point of view, I don’t dare to share my real opinions with you. This would create a distance between us if it continues and I don’t want that to happen. p: (after a short silence … sad) Maybe you don’t want that, but I feel like you’re walking out on me too! t: Yes, I understand that, and I think what is happening between us now is something which often happens when people don’t agree with you. You become very defensive and feel rejected and before you know it, you’re right in the middle of your punitive mode and you think that everyone who doesn’t agree with you thinks you’re an idiot and rejects you. I do understand your reaction though. In the past you were never allowed to have your own opinion and your father would make you out to be a fool whenever you said anything. But you have to realize that you’re in a different s­ ituation now. I don’t think you are stupid or a fool. I think that sometimes you deal with things well and other times not so well and I want to be able to tell you this without feeling forced into agreeing with you in everything. So, I would like to ask you not to isolate ­yourself and shut me out, but to try to discuss the matter with me in a calm and relaxed way.



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After confrontation, the patient will often become emotional and ­ ossibly experience the confrontation as punishment. In the example p mentioned, Nora initially feels angry and this is replaced by a feeling of sadness. The therapist should first pay attention to these expressed ­emotions. He should then explain why he confronted her with her behavior. After she has been confronted in this manner, there should be an opportunity to analyze why this happens to her so often and how this behavior is linked to the modes and underlying schemas. One can further analyze how and why these ideas were developed and can begin replacing them with more functional views and schemas. Nora eventually ­developed new beliefs, “if someone disagrees with me, that means they disagree with my ideas, not with me as a person.” In this way her underlying schema of not trusting people could slowly be broken down and replaced with more functional schemas. In a later phase of therapy, the patient can also develop new skills to cope with conflicts (for instance practice assertive skills) (see Schema Therapy Step by Step 2.03).

Setting limits When empathic confrontation is not enough to stop dysfunctional behavior, the therapist can consider setting a limit. It is imperative in good parenting that clear limits are set in time. There are two kinds of limit setting: a direct way and a “step by step” way. When there is direct threat for the patient, the therapist or someone else, the therapist has to stop the patient immediately. He can try to do this in a calm and firm way and try to connect to the angry child that threatens to violate the rules. Sometimes the violation is developing too fast and then he has to take action in the way he always would do in a critical situation. In addition to general limits on abuse, violence, and suicide, there are also personal limits. In this case the therapist can set limits in a “step by step” way. As personal limits differ for each therapist, there are no set guidelines on personal limits. However, the therapist is not meant to set too many limits or to do this too quickly. Setting limits is generally necessary when there is behavior involved that is unacceptable to the therapist or that could severely hinder the therapy. Initially, the therapist is easy‐going and flexible as a good therapeutic relationship has to be established. Once this has been accomplished, the therapist’s approach changes gradually later on in therapy. In most cases other interventions and empathic confrontation are enough to change problematic behavior. The therapist should only decide to

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start with limit setting in the way we describe here, when he really feels that he must stop the therapy if the patient refuses to change her behavior. Topics that often result in limit setting are: 1 Too much out‐of‐session contact or too many cancelations/missed sessions. 2 Unrealistic expectations regarding the nature of contact. For example, the patient stalks the therapist, intruding in the therapist’s private life. 3 Impulsive or destructive behavior such as threatening the therapist or threatening to destroy items in his office and/or engaging in self‐ destructive behaviors. And of course, threatening to harm other persons (especially partner or children). 4 Abuse of medication or other substances. For a detailed list of examples of transgressing behavior, refer to Table 4.2. With due observance of professional codes of ethics, the rules and regulations of the institute where the therapist works, and the law, each therapist will have his own personal boundaries. For example, a female therapist may have fewer apprehensions about putting her arm around the shoulders of a female patient compared with a male therapist. However, even here, personal choices are very often different and deliberation with a peer supervision group or a supervisor is imperative in case the therapist considers limit setting. On the one hand, there is a group of therapists who set too few limits. The members of the peer supervision group must be careful that these therapists do not offer too much extra attention to the patient or do so for too long of a period of time. Some therapists may be too distanced and uncaring due to their fear of setting limits or due to an emotional inhibition schema. Therapists who are too distant, might be concerned that the patient will begin to ask for more and more and eventually overwhelm them. They might also be afraid of conflicts or feel unable to set limits, resulting in a detached stance toward the patient. In this way these therapists avoid situations where they would need to set limits. On the other hand, there are also therapists with a schema like unrelenting standards or punitiveness who want to set a limit too quickly. Much of the irritating behavior of the patient comes from punitive or protective modes and must be tolerated by the therapist for quite a long time in order to change this in a therapeutic way. It is not the purpose of a peer supervision group to force their norms and values on its members. What one therapist may experience as exceeding his



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personal boundaries may be quite normal to another therapist. It is ­important that the therapist does not undertake anything with a patient that he is incapable of providing, or that is damaging to the patient. He also should not start with serious limit setting before consulting a supervisor or the peer supervision group. By far the single most important reason for setting limits is the safety of both patient and therapist. When the therapist sets too few limits the patient will, having experienced too many transgressions in her childhood, possibly continue her boundary exploration. This can be damaging to the patient, for example, when the therapist does not set limits on self‐injury. On the other hand, it can also be damaging to the therapist in both a physical and psychological sense. This might result in the therapist’s motivation to move on with therapy being strongly reduced. In this way the patient is again abandoned and thus one of her traumas for which she sought help is repeated. When the relationship between the therapist and patient becomes too close, the therapist may not dare to frustrate the patient enough. This results in her inability to build frustration tolerance. In a worst‐case scenario, the relationship develops into a personal friendship and is no longer therapeutic. If the therapist feels that his boundaries have been crossed, he must immediately make this clear to the patient in a personal, nonpunitive manner. Usually the patient does not know that the therapist has problems with her behavior. The patient has a similar level of understanding as a child who at her birth does not know what her parents will and will not allow. Once the therapist explains the situation to the patient, he must also give her the opportunity to change her behavior. Usually this suffices to set the boundary.

Sample dialogue: setting limits Nora drinks too much alcohol and she even sometimes drinks before she comes to the sessions. The drinking problem also makes things worse outside the session. In the beginning of therapy, the therapist has discussed this problem at lengths and together they have discovered that drinking was a part of the detached protector, because it numbs her feelings. She did diminish her drinking to a certain level for a few months, but then it starts again. The therapist tries to

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Schema Therapy for Borderline Personality Disorder c­ onvince this detached protector to stop drinking again by way of the two‐chair technique and he did imagery work to fight the punitive parent mode that increases the need of the protector. But whatever the therapist tries, Nora does not stop drinking. The therapist feels powerless to do anything about it and he cannot go on with the therapy when Nora does not stop abusing alcohol. T: Nora, I am afraid that nothing that we tried to help you to stop with drinking helped. You still drink too much and you even come to sessions under the influence. I am worried about it, because I cannot reach Little Nora often enough. And the effects of our work in treatment will fade away as the alcohol use interferes with the consolidation in your memory of the experiences in therapy. This means that when you continue to drink too much, our efforts are for nothing. And I also start feeling a little bit helpless too. N: I tried so hard, but it is too difficult for me to stop drinking. I feel so lonely and depressed between the sessions and then I start drinking again. This helps me to numb my feelings. T: I know that it is not easy but drinking helps you to numb your feelings in the short time, but it will get worse in the long run, because you lose contact with me. I need your healthy adult to take a little bit more responsibility. I want you to come to session sober because this makes me helpless. N: So, you are angry with me. T: No, I am not angry, but it is true that I do not know what to do next when you go on behaving like this. So, I want you to stop drinking alcohol at least from the evening before the session. N: I do not want to give you this feeling and I do not know if I will succeed, but I promise to find a way to come to session without drinking beforehand.

After setting limits the therapist discusses which modes the patient ­experiences as an effect of the limit setting. In the case of Nora, the punitive parent may respond with something like: “You’ve made another big mistake and deserve to be punished.” Little Nora then becomes scared that the therapist will leave her. Angry Nora could become angry, feeling she is again



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being treated unfairly, because her therapist expects her to give up the only way, she can protect herself. Finally, the detached protector would probably decide to not attend the next session at all. The therapist can then discuss one or more of the possible reactions per mode in an appropriate manner (see Chapter 9). He should also discuss which mode made the patient transgress. Should Nora continue drinking before the sessions, despite her good intentions, it could be the punitive parent who says, “You are a failure and will never succeed in changing your life and bad habits.” Unfortunately setting limits is not always straightforward. It is a good idea to have a plan of steps ready that can be followed when setting limits. This should include how you set the limits, how they will be tightened,and what the consequences will be if the border is crossed again. In Table 4.1 such steps are described. The word “consequence” may be associated with punishment. However, in this instance it is used to indicate an implication of continuing the transgression, to help the patient realize that stopping the behavior is a serious requirement of the therapist, not a punishment in the sense of letting the patient experience she is a bad person or a person with bad intentions. All consequences must be naturally connected to the transgression as well as being feasible. It is important that setting limits is a process that builds up and offers the patient the opportunity to change her behavior. Because of this, all necessary steps are fully described in Table  4.1, finally ending with the most severe consequence, which would be the termination of Schema Therapy and refer her to another treatment. Consequences administered in limit setting must take place gradually with the constant opportunity for change. For instance, repeated drinking should not immediately result in canceling the session. This would be an example of a very serious sanction and would not allow the patient the opportunity to change her behavior. Examples of appropriate steps and sanctions can be seen in Table  4.2 (see Schema Therapy Step by Step 2.04). Please insert Table 4.2 here Make sure not to follow through the sanction before the patient has first been given the opportunity to follow the limit set; but if necessary, administer the sanction. Just as a parent must follow through with sanctions in childrearing, so too must the therapist. As in childrearing, not doing so will result in more transgressing behavior. Should the consequences not be helpful, a break in therapy will give the patient time to think and eventually choose whether or not she wishes to continue with the therapy. Often the enacting of consequences is unnecessary

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Table 4.1  Steps in limit setting 1. Explain the rule; use personal motivation. when patient repeats the transgression: 2. Repeat the rule; show your feelings a little, repeat personal motivation. when patient repeats the transgression: 3. As above; announce consequence (don’t execute yet!). when patient repeats the transgression: 4. Execute sanction. when patient repeats the transgression: 5. As above; announce stronger consequence. when patient repeats the transgression: 6. Execute stronger consequence. when patient repeats the transgression: 7. Announce temporary break in therapy so that patient can think it over. when patient repeats the transgression; 8. Execute temporary break in therapy so that patient can consider whether she wants the present therapy with this limit. when patient repeats the transgression: 9. Announce end of treatment. when patient repeats the transgression: 10. Stop treatment and refer the patient. Based on Young (personal communication) and Arntz (2004).

as the patient will adjust her behavior once she is made aware of it. It is ­seldom that things go so far that there must be a break in therapy or therapy must be stopped. In the case of alcohol abuse of Nora, a temporary referral to drug/ alcohol rehabilitation may be unavoidable. In practice, most therapists have a tendency to wait too long to set limits. A therapist who does not set limits in a timely fashion may end up guilty of emotional distancing from his patient or may secretly blame the patient for his own dissatisfaction and react in an overly irritated manner. This can also result in the premature ending of therapy. In most cases limit setting does have a very good effect on the patient and the relationship. A lot of patients in fact did not receive enough or unpredictable limits during their childhood. When the therapist sets limits in an empathic, but clear way it will show that he cares about the patient and it makes her feel protected and safe. However, therapists should realize that if they start to set limits, they must be willing to carry out the ultimate sanction, that is stopping therapy. Setting limits is a control strategy which



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Table 4.2  Possible consequences for violating limits Common limit violations

Possible appropriate actions

Missed sessions

* Reduce contact outside of sessions. *Limit the following session to discussing the situation of not attending sessions. Skip 1 week. *Do not compensate by allowing the session to go over time. *Shorten the session by the amount of time that the patient was late. *Limit the topic of the session to tardiness. *Reduce the session to a 10‐min discussion on tardiness. *Limit availability out of sessions to a regular moment in the day. *Limit length of each (telephone) conversation to a few minutes. *Limit number of available moments to a set number of times per week. *Ask that this be limited. *Ask patient to express herself using different words. *Ask patient to leave the room and return when her aggression is reduced. *Therapist leaves the room for a period of time. *Make agreements on reducing use to normal levels. *During the session, only allow discussions about reduction of substance use. *Shorten session to a 10‐min discussion about substance abuse and repeat agreements about normal levels of use. *Temporary referral to drug/alcohol rehabilitation; continue infrequent sessions. *Agreements on reducing use to normal. *Limit access to prescription refills (e.g., once a week). *Pick up medication from caregiver daily. *Ask patient to adjust her appearance in a less distractive manner (e.g., button her blouse). *Turn chair so that you cannot look at the patient as much. *Ask patient to go home, change clothes and return later. *Return present. *Tell patient that you will throw the present away the next time and return present. *Throw away present. *Ask patient to take present home with her.

Always arriving too late (tardiness)

Too much (telephone) contact outside of sessions

Aggressive behavior toward therapist

Substance abuse (drug and/or alcohol)

Medicine abuse Defiant or aversive appearance Little presents

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might lead to a power battle, in which the patient prefers to sacrifice the treatment instead of sacrificing a part of their autonomy. It is therefore ­recommended to use empathic confrontation for behaviors that therapists feel should change but are not so unacceptable or immediately dangerous that they should be stopped by this control strategy.

Role playing and role reversal Another way of confronting a patient with the effects of her behavior is by role playing with role reversal. This is particularly effective when an explanation of the effects of the patient’s behavior on the therapist alone is ineffective. The therapist proposes that they reverse roles and then actually stands up and physically changes chairs with the patient. The therapist can then, for example, role play the protector mode by saying that there is nothing to discuss and everything is just fine. The patient (now playing the role of therapist) must try to think of a way to convince the therapist (now playing the role of patient in the protector mode) to talk about his problems. Usually most patients are very good in the role of the therapist and realize what is taking place in the session and why the therapist is stuck (in this case, in the patient’s protector mode).

Imagery rescripting Imagery rescripting can be used to clarify a problem in therapeutic relationship. In imagery the patient could link her reactions and feelings toward the therapist to past experiences (see also Chapter 5).

Therapists’ Schemas This therapy requires a long‐term therapeutic relationship with patients who not only have very strong emotions themselves, but also arouse strong emotions in those around them. Because of this, it is of the utmost importance that the therapist has good personal insight and is aware when the behaviors of others are activating his own dysfunctional schemas. It is conceivable that the therapist is not confronted with such issues when he addresses short‐term symptom‐focused therapy. But as it is the therapeutic relationship that is an important means of change in this therapy, self‐ knowledge is essential. We will not go deeper into this subject in this book.



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Knowledge of literature on the subject (e.g., Beck et  al., 2004; Burns & Auerbach, 1996; Farrell & Shaw, 2018; Young & Klosko, 1994), personal (learning) therapy, and a supportive peer supervision group may be necessary to practice this therapy successfully. A number of the more common pitfalls encountered in dealing with schemas are listed as follows. The relevant schema and coping strategies are shown in parentheses after each problem (see Appendix I):

• • • • • • •

Waiting too long to set limits and/or setting too few limits and/or spending too much time with the patient outside of sessions (approval seeking/recognition seeking and/or self‐sacrifice). Thinking that you are not doing well enough (unrelenting standards/ hypercriticalness or failure). Not discussing missed sessions (schema avoidance by the therapist, such as abandonment or emotional deprivation. Perhaps the therapist is afraid that the patient will stop therapy altogether if he approaches this subject and he cannot allow her to abandon him). Muting strong emotions (vulnerability to harm or illness, or emotional inhibition). Abusing the patient in order to counterbalance/neutralize/negate own ­personal shortcomings (emotional deprivation, dependence/incompetence, or entitlement/grandiosity). Too cold and stand‐offish when the patient needs support and understanding (emotional inhibition). Overly critical when the patient makes mistakes (negativity, unrelenting standards/hypercriticalness).

The last three points in particular would render a therapist unfit for the practice of this therapy. BPD patients were denied understanding and support during their childhood and therefore require a great deal of both support and understanding from their therapist. A therapist who is overly critical and/or abuses the patient, reinforces the punitive mode, and is not able to offer emotional support to the little child mode of the patient. Should the therapist become aware that he has trouble maintaining a good/healthy therapeutic relationship with certain patients, he can make a function analysis of the therapeutic relationship (see Figure 4.1).

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Schema Therapy for Borderline Personality Disorder Activating event: Therapist is going on holiday (Abandonment)

Patient’s interpretation: He is leaving me (Abandoned child)

Patient’s behaviour: Crisis

Patient’s feelings: Fear, Despair, Dejection

Therapist’s interpretation: I am abandoning her It is my fault I must alert the crisis services

Therapist’s feelings: Fear, Guilt, Resentment

Therapist’s behaviour: Refer patient to the crisis services Worry during holiday

Figure 4.1  Example of functional analysis of the interaction between therapist and patient (from the therapist’s perspective)

Self‐Disclosure Telling something about yourself or your family can be a very useful way to give psychoeducation and strengthen the therapeutic relationship. Schema therapists tend to use self‐disclosure more often than therapists of other orientations (Boterhoven de Haan & Lee, 2014). Giving direct answers to questions of your patient will give her the feeling that you are taking her seriously and that you are transparent about your feelings and intentions. It builds trust. That does not mean that the therapist is obliged to give an answer to any question the patient can think of, but it means that you try to be as straight as possible. The therapist must try to find a balance between close contact, fulfilling the needs of the patient, which is necessary for therapy, while at the same time maintaining the necessary distance from the client. Should too much distance between the two occur, sharing something personal is a good manner of improving contact. This should take place at an appropriate moment in therapy and should involve a topic that the therapist himself is “finished



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with.” Therapists should never burden patients with issues that they are not finished with. In this manner, the therapist’s self‐disclosure of how he reacted to a difficult situation in his own life can be helpful in the therapeutic process. By doing so, the therapist carries out his role of setting an example for the patient by helping to put things into perspective and showing her that difficulties are not impossibilities. Also telling something about daily life can have a good effect to give an example of what is “normal.” It can help to “de‐pathologize” schema modes, for instance explaining with a personal experience that the detached protector is a normal reaction when there is a high level of threat and lack of possibilities to do something, helps patients to become less critical of themselves. The main goal must be that the therapist knows what he aims at and has a good idea about what unmet needs (of the patient!) are involved.

Example: Nora was afraid that the therapist would get very angry when she would cancel a session because of the wedding of a very good friend. So, she doesn’t tell the therapist that she doesn’t want to come to the next session but reports sick via the secretariat. When the therapist finds out what happened they discuss why the patient was so afraid. This was explained by her experiences with her very strict and punitive father. It was very helpful for her that the ­therapist understood this very well, because he also had a very strict father. He confessed that he had done that too during his adolescence. This was a relief for the patient and gave them the opportunity to discuss when excuses are useful and when you ­better could tell the truth.

Cognitive Techniques and the Therapeutic Relationship If in a therapeutic relationship it becomes clear that the patient has certain dysfunctional cognitions regarding the therapist (“he thinks I’m a whiner”) and the therapy (“I should have been finished with this therapy a long time

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ago”) that are recurrent, one should discuss this using a cognitive approach when possible (see Chapter  6). The patient addresses these subjects by challenging her cognitions during the sessions or outside of the sessions. During the session the patient can check if her ideas about the therapist are correct. This requires the therapist to be as transparent as possible in his answers and not just explore why the patient has these thoughts about him (see Table 4.3). Table 4.3  Cognitive diary on the therapeutic relationship Activating event

Therapist yawns

Feeling Thoughts Behavior Challenging my thoughts

Fear He thinks I’m a whiner. I don’t say anything anymore. What demonstrates that he thinks I’m so boring? He’s yawning. Any more evidence? He just looked at his watch. What other explanations could there be for this? He always looks at his watch a couple of times during the sessions because he wants to make sure that there’s enough time for me to talk about everything I want to discuss. But he never yawns. Maybe he’s tired, after all it’s almost his vacation time. What if he really thinks I’m boring, what would happen? I’m scared he will stop treating me. Does this make any sense at all given my previous experiences with him? No, when I ask him what he thinks, he tells me, and he has never said that he thinks I’m boring or given any indication that he’s considering ending therapy. He has said that sometimes I try too hard to tell everything in too much detail. Perhaps that’s what I’m doing now. That means I’m not boring, but perhaps my story is boring. The punitive mode causes me to think that it’s my fault and that I’m boring. The protector mode results in me not wanting to talk anymore. What would be a better way to look at this situation? There’s no way for me to know what he’s thinking when he yawns. It’s unnecessary to instantly conclude that his yawn is a result of me or my behavior. What would be a better way to solve this situation? I could simply ask him what he thinks about me and if he thinks I’m boring. Relief

What mode caused these thoughts? Desired reaction

Feeling



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Behavioral Techniques and the Therapeutic Relationship Behavioral techniques such as reinforcing desired behavior (in particular therapy‐enhancing behaviors) both within the therapy sessions as well as practicing these behaviors outside of the sessions are an important part of ST.

Example of behavioral techniques and the  therapeutic relationship Nora had the tendency to look out of the window when she spoke of something that she was ashamed of. Because of this, she missed out on important information, in particular the nonverbal behavior of the therapist. While she heard no rejection in his words, she thought she might see rejection in his face if she dared to look. He suggested that she should look at him more often and test if her theories were correct with the reality of what actually happened. After a while, she began to look at the therapist more often and sometimes even dared to share more of herself. The therapist can also encourage the patient to try out certain behavioral experiments on him during the session.

Example of behavioral experimentation in the  therapeutic relationship Every now and then Nora would test her therapist by seeing if he would give a negative reaction when she said that she didn’t understand something. She did this without telling her therapist. Only after she was confident that the dreaded rejection would not be a consequence, she told her therapist about her little experiment and was very surprised with the results. She wanted to know with certainty that the therapist did not think she was dumb.

The behavior of the therapist during the entire therapeutic process is that of a role model for the patient, with the therapist modeling healthy behavior for the patient. Assuming all goes well, he is an example of respectful, transparent, honest, interested, nonjudgmental, trustworthy, and balanced behavior. The goal is for the patient to take on and adjust the different aspects of the therapist’s behavior in order to develop into a healthy adult.

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Summary Creating a safe therapeutic relationship is the central point of this therapy. While applying experiential, cognitive, and behavioral techniques, the ­therapist continues to employ the described style of limited reparenting. Time and time again he will approach specific problems with a specific technique in a friendly but clear and determined manner, as this is also the best way to behave toward a child whom you want to teach something. He will balance the change of techniques so as not to overwhelm the patient on the one hand, and not under‐stimulate her on the other. For example, when by using imagination strong emotions are triggered, it is sensible to take a little extra time during the next session to discuss what happened in the previous session and give it a place in a cognitive sense. In the following chapters we will discuss the different techniques: ­experiential techniques in Chapter  5, cognitive techniques in Chapter  6, behavioral techniques in Chapter 7, and specific methods and techniques in Chapter 8. This is followed by how one should apply these techniques to the different schema modes (Chapter 9).

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Experiential Techniques

Therapeutic techniques that are directed at feelings (see Table  3.1)—also referred to as “experiential techniques”—have an important role in treating BPD with ST. Most of these techniques can be used in current situations as well as with experiences from the patient’s past or future. Because of this, the following paragraphs will address present, past, and future applications. The following sections on imagery rescripting and historical role play are based on a paper by Arntz and Weertman (1999). Further references to this article are not given but should be assumed. This paper also discusses the theoretical background of these methods.

Imagery During an imagery exercise the patient tries to recreate a certain situation in her mind. In doing so, she experiences as it were, what took place during interactions with others, and what her emotions are. When the imagery exercise is directed at the future the patient tries to create an image of a situation in the future. The therapist explains of course that we never can foretell whether the picture is realistic, but he stimulates the patient to think of the most likely situation and how it feels to act in it. Similarly, if patients doubt whether the memory of a past situation is accurate, the Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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therapist reassures the patient: the effectiveness of the technique does not depend on the degree of accuracy of the image. It can be helpful to explain to the patient that imagery work is the recommended technique in the treatment of nightmares, and that nightmares are generally fantasy (though they generally have themes that correspond to things that happened in reality). The therapist can also point out that any memory has subjective elements, and that it is the memory that influences the person, not the reality (which has not been consolidated in the person’s memory). Rescripting is later added when either patient or therapist feels that some aspects of the situation must be changed or altered.

Applications and aims of imagery In the beginning of therapy, imagery can be used when one is looking for a connection between the patient’s current schemas and events from the past. As therapy progresses and a safe therapeutic relationship has been established, imagery rescripting can be applied in the following situations:

• • • •

situations in which there was emotional, physical, or sexual abuse (this includes traumatic situations with peers such as bullying); situations in which the patient’s emotional, physical, or developmental needs were not adequately met; curtailment of autonomy or expressing emotions; “parentification” when the patient takes on the role of agent between parents (caregivers), or when the patient has to take care of (one of the) parents or brothers and sisters.

One of the most important goals of imagery rescripting is that the patient discovers that it is the situation in which she was raised that was “wrong”; instead of thinking she is “wrong.” So the child discovers that she is not guilty of the things that did go wrong in the situation in the past. Another important goal is the emotional processing of traumatic events. The schemas that the patient has developed based upon these inadequate situations are slowly replaced by healthier schemas. Note that imagery rescripting is different from imaginal exposure, which is a well‐known treatment technique for PTSD. In imagery rescripting, exposure to the most traumatic moments is kept to a minimum, whereas actively changing the situation in imagery is the most important part. By using imagery rescripting, the abandoned/abused child can be protected and comforted. She discovers what her normal rights are. In the



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meantime the punitive side can be stopped by telling the caregiver that he should not treat the child in this way. The therapist can even help the patient to take revenge. The angry child can express her rage about the many violations of her rights and the healthy adult can learn when to take action when she sees situations in which the child was improperly treated. Imagery rescripting helps the patient to become aware of her feelings and needs, and to learn better ways of dealing with them. The ultimate goal is to change the dysfunctional schemas and modes. She starts to ask for help and support from the people she trusts. Imagery rescripting sometimes leads to surprisingly quick change, but often requires to be repeatedly used with different situations and different memories in order to ensure lasting change. In Figure 5.1 one can see that there are numerous starting and switching possibilities for imagery dependent upon what the therapy requires at that given moment. Imagery can be started when the patient tells about a recent unpleasant situation. The therapist can then begin with her imagining a safe place and then follow with the unpleasant experience or he can start off directly with the unpleasant experience. This is followed by making a transition into the patient’s past. The therapist can also suggest that they go directly back to an unpleasant situation from the patient’s past if he is aware of such a situation in her past from the intake interview or other personal history from the patient. Lastly if the patients reports memories or intrusions of the past, the therapist can use these as a starting point for imagery work. The main focus of this imagery work is on the (traumatic) experiences that played a role in the formation of dysfunctional schemas and modes. Before the therapist starts with imagery exercises, he must give an extensive explanation (see “Rationale of Imagery Rescripting”).

Patient tells about an unpleasant event

Therapist suggests going straight to an unpleasant event

Therapist suggests going straight to the past

Safe place

Present problem

Childhood memory

Figure 5.1  Pathways to childhood memories

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Rationale of Imagery Rescripting (to be used to explain Imagery Rescripting to the patient). 1  What happened to you as a child was awful, and when a child is not helped to deal with this in a proper way, serious problems can develop like borderline personality disorder, feelings of shame and guilt, lack of self‐worth, hating oneself, and problems in relationships (adapt to your patient). 2  In your case, the memories of what happened have not been processed well—as there was nobody to help you with that as a child. The meaning of these experiences as a child can be very damaging. For example, a child might conclude that she is bad and that’s why it happened to her; that nobody can be trusted; that it is dangerous to want closeness to other people; they might blame themselves, feel guilty and ashamed. Even when you know from a rational perspective that such feelings might not be correct, they can still feel as if they are true. 3  We can’t change what happened, and we cannot wipe out memories of what happened. 4  But we can change the meanings you took away from such events. 5  We can try to change these meanings by talking and reasoning, but we know from research that it is much more effective to use imagery. 6  Brain research shows that the brain responds in almost the same way to imagined events as to real events, even when the person knows that the event is imagined. This means that we can have a much stronger impact on the brain when we imagine things than when we just talk about them. 7  In Imagery Rescripting we are going to change perspectives of how you looked toward the awful things that happened to you. We are not going to wipe out memories, we cannot do that, but we are going to help you to get a different view on what happened and to deeply experience that, so that the meaning of what happened changes. This means that the painful feelings that are attached to these memories (like shame, guilt, disgust, anger, panic) can reduce, that you can restore your self‐worth



Experiential Techniques

8 

9 

10 

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and trust other people more. If you have an inclination to choose people that are not good for you, you will find that the treatment helps you to look for people that treat you better. If you are afraid of emotions, the treatment will help you to feel safer with emotions. Thus, the treatment can have many positive effects. Imagery Rescripting also gives you the possibility to express your feelings, needs, and actions that you had to suppress at the moment. For instance, if somebody is attacked, he or she might feel the inclination to fight back. But, if it is very dangerous to fight back, people (often automatically) suppress this inclination. Although this can be a very smart thing to do when you are powerless (the consequences of fighting back might have been disastrous), the suppression has unhealthy consequences in the long term. Hence, we will help you to express them in imagery, because now it is safe to do so. Children need protection against maltreatment and neglect, and if these nevertheless happen, they need to get support, to be soothed and calmed down, to be reassured, and to hear healthy views on who was guilty and who should feel ashamed. These needs are natural but were usually not met for people who develop the kind of problems you have. In Imagery Rescripting we help patients to experience that these needs are met, and although this is in fantasy, the brain responds to this as a healing experience. The treatment will trigger all kinds of feelings and new insights. Some of these might initially seems difficult to deal with, but I will help you with this. For instance, you might feel sad about what happened, and this sadness might initially feel difficult. However, sadness is a natural reaction and when suppressed leads to serious problems. It is ok to feel sadness, or other emotions, that might be evoked by the treatment, they are a natural part of the recovery process. Such emotions are not a sign that the treatment is not working! In fact, they can be a very good sign. In Imagery Rescripting, you will be asked to imagine that a traumatic event is starting to happen again. When it is clear what is going to happen, I will instruct you to imagine that I am with you in the image, and I will intervene to prevent or stop the abuse or other terrible things. I will help you to imagine that

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12 

13 

14 

15  16 

17 

there is safety, and that all the needs that you have as a child— around that image—are met. In the later phase of treatment, I’ll help you to imagine that you will provide this type of help for yourself—so you will imagine that you step in the image and help little by stopping the abuse or the other nasty events, and taking care of little . In Imagery Rescripting we will not have to tell all the details of what happened. This is not necessary for the treatment to be effective. So, if horrible things happened to you, and you rather not share all details with me, that is ok. When it is clear what is about to happen, and your emotions are sufficiently triggered that is when I will intervene in fantasy. If you find a specific intervention is not enough for you, this is not a problem at all. We can just rewind the script and try out something else. The more you come with your ideas on how the rescripting can be done, the better. We can make a list of the types of traumas and other nasty events that are relevant for your current problems we have to address. You can decide what to address in what order. We will also associate problems you encounter in your present life with experiences in your childhood, as these early experiences made you vulnerable for the present problems. When I have the idea that you might avoid addressing things that would be better for you to address for a more complete recovery, I will discuss this with you. I will not try to force you to do anything that you don’t want to do. We found it is better to use earlier memories rather than later memories. So, if we have a choice, we try to go for the memories when you were younger—these typically lie at the root of the problems. Usually we address one memory per session. It is not necessary to address all memories. Many have a similar meaning and once we start successfully changing how you feel about a relevant memory you will see that many other memories also change in meaning. So, we will be flexible in what memory we choose to work on—it depends on what is the most relevant at that moment in treatment. This was quite a long explanation. Do you have any questions for now?



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Imagery of a safe place It is a good idea to start introducing imagery by teaching the patient to imagine a safe place. In this way, the patient can get used to imagery while at the same time creating a safe imaginary place she can return to at any given time should other imagery exercises become too intense and evoke unpleasant emotions. Ask the patient to close her eyes or if she finds this too uncomfortable, to pick a point on the floor and stare at it. Tell the patient that it is easier to concentrate when she closes her eyes but she can also try to concentrate in another way. Then ask her to imagine a safe place. This can be a real place where she has been to or knows of, or it can be a fantasy place. If the patient does not know of any safe places, the therapist can make suggestions, such as a place in nature or another place based on the intake interview where he thinks she is likely to feel safe. Some patients cannot think of a safe place because for them, the world is simply too dangerous and there are no safe havens. In such a situation, it is almost impossible for the patient to imagine a safe situation. For these patients it is of the utmost importance that the therapist allows a very strong, safe therapeutic relationship to develop. The therapist must actively protect the patient during imagery rescripting, so that the therapist brings in safety. The imagery of a safe situation is not a prerequisite to other forms of imagery exercises, so if the patient cannot imagine a safe place, the therapist should reassure the patient and proceed with finding a negative childhood memory. During the subsequent discussion, a connection is made between the appearance of a mode in the here and now (e.g., the punitive side) and a (traumatic) event in the patient’s past. A variation to this is to skip the unpleasant present situation and ask the patient to try and find a memory of her childhood directly. This can be, but doesn’t have to be, an unpleasant situation. An example of this method is asking the patient to picture Little Nora together with her mother. Look at mother. What happens? How do you feel?

Using imagery in search for the roots of modes In the first phase of the therapy, the search for the roots of modes is done using imagery without rescripting (see instruction imagery for the case conceptualization). For example, one can start off with imagining a safe place. Then the therapist can ask the patient to let this image go out of her mind and imagine an unpleasant situation that she currently experiences. It

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is also possible to start directly with the unpleasant situation. The patient is asked to pay particular attention to the unpleasant feelings this situation evokes and then to let this image go from her mind but hold on to the feelings associated with the situation. The therapist continues by asking whether the patient has experienced this feeling as a child and instructs the patient to hold the feeling and wait until a specific memory pops up. The patient should not look for a specific memory in a controlled (cognitive) way, but rather wait for a spontaneous association. So if the situation in the present was a confrontation with an authoritarian boss, the connection to the past can be about the authoritarian father, but can also be something totally different. It is important to instruct the patient that she can just let pop up a situation spontaneously by concentrating on the feeling. If several situations of the past pop up, she can pick out one of them—the general idea is that the younger the patient was, the better. All situations from childhood will be relevant. The patient is then asked to describe the childhood situation in as much detail as possible. Once the image is clear she may return to her safe place and open her eyes again (see Schema Therapy Step by Step 1.03). It is of particular importance that the patient experiences this situation as if it is happening (again) in reality. The therapist asks her to use the present tense and imagine as many details about the situation as possible. By asking direct questions the therapist can help to clarify the situation and thereby assist the patient in this process (see phase 1, Table 5.1). Sometimes the image doesn’t become very clear despite good questions by the therapist. If this is the case the therapist should not insist too much in the first phase of therapy. Maybe there is a strong protector intervening because the patient doesn’t trust the therapist yet. This doesn’t mean that the therapist should stop trying to use imagery exercises, but he could spend time to find out what the reasons are that the patients uses the detached protector so strongly. Try to solve them. When the situation in the past is clear, the therapist can eventually ask what the patient wishes that would happen to make things better. If the patient doesn’t know what she needs, this makes clear that the patient has a very weak healthy adult. On the other hand, if she knows what her needs are, it gives some information about the development of her healthy adult part and her schemas. If she can indicate what she needed, she can try something out and notice the effect. It is not intended to rescript the situation, but the patient may discover why it used to be so difficult to do this in the past.



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Instruction imagery for the case conceptualization 1. Close your eyes and find a safe place in the here and now. Take a good look around. Where are you? Are you alone or with someone? What do you see, hear, smell (or other sensations)? How do you feel? Focus on that feeling. 2. Let go of the image and the feeling and imagine a situation in the present where you feel uncomfortable. Take a good look around. Where are you, what’s wrong, who are you with? What do you see, hear, smell (or other sensations)? How do you feel? Focus on that feeling. 3. Hold on to this feeling, but let the image fade away. Let a childhood situation emerge, in which you feel the way you feel now. • If it doesn’t work right away, concentrate on the feeling, but don’t actively search. • If more than one situation arises at a time, choose only one. Everything is good. 4. When you have found a situation. Take a good look around you, where are you? What do you see, hear, smell (or other sensations)? What is going on? Who are you with? About how old are you? What is happening? How do you feel? What does this mean for you? What do you need? 5. Is there something you would like to do but might not dare? What stops you? 6. Possibly try out what you would like to do or think of someone who can help you (skip this if it is too complex and go to 7). 7. Now let go of your feeling and the image and move back to the safe place from the beginning. Take a good look around and concentrate on your feelings. 8. Open your eyes and discuss what possible connections are between difficult situations and feelings in the present and past. State how this may have influenced the formation of one or more of your schemes or modes. When the situation in the past is quite traumatic and the patient starts to relive the past situation again, the therapist has to stop the imagery immediately without going back to the safe place. He has to prevent the reliving of the trauma because this is uncomfortable for the patient and she could become

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afraid of the imagery work. The only goal of an imagery exercise in this stage of therapy is to discover a connection between unpleasant (strong) emotions in the present, things that took place in the past, the core figures involved in the situation, and the schema that developed by those experiences.

Sample dialogue of searching for the roots of modes T: Close your eyes and imagine a safe place in the here and now. P: I see myself sitting on the sofa with the cat on my lap. T: You’re sitting on the sofa with the cat on your lap and how do you feel? P: Lovely, relaxed. I don’t have to do anything. T: OK, concentrate on that feeling. (Short silence) T: Let go of that relaxed feeling and let raise a situation in the here and now which is unpleasant for you. P: I forgot to give an important letter to my boss. He looked really angry. T: How do you feel? (please tell what happens as if you are really present in that situation) P: I’m scared. T: What happens now? P: I say that there were a lot of phone calls and I was very busy. But he just brushes me aside and starts reading the letter. T: So, you are brushed aside. And how do you feel now? P: Stupid, inferior, bad. T: Hold on to that feeling but let go of the image and see whether a memory of a situation from your childhood, which gave you that same feeling pops up. P: I don’t know. T: Try to hold on to that feeling of being stupid and inferior. You don’t have to actively look for situations, they will come in time. But hold on to that feeling. P: Now I can remember a situation at school. I didn’t understand what the teacher was explaining and she made me look like a fool in front of the entire class.

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T: You’re at school. How old are you? Where are you physically in the class? P: I am in the third grade. I’m standing at the board and I write the wrong thing on the board. T: What happens now? P: The teacher walks toward me and crosses out the word and says in a nasty, angry voice “Nora, you nitwit, sit down, you can’t do this.” And all of the children are laughing at me. T: How do you feel now? P: I’m so embarrassed! I wish the ground would just swallow me up. I want to cry, but I don’t. T: So, you feel very sad and you’re embarrassed because the teacher is so angry. Optionally: T: What did you want to happen? P: That the teacher stops being mean to me and the children stop laughing. T: So, you need protection and respect? (Patient nods) T: I think that’s clear and enough for right now. You can let go of this situation and that feeling and return to your safe place. On the sofa with the cat. (The therapist leads the patient back to the safe place and then asks her to open her eyes.)

Table 5.1

Questions during Imagery Rescripting

Imagery Rescripting: two‐phase model Phase 1 What is happening? What do you see, hear, and smell (other senses)? Who is there with you? How old are you? What do you feel? What do you think? What do you do? (continued)

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Table 5.1  (Continued) Phase 2

The therapist intervenes. (In time) What do you think about what happens now? How does X (the offender) react? Therapist intervenes again if necessary How does X react now? Therapist comforts the child and offers to do something else How does that feel? Is there something else you need? (Continue this until OK)

Imagery Rescripting: three‐phase model Phase 2 (in the three‐phase model)

Phase 3 (in three‐phase model)

The therapist asks Healthy Nora to intervene What do you think about this? Look at Little Nora and what do you think she needs? What do you want to do? OK do it (Healthy Nora does something to stop the offender) Is there anything more you want to do? (E.g., comfort the child) OK do it (Healthy Nora comforts the child) continue till the child is OK Nora is in the role of Little Nora again. Therapist repeats what Healthy Nora does What do you feel? Is there anything you need more? OK, ask X (X is the healthy adult (therapist, helper, adult self)) (Allow Little Nora to ask Healthy Nora to do this; in this way the exercise also becomes an exercise in expressing her needs.) What is happening? What do you feel? Is that good? Is there something else you need? (Continue this until OK)

Repeat or change parts until the patient agrees that it is good.

Imagery Rescripting In the treatment phase of therapy, after completing the case conceptualization, imagery exercises are expanded to include rescripting. While the immediate reasons for using this method might be very diverse, the central goal remains the same, that is, that of changing the meaning attached to the past experiences. The therapist explains that while it is not possible to change the past, it is possible to change the conclusions one makes based upon the past.



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For BPD patients, rescripting initially takes place in two main phases. In the first phase, the patient imagines the (traumatic) childhood memory from the perspective of the little child, in the second phase the therapist enters the image to rescript. In final phases of treatment, the patient may start to rescript herself by entering the image as a healthy adult. Then a third rescripting phase is added in which the patient experiences her adult rescripting from the perspective of the little child and asks for additional actions from the adult if she needs them. For obvious reasons this can only take place once the patient has developed a strong and healthy adult mode. The basic two‐phase model for imagery rescripting is described in the following section. The three‐phase model follows in the next section.

Basic model for imagery rescripting during the first part of the therapy During the first part of treatment the patient has not yet achieved a strong enough healthy adult mode. Because of this she does not understand normal parent–child relationships and is not capable of imagining how a parent would (or should) react to a given situation. This inability to understand a normal parent–child relationship can be very serious and far‐reaching. Some patients have no knowledge of basic life skills or the ability to care for themselves. As a child, they lived a rough life on the streets, or did their best to make themselves invisible at home, where they had to take care of themselves. It is easy to understand how such an individual would have no idea of how a “normal parent” would react to a child who did something wrong, or if something terrible happened to the child. The therapist must therefore represent a model of good parenthood (see Chapter  4, “Limited Reparenting”). In imagery rescripting exercises the therapist has to think how a healthy parent would react in the given situation. It is not necessary for the therapist to actually have children of his own in order for him to be aware of the appropriate parental response to a given situation. Usually, common sense and sound feelings will do. We will now describe how this two‐phase imagery rescripting takes place. Table 5.2 presents an overview.

Phase 1: Imagining the original situation The precursor to phase 1 involves the patient imagining a safe place or a recent unpleasant situation. The therapist can make use of information from the patient’s background as a starting point for the imagery (see Figure 5.1). The patient imagines an unpleasant situation from her childhood in as much detail as possible. This does not have to be the most traumatic event she has experienced, as less powerful events also resulted in faulty

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Table 5.2 The two phases of the basic model of imagery rescripting during the first phase of therapy Phase 1 Phase 2

Patient = child Patient = child; Therapist rescripts

Original situation as the patient experienced it. Rescripting: the therapist rescripts the situation. The patient experiences the intervention of the therapist as a child. She requests and receives as much intervention from the therapist as she deems necessary.

conclusions and contributed to dysfunctional schemas. It is also unnecessary for the patient to recall her earliest memory as the events related to the formation of dysfunctional modes usually repeatedly took place, and a memory that is triggered is usually exemplary. Further, it is not important to be completely sure whether all the details are 100% accurately remembered or not. The purpose of this exercise is not to search for the absolute factual truth, but rather to change the meaning of the generalized schematic representations of typical experiences from the patient’s childhood. While the patient attempts to recall a concrete situation and to experience it from the perspective of the little child, the therapist continues to ask about her feelings and experiences. The therapist inquires as to sensory experiences (What do you see, hear, smell, feel?), to emotions (What do you feel? Are you angry or frightened?), to thoughts (What are you thinking now?), and to behaviors (What are you doing? What is happening?) (also see Table 5.1). Strong emotions are usually a good indicator that one is dealing with an important memory. It is important to know that the therapist has to adapt his tone of voice and the language he uses to the age of the child. So, he talks in a friendly, soft, and reassuring way as he also would do to “normal” children of this age.

Example of phase 1 imagery Nora is eight years old and has had a bad fall from her bicycle and cut her leg on barbed wire. Her mother does not help or comfort her. She is angry with Nora and spanks her. P: I’m in the kitchen with my mother. T: What happens there? P: I fell and my leg is really bleeding. I’m crying. T: How do you feel? P: It hurts and I’m scared because it’s a pretty deep cut from barbed wire.

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T: What do you do? P: I ask my mother to help me, but she yells at me to stop whining. She says my leg will get better on its own. She wants to know if the bike is damaged … T: And then? P: I’m afraid to say anything because the bike’s wheel is bent out of shape. My mother turns to spank me. (Patient begins to cry and shake.) T: OK, let’s stop here. We know enough and don’t need to relive the entire situation.

Once the memory is clear, one may proceed to phase 2. It is unnecessary to relive the entire memory. It is enough that the patient experiences the emotions attached to the situation/memory. Sometimes it is helpful to discuss phase 1, before proceeding, but generally the therapist can suggest that the patient keeps her eyes closed and phase 2 may begin.

Phase 2: Rescripting by the therapist At the moment when something serious threatens to take place in the imagery, the therapist stops the situation and says that he is there to help Little Nora. He asks the patient to imagine that he is in the same place with her at that moment. Don’t ask permission to enter the image but tell the patient (in the child position) that you are now with her. Asking permission is risky as the patient might refuse, for example, because she doesn’t want you to enter a dangerous situation. Then the old meaning would be reinforced—there is nobody to help me and the perpetrator has all the power— which is obviously not the effect we are aiming for.

Example of phase 2: the therapist appears in imagery T: I’m coming into the kitchen. Can you see me? (Patient nods) T: I’m standing between you and your mother. I’m stopping her from raising her arm to hit you. Do you see that? P: Yes, but be careful, she’s very strong.

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The therapist proceeds by doing anything and everything necessary to protect and comfort Little Nora. He stops the attacker and, if necessary, sends him/her away. If necessary, the therapist can use fantasy to protect the child from being attacked. He can suddenly become much stronger or larger in order to stop a violent attacker. Or he can put a wall or fence between the patient and the offender. He may also enlist the help of the police or child welfare office. So the first thing the therapist must do is make the situation safer for the child. The only thing that will not magically change is the offender (mostly the parent). Although the patient sometimes asks the therapist to change the parent in a caring and loving person, this will not work. The patient has a strong memory of her parent(s) as a neglecting or aggressive person and it is not plausible that this parent is able to change in fantasy (especially if the parent is still behaving like that in the present). During the rescripting phase the therapist has to adapt his tone of voice and his language dependent on the one he is talking to. If he talks to the offender he can use an adult and even angry voice. But as soon as he turns to the child he talks more softly and friendly.

Example of phase 2: the therapist appears in imagery and intervenes (continued) T: I say to your mother “STOP, you may not hit Nora. Don’t you see that she’s seriously injured?!?” P: Watch out, my mother is bigger than you are. T: Don’t worry, I may be small, but I’m very strong. I’m holding your mother’s arm. What happens now? P: My mother is very angry with you. I see it in her face, but she doesn’t dare hit me as long as you’re here. T: Mrs. X your daughter needs to see a doctor; that looks like a very nasty cut. P: Now my mother is swearing at you and says that I’m a pain in the ass and … T: Stop that immediately and leave Nora alone. She needs medical treatment. P: She wants to hit you.

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T: I’m picking her up and putting her in the hallway, out of the kitchen and I lock the door. She’s gone! P: Yeah now she can’t hit you. T: And she can’t hit you either. She may not come back in as long as she behaves like that.

Once the attacker has been sent away, the imagery continues. Little Nora also needs support, comfort, and care. She is usually very shocked and worried about what will happen next. Just as a good parent cares for his child, the therapist must also continue to care for the patient once the threat of attack is gone. He can do everything a “real” parent would do to reassure a child such as speaking in a reassuring tone or manner and comforting the patient by sitting next to her or having her sit on his lap. The patient experiences this moment as a young child and she will find this very normal and feel very supported and reassured by this act. The patient also finds it supportive when the therapist follows such an unpleasant situation with a very pleasant situation such as playing a game, going for a walk, or having ice cream. Of course, this all happens during imagery rescripting, so only in fantasy. The therapist doesn’t touch the patient in reality. He only says that in the image he sits beside her, holds her hand or let het sit on his lap when the patient is a young child in the image.

Example of phase 2: the therapist helps and comforts during imagery T: How are you doing Nora? P: I’m still scared because soon she’ll come back in and hit me. And now she’s even madder because you helped me. T: Then I think it’s a good idea if she’s locked up somewhere where she cannot get you. Where shall I lock her up? In jail? P: Yes, but far away and somewhere where she can’t escape. T: OK I’ll have her locked up on an island on the other side of the world. How do you feel now? P: Calmer but still very sad.

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The therapist should be aware of the fact that most patients do not know what they need when the offender is stopped or sent away. So in this phase of therapy it useful to ask, “What do you need now?” but don’t expect that the patient is able to verbalize this. Don’t ask, “What do you want me to do next?”, because this assumes too much of a healthy adult mode. The patient has no experience with what a good parent can do. So, you have to use your own fantasy to know what a little child in these kind of situations needs. For example, in this example comfort and a general practitioner. Often the patient is also frightened of the later consequences that this care and attention will have in the long term and she must be reassured about the future. The child fears punishment for expressing her needs or being helped by the therapist. The therapist must make sure that the child understands how to contact the therapist if something goes wrong. Because this all takes place within the framework of imagery, it is possible to use both realistic (a cellphone) or fantasy (a magic spell) methods of reassurance. The situation can appear so unsafe for the patient that it is not sufficient for the therapist to return when the patient needs him. In this case, the therapist can suggest that he takes the patient to look for a safe place to live, for example with a nice family she knows, or with the therapist. The essential point of this intervention is that the patient feels safe and experiences the therapist as supportive.

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Example of phase 2: the therapist takes the patient to a safe place during imagery T: Is there something else you want to say? P: Yeah, I’m scared that my mother will come back and really let me have it because I said you should lock her up. T: So you’re scared of being left here alone? (Patient nods) T: Is there anybody who you could live with? Anybody who is nice to you and who would like to take care of you? P: Perhaps Auntie Rose … Yes, she is always nice to me. T: Shall I take you to your Auntie’s? You’ll be safe there and you can call me if you need to. (At last the patient begins to relax and carefully laugh) T: Come with me, does your Auntie live far away? (Patient shakes her head no) T: I take you to her house …. So, here we are. Let’s ring the bell. Your Auntie opens the door and is very happy to see you. Do you see that? (Patient nods and smiles) T: Auntie Rose, I’ve brought Nora to you because she’s had a nasty fall from her bike and I have called the doctor to come to check out her leg and she would like to stay here with you. T: (to patient) What does your Auntie say? P: She says it is fine and has me sit on the sofa by the TV. T: OK we’ll wait for the doctor and then I’ll leave. I’ll arrange it with your Auntie that you can live with her, and that I visit you daily until you’re better. What do you think of that? P: That’s nice. T: Is that enough or are there other things you would like? P: No, this is good. I’m glad that I can stay with Aunt Rose and that you’ll visit me every day. T: I am also glad that you can stay with Aunt Rose. She will take care of you when there is a problem like an accident with your bike, and also in other situations. It was not your fault that you fell, on the contrary that was bad luck. Your mother is not able to help

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After this, the patient may stop the exercise and open her eyes. Then the therapist discusses the meaning of this imagery in terms of her schemas. Returning to a safe place is unnecessary in this case, as the patient has been brought to a safe place in the therapist’s rescripting of the situation. In many cases the patient has already concluded that everything was her fault during her youth, and that her parent had the right to be angry with her or mistreat her because she was a dumb, bad, or lazy child. By rescripting the situation the patient becomes aware that she was not wrong and that she did not deserve the mistreatment, but rather that she was a small child who was in need of care and that her parent did things that a normal parent simply would not do. Her self‐image, which still tells her that she is bad, dumb, or lazy when she makes mistakes, can be adjusted using this technique. Whenever possible an alternative interpretation can be formulated and written out so that the patient can take this home with her. In any case, the most important issue is that the patient starts to feel about herself in a healthier way. “I wasn’t guilty of the situation, but rather my mother should have kept her hands to herself and … I feel relaxed and not nearly as scared.” We also suggest that the therapist tries to do something nice together with the child at the end of the imagery. So, he thinks of something the child of that age would normally like to do when the bad or sad things have stopped. This is usually eating something she likes, playing, or going somewhere (playground or zoo).

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Imagery Rescripting in the Final Phase of Treatment Once a patient has moved along further in the therapeutic process and has developed her healthy adult mode, she herself can execute the rescripting. Now imagery rescripting has three phases (see Table 5.3). The first phase is identical to the first phase previously mentioned. Phases 2 and 3, while slightly different from phase 2 described earlier, retain the same essential points of protecting and comforting the child while helping her to adjust her faulty conclusions.

Phase 2: Rescripting by the patient as a healthy adult After phase 1, the patient is asked to imagine entering the situation as a healthy adult. The therapist continues to ask the patient about her feelings and thoughts and what, from her healthy adult perspective, she thinks should be done for the little child. It is not the purpose of the therapist to impose opinions or actions on the patient. It is far more effective for her self‐confidence when she makes these decisions for herself. Of course the therapist can coach the patient a little bit but only when needed. Table 5.3 The three phases of the basic model for imagery rescripting during the second phase of therapy Phase 1 Phase 2

Patient = child Patient = adult

Phase 3

Patient = child

Original situation as experienced by patient. Rescripting: situation evaluated by patient as an adult. Patient intervenes as an adult. Rescripting: patient experiences the intervention of the adult as a child. She requests and receives additional interventions from the adult.

Sample of imagery with Big Nora as a  healthy adult rescripting T: You’re now Big Nora. Can you imagine that? P: Yeah a bit. T: You are in the kitchen and you see what is happening to Little Nora.

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Take note that the patient, when she intervenes as a healthy adult, not only takes action against the people who maltreat the child, but also pays attention to the little child. The therapist can ask the patient, while in the role of a healthy adult, if she knows/sees anything else the little child may need. If so, the therapist stimulates the healthy adult to do what she thinks should be done. If the patient forgets to explain the true reasons for the abuse or neglect and forgets reassuring the child, the therapist gently reminds the patient (as an adult) of this. If the patient thinks that everything is OK and the child’s needs have been met, she can move to phase 3 and actually check to see if the child’s needs have been met sufficiently.

Variations with a patient only partially capable of being in the healthy adult mode When the patient is in a healthy adult mode, but is unsure of how to continue further, there are two variations of phase 2 that can be used: either a helper is sought, or the therapist coaches the patient. A helper can be someone from the patient’s past (e.g., a relative or teacher), from her current situation (e.g., a partner or friend), or a fantasy figure (e.g., Superman). The therapist asks the patient to think of someone who could help support her to become and behave as a healthy adult and act against the aggressor or abusing adult; someone who can help protect the child. The therapist agrees with any helper who appears



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to have a healthy, positive influence, but will refuse those whom he knows as being negative or abusive either currently or in the patient’s past. The patient is asked to have the helper join her in the imagery exercise and that he/she does or says things the patient is unable or afraid to do or say. The advantage of intervention by a helper instead of the therapist is that the patient herself must decide what the helper says and does and in this way becomes more actively aware of what an appropriate response should be as well as more aware of what a child’s needs truly are. The patient’s share is greater and her own feelings of self‐worth and value are strengthened. If the patient is unable to think of an appropriate helper, the therapist can try to coach her by suggesting things to say or behavior that is related to what she had earlier thought of. This is particularly helpful the first time the patient tries to rescript from the healthy adult perspective, and also when she says appropriate things but does not fully succeed in stopping abuse or sending away a punitive parent. In any case, it is important that the maltreatment is stopped in phase 2, otherwise the little child cannot feel safe, and feeling safe is one of the ultimate goals of imagery rescripting.

Phase 3: Rescripting experienced by the child The aim of phase 3 is to check if the little child has received the support she requires in order to meet her needs and to better integrate this new experience into her (childish) schema. The therapist asks the patient to close her eyes again and return to the little child in the imagery situation, viewing the intervention by the patient as an adult. The therapist describes what Big Nora does to protect Little Nora and asks the little child how she feels and thinks about the intervention Big Nora has made. Are there other things she needs or wishes to change? The therapist then prompts Little Nora to ask Big Nora for it, and to imagine what happens next. At this point the therapist can speak on behalf of Big Nora. The therapist continues to ask these questions until all of Little Nora’s needs have been met. In this manner the patient can integrate new insights in her self‐image. In the third phase the patient extends the rescripting in such a way that not only the threat is eliminated, but that also her other needs are met (like comfort, support, or praise). In this way she learns to acknowledge her needs and to express her needs to others.

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Example of imagery rescripting, phase 3: The little child is asked if she has further needs T: You’re now Little Nora again and in the kitchen with your mother. (Patient nods) T: You see Big Nora coming in and just at the moment your mother is going to hit you, she stops her. She says that your mother cannot hit you and must take care of your injured leg. What do you think of that? P: Good, now she can’t hit me. But my mother is still angry. T: Certainly! And now Big Nora puts her outside. How do you feel now? P: Better. T: Is it better or is there something else you need? P: My leg still hurts and I’m very shaken up by the whole thing. T: Tell that to Big Nora. P: I’m still bleeding and my leg hurts and I’m scared. T: Big Nora can see that and is getting the doctor and then she’s sitting next to you. Is that better? T: P: T: P: T: P: T:

(Patient nods and appears relieved) How do you feel now? Is everything OK? I need a hug and a tissue. OK, ask her! Can you give me a tissue and hug me? What is Big Nora doing? She gives me a tissue and hugs me. How does that feel? (After some time.) Is there anything else that you need? Is there anything else you want Big Nora to do?

If necessary, Big Nora can take her to Aunt Rose’s house as in the example of phase 2 rescripting. However, it is also possible that the patient asks Big Nora to stay and care for her and that this is more appropriate to this phase of treatment (see Schema Therapy Step by Step 3.05). After this third phase, as with the second phase, patient, and therapist reflect on the implication of the rescripting and the emerged needs, feelings, and new insights for the adjustment of dysfunctional schemas. It is



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important to take enough time to integrate the new insights and form a new perspective on the patient. So conclusions are drawn on a schema level (it was not your fault, you are not a failure, but your parent didn’t know how to react in a healthy way). The therapist can also add more psychoeducation about what normal parenting is and what normal needs of a child are.

Imagery Rescripting: Changing Behavior Patterns in the Future Imagery is a very helpful tool in changing behavior patterns. Trying out new behaviors is often hindered by the patient’s dysfunctional approach to dealing with problems. The patient herself often does not know why attempting these new behaviors is problematic for her. Imagining a recent situation in which she did not succeed in trying out new behavior, allowing the patient to describe the entire situation in detail, is sometimes more helpful as a form of information gathering than simply asking for a verbal description of the situation. Rescripting is then directed toward what the patient would like to have seen happen, but was unable to achieve. During the imagery she can practice effective ways of problem solving. Young, Klosko, and Weishaar (2003) describe imagery in which the patient describes the block and attempts to work through it: “For example, the block might look like a dark weight pressing down on the patient. On questioning, the patient reveals that the block conveys the same message as a pessimistic parent. The patient pushes the message away by pushing away the block.” Imagery can also be used to work on future situations. She can find out what she is going to do or say and how she would like to act out of a more healthy adult perspective. She can use these kinds of exercises to discover if she wants to do the new behavior anyway. If for instant the patient feels that she has to talk to her parents to explain all about the therapy and ask them for more sympathy, she can do this in imagery. Sometimes it works out fine and she has prepared this conversation in a good way. Sometimes she discovers that it is no use to ask her parents for more sympathy, because they probably will react the same way as in her youth. In this case she can decide not to have this conversation with her parents in order to protect herself from further harm.

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Imagery rescripting: changing behavior patterns in the future if the detached protector is interfering For a long time, Nora has been unsure of what she wants to do with her life. She does not know if she wants to study or work. She is completely unclear as to which direction she may even wish to develop. The therapist suggests that it might be a good idea to try and investigate this blockage in an imagery exercise. T: Close your eyes and imagine that you’re in a quiet, peaceful place. Where are you? P: I’m walking in the park with Rob. T: You’re walking with Rob and he asks you what you’re going to do with the rest of your life. P: My first reaction is to change the subject (so the protector becomes active). T: It’s good that you’re aware of this. Try to think of another reaction to his question. P: I tell him I don’t know and need to think about it. T: OK start thinking about it. P: I can’t, I feel paralyzed. T: What do you mean “paralyzed”? What or who is paralyzing you? P: The thought that I must make the right decision and can’t try something out first. It feels like I’m tied to whatever decision I make. T: Try to loosen those ties. Of course you can try different possibilities out and make mistakes. This idea that you cannot make mistakes comes from your father, but he is no longer allowed to hold you back. P: Yes, that is right, but making decisions is still frightening for me … the possibility of making mistakes. T: Try to free yourself from these ideas and begin to think of different possibilities. P: OK that feels a bit strange, but not as paralyzing. T: So what’s holding you back from thinking about your future is your fear of making mistakes and that’s why you continue to avoid the subject.

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The therapist can now ask the patient while she is in the process of imagery to think about what she wants to do in the future and share these thoughts with Rob. Another possibility is to stop the imagery exercise and discuss how she can learn to acknowledge this blockage at an early stage and teach her how to break through her tendencies of avoidance. Other situations that the patient may be avoiding, despite having achieved the level of a healthy adult, may also be dealt with using imagery. This is particularly helpful when the patient is embarking on a new relationship and her old schemas and modes are becoming active again. The patient can try out new behaviors in imagery and test out which styles and approaches best fit her.

Imagery rescripting: changing behavior patterns in the future if the vulnerable child is becoming too overwhelming Another problem could be that the patient switches to her vulnerable child instead of reacting as a healthy adult. T: So you want to discuss with your friend that you feel criticized by her. P: Yes I want to tell her that I do not like her comment about my clothes. T: OK close your eyes and imagine that you see her. And tell her what you think of this. P: “I do not like the way you talk about my new dress. I like this dress and I become uncertain when you say it is a strange model.” T: How does she react? P: She looks surprised and also a little bit angry (starts crying). I don’t know what to say. T: I think that Little Nora is present now. Try to make contact with Big Nora again. What can she say? P: “It makes me a little bit sad and disappointed when you look at me so angry. I had hoped you would like my dress. Why are you angry? It seems like you do not like it that I have my own taste. Do you not like me to be more independent from your opinion?” T: Good questions. What happens next?

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The therapist can discuss with Nora if she is afraid of her friend because she looks angry in the same way her father did. Nora learned to submit and has to learn to be more assertive toward her current friends. Even if her friend disagrees with her choices, she still can go her own way (see Schema Therapy Step by Step 3.08 Future Imagery—Mode awareness & mode management and 3.09 Future Imagery—Behavioral Change).

Frequently Asked Questions About Imagery Rescripting The use of imagery rescripting can be hindered by various different problems. The most common and significant problems faced during this therapeutic exercise are described below. Video examples of how to address difficulties with applying imagery rescripting are offered by van der Wijngaart and Hayes (2018). When can I start with imagery? In most cases the therapist can start with imagery the sooner the better. In this way the patient gets used to it from the beginning. In session two or three you can start with imagery without rescripting in order to discover (the origins of) schemas. If the patient is very suspicious it can take some more time and efforts to lower the distrust. The therapist can introduce the imagery step by step (see the next questions). What can I do when the patient resists imagery? One of the exercises that can help to lower the threshold for imagery is starting with an imagery of a situation that has nothing to do with difficult situations. You could ask the patient to imagine that she is a child and you go together to a candy store or a toy store and she is allowed to choose the candies or toys she wants to have. Another starting imagery is asking the patient that she is walking outside town in the hills. She sees a child walking toward her from a great distance. The child gets closer and suddenly she sees that the child is herself as a little child. Ask what the child looks like and how it seems to feel. Then let the patient think of what she wants to say or do to the little child. Let the patient say something to the child. Then she walks on or stays with the child if she wants to.



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What can I do if the patient cannot think of a safe place? When the patient is not able to find a safe place, there are several ­possibilities to help the patient to create a safe place. The first possibility is to help the patient to look for a fantasy place. You can use examples from movies or fairy tales or describe a safe place linked at the life h ­ istory of the patient. As described before it is not always possible to find a place that seems safe enough. In that case the room of the therapist can become the safe place when the patient is able to trust the therapist sufficiently. Is it always necessary to start with a safe place? It is not necessary to always start with a safe place. As the therapy ­progresses, the imagery can also start with a difficult event in the past or present if the patient feels more comfortable in the session. Some t­ herapists never use a safe place. What if a patient says she is unable to find a memory or says she has no memories from her youth? When a patient is unable to “find” memories or says she has no memories from her youth, it is likely that she consciously does not want to be reminded of these memories or that she has buried them away and actually does have difficulty remembering them. By using imagery to recall a pleasant memory, often memories of very unpleasant situations can emerge. Should the fear of painful memories or punishment play a large role for the patient, it is helpful to acknowledge these feelings and explore which modes are involved. The punitive parent mode in particular should be addressed immediately. After effectively dealing with interfering modes, imagery work is often possible. When there is a high fear of losing control, the therapist must allow the patient as much control as possible in the imagery. The therapist can first ask the patient to try—with her eyes open—to look at a focal point or agree upon a certain length of time. This gives her more control and a greater feeling of safety. Should this prove to be too threatening, then it is likely that it is too early in the therapeutic process for this technique and the therapist must work further on developing a trusting relationship. If the patient disassociates, the therapist must stop the exercise and bring the patient out of this state. Possibly, more security in the therapeutic relationship must be established before imagery can be attempted again. In many cases, simply continually attempting to do imagery will lead to a childhood memory.

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Another option is to ask the patient to bring pictures from her childhood (and her family in childhood) and discuss them with the patient. The patient can also visit the neighborhood and the house where she lived as a child. What if a patient does not (want to) close her eyes? When the patient does not close her eyes, the therapist can explain to the patient that with her eyes closed she can concentrate better on the exercise; however, this can also be achieved by staring at a fixed point or focal point in the room. Sometimes the patient cannot close her eyes or does not dare to do so because of the fear of being looked at or judged by the therapist. She may also fear that the therapist may do something unexpected. First, the reasons for not daring to close the eyes are explored. Then the patient can make suggestions to how the therapist could help her to feel safer; for example, that the therapist also closes his eyes or turns his chair or physically moves away from the patient. The therapist can also suggest that the patient tries closing her eyes for 1 or 2 min to get an idea of what it will feel like, and then propose a gradual increase in the length of time having her eyes closed. When the patient has several memories of the past at the same time, which memory should I choose? It can be very threatening when the patient is flooded with many memories that often overlap one another. The first thing the therapist can do is telling the patient that it is not a big problem and she can pick one of the memories, because all the situations can contain valuable information. If she is still unable to choose one memory, this can be a sign that her life is still too chaotic, and she must first organize herself before starting imagery exercises. If the patient is able to choose a memory, try to choose one during which the patient was young. When she is young it is self‐evident that the child cannot be expected to act like an adult or to take adult responsibilities like running the house or taking care of a baby. Further, at this young age it is easier quickly and clearly to make the patient aware that overly punitive punishment and/or (sexual) abuse was the responsibility of the parent(s) and not the child. What if the patient always brings up the same memory? If the patient always brings up the same memory the therapist can suggest doing an imagery exercise about another subject. Especially when



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the therapist knows that important experiences from her past have not been addressed, there is perhaps avoidance of painful subjects. The therapist can suggest dealing with these subjects by means of imagery and explain that it is important to rework these events with rescripting as well because they are important influences of her dysfunctional schemas. What can you do when a patient refuses or is unable to act against a punitive parent out of a misplaced sense of loyalty? One can explain that the purpose is not to reject her parent(s) completely as they are now, but rather to address the behaviors her parent(s) expressed during her youth that are related to the formation of her dysfunctional schemas. She need not reject everything about her parent(s), but she must weigh which values and norms she wishes to retain from her parents and which she wishes to reject. What if the patient does not want to allow the therapist to enter into the situation in the past? If this is the case, then the patient is usually afraid that the therapist cannot handle the situation. She is probably afraid that the perpetrator will attack and damage the therapist. The therapist must then reassure the patient that he can handle the situation by getting bigger and stronger or getting extra helpers (e.g., the police). The therapist has to do everything in his power to get into the picture and to bring the patient to safety. What if the patient thinks the intervention is wrong? Every now and then, after the rescripting, the patient may be dissatisfied with her own intervention or that of the therapist. In that case, phase 2 can be repeated using a different intervention. If, for example, the patient first wants to have Big Nora or a helper beat up her father as a form of revenge, but on second thoughts decides locking him away in a prison is a better idea, then this is changed in the imagery. However, with each rescripting it remains necessary to protect and help the little child. An imagery exercise that allows an abusive or violent parent to continue abusing results in the trauma being repeated. Should this situation arise, the therapist must immediately intervene and stop the abusive parent. What if the patient finds the intervention unrealistic? The simplest solution to this problem is to think up a different intervention. However, sometimes this does not work and the patient’s fear of

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becoming overly emotional plays too large a role. The protector attempts to escape by declaring that the intervention is unrealistic. If this is the case, the therapist must support the patient as much as possible so that she tries. In other cases, the therapist can explain that, despite imagery rescripting being a fantasy technique, it is extremely helpful in processing memories of childhood experiences that underlie her present problems. Some patients like some explanation about the plasticity of memory, while others feel reassured by explaining the empirical evidence for the technique. What if the patient tries to change the parent into a friendly person? Especially when the parents were not extremely violent or abusive, the patient wishes to change the behavior of the parent in the past memory. She wants the parent to become nice and friendly. Most of the time this is not going to work, because the real parent never behaved that way. Nevertheless, we recommend following the need of the patient and invite the parent to meet the need of the patient. Most of the time the patient discovers that the parent is not able or willing to do this, or that this behavior is so implausible that this new script does not have the desired effect. Sometimes this becomes clear in the session so that other people (e.g., the therapist) can meet the need. And sometimes this becomes clear in the next session. In this case one should try to rescript the memory again in a better way. What if the patient feels guilty because she did not do anything to stop the abuse when she was a child? In such cases it is reassuring to explain to the patient exactly what children of that particular age are normally capable of doing. Remember, her knowledge of normal development is often severely limited. By observing children in her direct environment, the patient can be made aware of just how small and young a child of, say, four years old actually is and how little control she has over her life and surroundings. The therapist can also use examples from his own childhood as samples of a “normal” childhood. What if patients only report memories of their later childhood? Some patients only report memories of their later childhood, say after 13 years, but cannot find earlier memories. The therapist can ask the patient to try to find, via the adolescent memory, earlier childhood memories. If this doesn’t help he can ask the patient to concentrate on



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the bad feeling in the adolescent situation and then let the image go and wait till another memory pops up from earlier childhood. Another possibility is to ask the patient to remember an early childhood situation known from the anamnesis or other sources. Often however, a specific mode interferes with this; for example, the detached protector (preventing strong emotions and helplessness) or the punitive parent mode (a rebellious adolescent is easy to blame). In such cases, techniques appropriate for these modes should be used first (see Chapter 9). What if the patient is unable to put herself in the child’s perspective? This is a common problem for patients who were forced into semi‐­ parenthood as children. They were required, out of necessity, to behave as “adults” at a young age and have a very limited concept of how a child experiences the world. The therapist must attempt to take over the parental responsibilities from the little child and pass them on to a responsible other (e.g., child welfare services, a social worker, another therapist). Only then can the patient feel free enough to experience her own needs. Another method to help the patient feel more like a child is for the therapist to talk to her during imagery in the way an adult speaks to a child. If the patient has no idea what normal needs of children are, the therapist can also provide her with psychoeducation. He can encourage her to read children’s books or watch films about children with a “normal” youth. He can also tell about his own youth or how he treats his own children. Do the patients understand the difference between imagery and reality especially when therapy is a lot of intimacy between the therapist and the abandoned child? Our experience is that patient always understands that there is a difference between what the therapist does in imagery and what he will do in reality. If the therapist puts his arm around the little child or even takes her on his lap in imagery the patient doesn’t expect the therapist to do that in reality during the session. Borderline patients missed a lot of intimacy and receiving love and warmth in imagery helps them a lot in healing the abandoned and abused child. If the therapist is not able to give the patient what she needs in imagery is it acceptable to limit the limited reparenting in order to feel comfortable? Giving enough support and protection to the abused and abandoned child, as if it were your own child, is necessary to heal the child mode. This

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includes cuddling or hugging the child when it is very upset. So the needs of the child mode are the guideline for the actions of the therapist and not his emotional inhibition. If the therapist feels uncomfortable with these kinds of interventions, he could discuss this with other schema therapists in order to find out what makes this difficult. Not uncommonly the rules from earlier education in psychotherapy obstruct these interventions, because touching the patient is forbidden. The therapist should be aware of the fact that he only touches the little child in fantasy and not in reality. Is it dangerous to use aggressive actions during the rescripting phase? Therapists often are afraid of encouraging aggressive deeds against offenders. However, when the child is abused severely and is very afraid of the offender, just telling the offender to fuck off is not enough. So if the patient suggests stronger actions, even killing the offender, the therapist should not hesitate to do this. Arntz, Tiesema, and Kindt (2007) found that using aggressive phantasies in imagery rescripting lowered the anger and increased the self‐control, more so than with imaginal exposure treatment. A lab study didn’t reveal any risks, but this study was ran among students (Seebauer, Froß, Dubaschny, Schönberger, & Jacob, 2014). Till now we do not know of any case in which aggressive imagery rescripting led to aggressive deeds in reality. There is still a lot of discussion whether it is safe to allow taking revenge in imagery rescripting when applied to patients in the forensic field. Research about this issue is necessary. Is there a risk that the patient decompensates? Imagery rescripting is a quite structured exercise in which the therapist always stays in contact with the patient by asking where she is and what happens. So if the patient seems to get overwhelmed by emotions or starts to dissociate, he can stop the imagery for a moment and discuss what is happening. Another solution is to start fighting the punitive parent in time so before he gets too threatening. In other cases the imagery can be done in little steps and the therapist can give the patient more control over the exercise. Imagery rescripting is now regularly used as a safe treatment for patients that were 20 years ago believed to decompensate from any kind of trauma work. Does medication influence imagery rescripting? Sedating medication does suppress strong emotions. So imagery rescripting might have less effect. Giesen‐Bloo et  al. (2006) found



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afterwards that BPD patients did profit less from schema therapy when they used this kind of medication. This is not yet verified by a ­controlled study. Imagery rescripting is a powerful tool to evoke changes in the patient’s schemas. As previously mentioned, with BPD patients, this technique is not continuously used in numerous, consecutive sessions. However, therapist and patient may both avoid imagery rescripting and therefore it is wise to plan the use of it during a prolonged period once every two sessions. Alteration of imagery rescripting with other experiential as well as cognitive and behavioral techniques is recommended.

Role Play Role play directed at changing schemas can be helpful in dealing with situations from the patient’s past as well as from recent events. Role play focused on the patient’s childhood, also referred to as “historical role play,” can result in strong results, similar to those seen in imagery rescripting. It depends on the therapist’s and patient’s preferences as to which method is most often used. The areas of application for the use of historical role play are similar to those of imagery rescripting (see the beginning of this chapter). For obvious reasons, the therapist cannot play the role of an abusive parent. Abuse is therefore most often dealt with by imagery rescripting. Another difference between imagery rescripting and role play is that the latter can also be used to give the patient more insight into her own part in the interactions with her parent(s) as well as to the motivation that her parent(s) could have had, which the patient did not experience as a child (see “Phase 2: Role switching”). The absence of the father during childhood may be experienced by the patient as rejection and a lack of love. This contributed to her feelings of inferiority. When doing role play, it could become evident that the father did in fact love his daughter, but stayed away to avoid arguments with the mother. The absence of attention is correct; however, the patient’s conclusion that this was based on her father finding her an unworthy daughter was found to be a faulty assumption. This form of role playing is indicated for clarifying ambiguous situations. That is, situations in which the parent’s behavior was indeed dysfunctional, but not motivated by rejection of her as a little child.

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Historical role play In preparing for role play, both patient and therapist search for relevant experiences from the patient’s past. Often there are a number of current situations in which the patient is regularly stuck. These are usually linked to events from her past, which are similar to these current situations. In Nora’s situation, she continually got stuck in situations at her work when she felt others ignored her feelings. She would then become frightened and feel isolated. She thought that her superiors did not see that others were ignoring her and felt they would label her a complainer if she herself brought this to their attention. The therapist and the patient try to link this situation in the present to a comparable situation in the past. When a relevant situation in her past is found, therapist and patient explore which schemas or modes were developed or strengthened by it. This is followed by a three‐phase role play (see Table 5.4). It is important that different chairs are used during role play from the regular chairs and/or places used by the patient and therapist during “normal” sessions. This helps to avoid role confusion. Just as with other forms of role playing, the situation is enhanced by the furniture and items in the therapist’s office. The patient must immerse herself in the past situation as much as possible. She must try to become the actual eight‐year‐old Nora as much as possible in order to relive the feelings and be able to draw the same conclusions. To help this process, both patient and therapist use the present tense when speaking. The therapist does his best to accurately imitate the parent or other individuals involved. Table 5.4  The three phases of historical role playing

Phase 1 Phase 2

Phase 3a Phase 3b

Division of roles

Role play

Patient = child Therapist = the other person Patient = the other person Therapist = the child

Original situation

Patient = child Therapist = the other person Patient = child Therapist = healthy adult

Original situation; role switching The patient experiences the perspective of the other person involved in the situation. Patient now tries out new behavior, in accordance with the new insight about the intentions of the other If the perspective of the other person doesn’t change the schemas at all the therapist can rescript the end of the role play by playing the reaction of a good parent

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If more individuals aside from therapist and patient are required in order to allow a more accurate role play (e.g., due to gender differences), one can ask others to be involved in the role play (e.g., friends of the patient or colleagues of the therapist).

Phase 1: The original situation The original situation is acted out. The patient plays the role of the child and the therapist plays the role of the other significant person (usually the parent) as directed by the patient. Role play must involve a concrete moment in which the patient developed dysfunctional ideas in her past. The role play should not take very long (about 5 min or even less). The patient describes the situation as accurately as possible, as well as providing information as to the behavior of the person the therapist is playing. The therapist must ask as much as necessary about the individual he is playing in order to accurately “become” that person. This preparation should not take half of the session, but should be brief. If not, there is a strong chance that all three phases of the role play will not be completed during a single session. Whether or not the role play is in fact accurate will be evident during the role play itself.

Sample of historical role play phase 1: enacting the situation Situation: Nora is depressed because her colleagues have not involved her in the yearly personnel’s outing. This reminds her of when she was bullied at school and no one helped her. The concrete situation is that she comes home from school and tells her mother that she is being bullied at school. Her mother (M) does not react. Role play 1: Enacting the situation The therapist plays the mother. He is standing by the table and is busy cleaning. The patient is Nora, eight years old, and has just come home from school. P: T = M: P: T = M:

Mum, they are bullying me at school again. They took my new pen and broke it. (annoyed) I’m busy; I don’t have time for this. But now it’s broken and doesn’t.… Not now! I already told you! (Patient walks away with a sigh.)

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After the first phase of the role play the therapist steps out of his role and invites the patient to sit back in the original seats. They discuss whether or not the role play was accurate in terms of the real situation in the past and whether or not the same emotions were evoked. If the role play was not accurate, then the patient must provide extra information so that the role play can become more authentic. It is then repeated. This is followed by writing down the development of the dysfunctional interpretation, including the accompanying feelings. Then both therapist and patient try to make connections between these interpretations, feelings, and the various accompanying modes. The therapist should make sure that interpretations related to the self, to the other person(s), and to the assumed view the other person had about the child are addressed. The patient is just as sad and powerless as when this event actually took place and she concludes: “My mother was short with me, therefore she thinks I’m an annoying child.” This conclusion contributed to the formation of her abandoned child mode: “No one loves me” and “I am worthless.” The therapist writes all of this on a board or on a form about the historical role play (see Appendix K “Form for the Historical Role Play” and “Example of a historical role play”) using the patient’s actual words. The therapist may ask the patient to rate the believability (0–100) of these conclusions and write them next to each conclusion on the board or the form. This interpretation has contributed to her schema of defectiveness/shame and the abandoned/abused child mode.

Phase 2: Role switching In phase 2, the therapist suggests that they switch roles. The patient then attempts to immerse into the other individual, while the therapist now plays the role of the child. In preparation for the role play, the therapist emphasizes that the patient must try to “become” the other person (e.g., mother) as much as possible. They discuss a number of typical characteristics the mother (or other individual) possesses, as well as the situation the mother was in during this period of her life (e.g., mother had four small children and could not cope with the family because father was often away from home for days).

Sample of historical role play phase 2: role switching Nora plays the role of mother and is standing by the table, busy cleaning. The therapist is Nora at eight years old and has just come home from school.

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T = N: Mum, they were bullying me at school again. They took my new pen and broke it. P = M: (annoyed) I’m busy, I don’t have any time for this. T = N: But now it’s broken and doesn’t.… P = M: Not now! I already told you! (Therapist/Nora walks away with a sigh. Patient/mother sighs.) After the role play both patient and therapist return again to their seats and dwell upon the thoughts and feelings the patient is experiencing. During this discussion the therapist does first pay special attention to signs that the patient has changed her view about the reasons for the behavior of the other person (in this example the mother). He does that by asking the patient to stick to the role of that person for a moment and “interviewing” her as if she is that person. The therapist asks if this person really thinks what the patient (as a child) concluded after the first role play. When this is clear the therapist asks the patient to describe her thoughts and feelings about this situation from this new perspective, if appropriate.

Sample of discussing phase 2 T: Let’s look at this role play from the perspective of your mother first. So stick to the role of your mother as you played it a minute ago. What happened? P: While playing my mother, I realized that I was too tired to listen to my daughter and that’s why I was so short with her. T: But what did you think about Nora? Was she annoying? P: No, I didn’t think she was annoying. I didn’t hear what she was saying well because my head was full of worries. T: If you didn’t think Nora was annoying, why did you sigh? P: Because I was very tired. I find it exhausting taking care of four small children. T: Okay, now we know what mother really thought, let’s go back to you and your assumptions after the first role play. (T. is pointing at the board or the form), what would you like to change? P: That my mother was tired because she had to take care of four young children and it was too much for her. That’s why she was so uninterested in me.

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This new understanding can lead the patient to a reformation of the original assumptions. “My mother was short and had no time for me, but this had nothing to do with me, but rather was due to her being overly tired.” The therapist writes this new text under the original assumption. He also investigates whether the patient can adjust her ideas about herself. The patient should also be encouraged to look at her own role in the situation from the perspective of the parent looking at the child and comment on what she notices. Perhaps the child withdrew very early so that the parent was not confronted with his or her dysfunctional behavior.

Sample of reflection phase 2: personal share T: P: T: P: T: P: T: P: T: P: T: P: T:

What did you notice about your daughter as a mother? Nothing. What do you mean “nothing”? She doesn’t react to anything I say. Do you have any idea why she doesn’t respond? My mother doesn’t know, maybe because she’s busy with other things, but I was so scared, I was scared she would go crazy if I bothered her. But does mother think that Nora is an annoying child? No not at all, she is a quiet child that has consideration with me. So, you would not say she is worthless? No, I have no time for her. I am glad she doesn’t ask too much attention. Nora, tell me what do you conclude? I feel a little bit less worthless Now we can add a bit to your original assumption.… I didn’t push her because I thought she would break down, but I am not worthless.

The therapist must explain that the child had no other options as she was completely dependent upon her parents, and seldom saw how “normal” parents react. Usually there are other examples from the patient’s past in which she was directly labeled as difficult and/or annoying, which

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reinforced the belief that she was difficult. It is not the purpose of this exercise to make the patient feel guilty about her behavior afterwards (see “Frequently Asked Questions About Historical Role Play”).

Phase 3a: Rescripting when the interpretation about the  other person changes During the third phase, the therapist again asks the patient to play the role of the child, but to use the new information she has learned from the previous role plays and subsequent discussions. For example, the patient can be more assertive and even speak in a louder voice. The therapist has to prepare the new behavior carefully. He has to realize that the patient finds it difficult to react differently than she is used to. So, the therapist can suggest a new reaction or even can model it and ask the patient to imitate it in the role play. If the patient does try the new reaction, the therapist must not forget to reward the patient afterwards, even when it is not a perfect assertive reaction. Any effort to do something new is worthwhile, because it is the first step in developing the healthy adult. As this is now a new situation, the therapist is required to improvise in his role of the other person to accommodate the new behavior of the child. Once this improvisation is believable to the patient, the therapist can move on to reflecting upon this entire process and further re‐evaluations of the original assumptions.

Sample of historical role play phase 3a: trying out new behaviors In preparation for this role play, the therapist emphasizes that it is now time for the patient to try out new methods for getting her mother’s attention. The therapist plays the mother, stands next to the table and appears to be busy with cleaning and caring for the household. The patient plays Nora, eight years old, and has just come home from school. P:

Mum, they were bullying me at school again. They took my new pen and broke it. T = M: (Annoyed) I’m busy and don’t have any time right now.

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P:

But it doesn’t work anymore and …. They also called me names and hit me. T = M: Not now! I told you I am busy! P: Mum, don’t you hear me?! They hit me and I have a bruise on my arm. T = M: (Looks up tired and says shocked) What did you say about a bruise? What did your teacher say? P: Nothing, she didn’t see it. T = M: This has got to stop. I can’t leave here, but I’ll ask Aunty Rose to go with you to school tomorrow and the two of you can talk to your teacher about it.

The therapist used his knowledge about the patient’s personal history to improvise the situation of Aunty Rose helping out. Aunty Rose lived very close to Nora and her family and often helped out when Nora’s mother needed extra help. Should the patient find this improvisation unrealistic, the therapist must try something different. The therapist and patient finally come to the following conclusion: If I had been clearer and as strong as an adult, and had told my mother that I was being bullied daily and that my teacher did nothing about the whole situation, then my mother would have either helped me herself or asked my aunty to help me, despite the fact that my mother was very tired. She would have done something. I am worthy of being loved and I am not worthless. The goal of phase 3 is not to give the patient the idea that she should have done things differently in the past, but rather for her to experience the fact that there are different possible interpretations and ways of dealing with this kind of situation. By doing so, the role play can be applied to different, more current situations in her life. The implication for the future can be that she tries to be more assertive. This will help to give Nora, for example, a better understanding as to why she does not like to feel left out by her colleagues at work. It will also become clearer to her that she should discuss this with the management at work (see Schema Therapy Step by Step 2.06 Historical role play).

Experiential Techniques

Example of a historical role play ROLE PLAY 1 (the original situation) Patient plays herself as a child. Therapist plays the other person. Conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐100 Assumed perspective of the other person:

0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐100 ROLE PLAY 2 original situation: role reversal Patient plays the other person. Therapist plays the patient as a child. Alternative assumed perspective of the other person:

0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐100 Alternative conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐100 ROLE PLAY 3 Patient plays herself as a child, but tries out new behavior. Therapist plays the other person. Alternative assumed perspective of the other person:

0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐100 Alternative conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐100 Original conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐100 Implications for the future

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Phase 3b: Rescripting when the interpretation about the  other person doesn’t change If the parent’s behavior remains the same and he/she actually did reject the child, the therapist must not try to “convince” the patient that this parent in fact had good intentions. The goal of the role play is to change the schemas of the patient and not to change history. There are several ways to change the schemas in another way with the aid of the role play. The therapist should explain that the fact that the parent is unable to love his own child does not mean that the child is bad, but that the parent is unable to love his child. So the parent is the problematic figure and the patient must be protected against him The first way is inventing new behaviors that the patient wants to try to make clear that he is not accepting the wrong behavior of the parent. So rescripting could be that the child becomes angry and walks away. The second way is that the therapist plays a good parent and tells the real parent what he thinks about the situation and how wrong it is to treat a child like that. This has the same effect as being the healthy adult in imagery. Subsequently he takes care of the child and fulfills her needs in a proper way. The only difference here is that the therapist cannot touch and comfort the child in a physical way, but he can do a lot by using the right words and adopt a friendly attitude. If the parent becomes too violent when the child becomes angry or if the therapist disagrees with him, a role switch should be used: the patient is again in the child role, the abusive parent symbolically on an empty chair, and the therapist limits the parent, and sends him away (e.g., put the empty chair outside the room) after which the therapist takes care of the child. In later phases of therapy, this “drama rescripting” can also be done by having the patient take the role of healthy adult, confronting the parent and taking care of the child.

Frequently Asked Questions About Historical Role Play Problems faced in the practice of historical role play are similar to those of imagery. The most important problems are the following: How can I simplify a role play when it is too complicated? If during the preparation a scenario for role playing is discussed involving many different scenes, the therapist must help the patient to shorten



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the role play. Together with the patient, they must choose which s­ ituation had the most influence on the development of the schema or mode. What exactly happened before or after that moment is not that important. The patient can explain what happened before to explain why this situation became so awful. But the role play is only about that specific moment. The patient could also tell what happened afterwards, but this is also less important because the goal is not to change history, but to change the schemas and the modes. The patient cannot play the role of the other individual The reasons as to why the patient is unable to play the role of the other person must be looked into further. If no clear reason can be found, it is helpful to re‐explain the rationale behind role play. Ask the patient to make one more attempt before deciding that she cannot do it. A possible explanation is that she is required to play an individual who is aggressive. The therapist can choose to skip phase 2 and ask the patient to try a different behavior in phase 3. Yet another possibility is to switch to imagery rescripting. How can the patient prepare the new behavior? It is not easy for the patient to think of a new reaction in the past situation. Therefore the therapist has to help her to find a reaction which is not too difficult. Normally the new reaction consists of a short sentence like “I want you to listen to me” or “I don’t want to do this.” The therapist can model the text and the attitude of the child in order to make it easier for her to play this new role. The patient feels guilty after phase 3 because she did not react in this fashion during the actual situation The therapist must explain that as a child it was impossible for her to have this type of reaction due to her circumstances as well as the lack of examples of other possibilities in her life. Only once she became an adult was it possible, with the help of a therapist, to think up alternative reactions and try them out. The therapist is concerned that he is making the child feel guilty about her past behavior This train of thought is a mistake on the part of the therapist. The patient cannot feel guilty about this period in her life as she was a child and

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unable to know what to do in this situation. The role play can put into perspective her personal role as well as the role of her parent(s). This can actually have a very cathartic effect on her personal feelings of guilt as well as on her feelings about her parent(s). The patient can come to the following conclusion: “When I was a child, I was easily frightened, but now that’s no longer necessary. My mother’s reaction to my fear was inappropriate because she was overwhelmed and overly stressed with taking care of a young family, while father often was away from home for days.” This will result in very different emotions than the thought “My mother didn’t love me.”

Role play of a current situation Just as with the historical role play, recent situations can be acted out in three phases. In role plays with current situations, the focus is not on the development of the patient’s schemas, but rather on the way schemas are maintained by misinterpretations of the behavior of others. In particular phase 2 involves role switching and offers the patient the opportunity to reinterpret the behavior of others as well as the effects of one’s own behavior on the behavior of others.

Sample of role play of a present situation It was unclear to Nora why she got into arguments with her boyfriend when she was in the punitive parent mode. While in this mode she was very critical of him and he could not do anything right. After participating in a few role plays in which Nora played the role of her boyfriend, she developed a better understanding of the effects of her behavior when she was in this mode. She further began to understand that his irritated reaction reinforced her punitive side (even he’s against me). She became more and more aware of the negative cycle in which she became stuck. She discussed with her boyfriend the idea of having a time out of half an hour if this should happen again so that she could try to stop her punitive side.



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As previously mentioned, historical role play is helpful in ambiguous situations in which the behavior of another individual (generally the ­parent) is interpreted in a black‐or‐white manner. The present role play is similar to historical role play, only now the patient uses situations she is currently dealing with as opposed to events from her past. During each phase of role play, the therapist tries, together with the patient, to write down the dysfunctional interpretations and the new perspectives as clearly as possible. The relationship between cognitive, behavioral, and experiential techniques is more clearly present in these role play techniques than in that of imagery rescripting. This relationship remains strong in the following two‐ or‐more‐chair technique, which will be described in the following section.

Two‐or‐More‐Chair Technique Most BPD patients find it difficult to realize that they have different sides or modes. When they flip into a mode they are not aware of the fact that they behave in a dysfunctional way. The best way to make this clear is using ­different chairs for different modes. This is especially useful for BPD patients who find it difficult to cut themselves free from their punitive or protective modes. It is also a useful method when there is a battle between old, dysfunctional, schemas or modes and the healthy adult. This is also referred to as a “schema dialogue.” First, the two‐chair technique is discussed as it can be used for the punitive (or demanding) parent, next with the protector modes. Then, the multiple‐ chair technique, that involves multiple modes, is discussed.

Two‐chair technique for the punitive parent Should the patient appear to be in the punitive mode during a session, the therapist must first clearly state this to the patient. Usually the patient is unaware of this fact. Because of this, the therapist must explicitly state, which mode is on top during the session. He then suggests that this mode be placed on a separate chair (see Table 5.5). The therapist can make a choice between two options. He could ask the patient to sit briefly in the chair of the punitive parent to have the message of that mode articulated. Or he can leave the chair of the punitive parent empty and ask the patient what that side says to her.

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Table 5.5  Two‐ and multiple‐chair technique Mode Punitive parent Punitive parent Punitive parent Protector Protector Protector Protector Mode

Two‐chair technique Placement of Therapist mode Empty chair Coaches the patient as a healthy adult Empty chair Healthy adult Other chair Healthy adult Empty chair Coaches the patient as a healthy adult Empty chair Healthy adult Other chair Healthy adult Other chair Abandoned child Multiple‐chair technique Placement of Therapist mode Two empty Coaches the patient chairs as a healthy adult

Patient Healthy adult Abandoned child Punitive parent Healthy adult Abandoned child Protector First protector, then abandoned child Patient

Punitive parent Healthy adult and protector alternate Punitive parent Two empty Healthy adult Abandoned child and protector chairs alternate Punitive parent Two other Healthy adult Punitive parent or and protector chairs protector alternate Punitive parent Three other Healthy adult or Punitive parent or and protector chairs abandoned child protector alternate Two‐chair technique with schemas and coping strategies Mode Placement of Therapist Patient mode Schema Other chair Coaches the patient Healthy adult as a healthy adult Coping strategy Other chair Coaches the patient Healthy adult as a healthy adult

In the first case, the seat, where the patient was sitting, remains free for the abandoned and abused child (Little Nora). The therapist must take care that the punitive parent doesn’t get too much time and space, because that makes this mode stronger and the vulnerable child gets hurt. So, after a

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short time the therapist asks the patient to come back to her original chair. He can also ask her to move her chair a little bit more next to him. Because in this way they can go against the punitive parent together. If the therapist does not ask the patient to sit in the chair of the punitive parent, he can immediately continue. It is helpful to write the punitive messages on a piece of paper and put this on the empty chair. The therapist continues by making it clear to the punitive parent that his presence is damaging to Little Nora. He talks to the empty chair. The empty chair cannot talk back so the therapist has to ask the patient how the punitive parent reacts. If she tells him that the punitive parent refuses to disappear, the therapist must go against the punitive parent with more effort. If necessary, he raises his voice to make it clear that the punitive parent has to stop. In some cases, the punitive parent still is not silent, so the therapist can use words like “be quiet, shut up, I do not want to listen to you.” Even then the punitive parent could go on and the therapist has to carry on with the fight till he has won. So, he can put the empty chair further away or even put it outside the room! The therapist continues to fight the punitive parent until he is silent. The therapist must win or the patient will feel that the punitive parent has won and she will become more frightened. When the punitive parent is silent, the therapist turns to Little Nora and asks her how she feels and thinks about it. He uses a soft and friendly voice to calm and comfort Little Nora in order to make her feel better and safer. When dealing with a punitive mode, which is entirely negative regarding the patient, the therapist acts in a very confident, even angry, manner to force the punitive mode into silence. (See Schema Therapy Step by Step 2.10 Punitive Parent — Chairwork.)

Example of two‐chair technique with the punitive parent p:

I overslept again yesterday, so I can pretty much forget my new job. I’m so stupid. t: I hear you talking in a very negative way about yourself. I think that I’m hearing your punitive parent side. Is that correct? p: It’s just plain stupid to be late for your second day of work. t: I don’t think that you’re stupid at all and I suggest that we put your punitive parent side onto a different chair.

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(Points to an empty chair.) Would you like to sit there and tell me what your punitive parent is saying? p: If I have to. (Moves capriciously to the other chair.) OK, I’ll say it again; I think it’s just plain stupid to oversleep for a second time. T: OK I have heard enough. Please Nora move over to the chair next to me (he slides the chair a little bit closer besides him). t: (Talks to the empty chair) I don’t think it’s stupid and you’re not helping Little Nora at all by being so negative about her. Turns toward Nora and asks “What is the punitive parent saying now?” p: She is stupid and she’s never going to learn. t: (In an angry voice toward the empty chair) Stop immediately! You’re continuing to belittle Little Nora and I won’t have it! (In a soft voice to Nora) What is the punitive side saying now? p: Yeah but she really is stupid, always causing problems, and being irresponsible … t: (Verbally attacking the punitive mode) Stop it! Leave Nora alone until you can be nice and helpful to her. As long as you are talking this bullshit I don’t want to hear you again. (Patient is silent.) t: What is the punitive side saying now? p: Nothing anymore. t: (In a friendly tone toward Nora next to him) I am glad that negative voice is silent now. I am sure there were reasons for you to oversleep and I am sure you didn’t do that on purpose. Now tell me, what was the reason you overslept? p: (Sadly) I was up half the night and when I finally fell asleep, I ended up sleeping through the alarm clock. t: So you were up late and couldn’t sleep, that’s awful. Were you worrying about something?



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As already described, many patients find it very difficult to sit in the punitive parent’s chair particularly when the therapist becomes angry at the mode. To prevent this, the patient returns to her own chair when the therapist really starts to fight the punitive parent and the therapist can talk to the empty chair (see Table 5.5). This allows the patient to be a spectator to the battle between the therapist and the punitive parent. If, nonetheless, she becomes afraid of the therapist, he can reassure her again and explain that he is against her punitive side and is not against Little Nora In the end phase of therapy the patient can also fight the punitive side herself, changing chairs and successively playing healthy adult and punitive sides (Young, Klosko, & Weishaar, 2003). However, we suggest only using this method when the patient can successfully play both the healthy adult and the punitive parent modes (see Schema Therapy Step by Step 3.04 Punitive Parent Chairwork end phase). The role of the therapist must then be limited to that of coaching the healthy adult. Often the problem is that the patient cannot formulate the words for the healthy adult and therefore needs coaching. But more often, and especially in early phases of therapy, the two‐chair technique with the therapist fighting the punitive side is used to temporarily silence the punitive mode. Patients feel protected and relieved after this exercise. The therapist can then use the rest of the session to comfort and help the patient as long as the punitive parent remains silent. He is also in a better position to then help the patient with her problems.

Empty chair technique for the demanding parent mode The empty chair technique should also be applied to the demanding parent mode, if it is playing a role in the problems of the patient. However, there is an even higher risk that patients (and therapists!) believe that this mode is actually functional and that they resist addressing it, as they are afraid that they will end in doing nothing at all. Our present culture is full of high demands, and therapists might themselves suffer from (too) high standards. Thus the risk is that the demanding parent mode is not adequately addressed. Therapist should be aware of any problems they might have with seeing the dysfunctional aspects of the demanding parent mode and try to correct them for themselves, so that they are able to address this mode in their patients. The chair technique might have an immediate effect of silencing the punitive or demanding parent, this will not hold without repetition. The technique should be used very often before it will have a lasting effect.

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Moreover, patients should learn to apply it themselves. So in later stages of treatment, the therapist coaches the patient (in her healthy adult mode) to fight the voice of the punitive or demanding parent. Patients with severe and persistent dysfunctional parent modes should practice applying the empty chair technique at home.

Frequently Asked Questions About the Two‐chair Technique With the Punitive or Demanding Parent What can I do if the patient just wants to sit in another chair? In the beginning, the therapist can also use dolls or cards of modes to symbolize the modes. But if the patient is able to sit on the different chairs herself, the change at an experiential level is more powerful. What can I do if the patient does not tolerate the therapist going against the chair of the punitive parent? There are times when the patient simply cannot tolerate the therapist’s anger with the punitive parent, even when the chair remains empty. The punitive parent is after all a part of the true parent and some patients feel that fighting the punitive side will result in losing the whole parent, an idea that they cannot tolerate, despite the abuse and mistreatment that the parent may have caused. The therapist must then explain that the technique is about silencing that punitive part of the parent which is detrimental for the patient. This is not that she must totally reject her parent(s). Often psychoeducation as to what a normal parental response is to a child’s mistake is helpful. The therapist further explains that one learns more from making mistakes if they are accepted than when one is humiliated for making mistakes. In this way the patient learns why the therapist felt the punitive parent’s reactions were so exaggerated and damaging. A possible compromise is that the therapist uses a less angry tone when dealing with the punitive parent. Nevertheless, it is his job to ensure that the punitive parent remains inactive, otherwise this mode will continue to command the patient’s feelings. Despite the patient’s resistance it might be necessary to be very firm in sending the punitive mode away. A symbolic action which is often helpful, is to put the empty punitive parent chair outside the room. The idea that the patient might get that the therapist rejects the parent as a whole can be corrected (or prevented) by weaving in messages to the punitive parent on the empty chair like:



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T: “I know you also do good things for Little Nora, but this is unacceptable behavior.” T: “You can come back when you can really help Nora.” What can I do if the patient feels alone or anxious without the punitive voice? In such a case, the therapist can explain that without the punitive voice there is more room for the emotions of Little Nora. Then he can investigate together with her what her unfulfilled needs are and how to fulfill them with the help of the therapist, her friends, or her own healthy adult. What can I do if the patient thinks that without the punitive parent, she no longer has norms and values? The therapist can explain that the norms and values of the punitive parent are far too black and white, and rigid. He promises her that together with him she will develop a healthy adult in which normal norms and values, chosen by herself, are given a place. Hearing punitive voices: pseudo or real hallucinations? We found out that at least 50% of BPD patients experience the messages of the punitive parent mode in the form of a voice telling them these punitive things. Often, but not necessarily, it is the voice of the punitive caregiver(s). Patients are often reluctant to tell you this, as they are afraid of being labeled psychotic and then not getting the treatment they need (which is, sadly, often the case). We didn’t experience any influence on the effectiveness of the empty chair technique to fight the punitive parent mode whether the patient experiences the punitive messages in the form of a voice or in the form of thinking. Usually BPD patients don’t make a source misattribution: they are aware that their own mind produces the voice. Although many see this awareness as an essential part of the diagnosis (such experiences are the called pseudo hallucinations) the DSM does not require source misattribution for the diagnosis of psychosis. This would imply that more than 50% of BPD patients would have a comorbid psychosis (see also Merrett, Rossell, & Castle, 2016), which we tend to disagree with—it is an artifact of ignoring the fact that it is false source attribution that is essential in loss of reality testing that is central in psychosis We recommend to ignore this diagnostic debate, and treat BPD patients who hear punitive voices with correct source attribution just as any other BPD patient.

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Therapists can reassure their patient by telling them that more than 50% of BPD patients experience their punitive parent not only by having punitive thoughts, but also by hearing a voice, and then asking how this is for your patient. If the patient acknowledges they hear a voice, it is extremely helpful to ask whether the voice sounds like a person from the past, and if so, what person. The same questions should be asked about the content: is it something that has been said (repeatedly) before? Who said it?

The two‐chair technique with the detached protector While the therapist’s tone may be more neutral when dealing with the detached protector (see Chapter  9), his purpose remains the same, that is, ensuring that the mode, in this case the protector, retreats so that he can continue the therapeutic session with Little Nora in the other chair (see Table 5.5). Just like with the punitive parent mode, the therapist can make a choice between two options. He could ask the patient to sit briefly in the chair of the detached protector to have the message of that mode articulated. Or he can leave the chair of detached protector empty and ask the patient what that side says to her. In the discussion with the detached protector, the therapist indicates that he understands that he was originally very useful and protected Nora against the extreme situations in which she grew up. He then explains, that he is no longer needed because the circumstances have changed (see Schema Therapy Step by Step 2.05 Detached Protector Chairwork).

Example of the two‐chair technique with the protector t: So how are you doing today? p: (In a flat tone) Good. t: How was your week, did anything happen that you want to talk about? p: (Looks away and yawns) No, not really. t: So everything’s fine. p: Yeah, maybe we could have a short session today. t: I think that you are really in the protector mode today. p: No, what do you mean? Everything’s just OK with me.

Experiential Techniques t:

p: t: p: t: p: t:

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You called me earlier this week saying that things were not so good with you and yet now you keep telling me that everything’s OK. That’s why I think you’re in the protector mode. I suggest we put it in the other chair so that we can try to set it on the sidelines. But I’m not in the mood to sit in the other chair. I’m way too tired. May I then say something to the protector in an empty chair? Fine with me. (To an empty chair) I know that you’re here for a reason, because some nasty things have happened this week. But I would like you to give me the chance to talk to Little Nora. That’s not going to help. (To the empty chair) I can see that you’re having trouble leaving and letting Little Nora deal with her unpleasant feelings, but I am here to help her out. So I would like to ask you to let me connect to Little Nora, if only for the rest of this session. I understand you are necessary to protect Little Nora from becoming desperate when she is all alone and feels bad. But now I am here to help Nora and therefore I would like to ask you to step aside, just for the moment, so that I can take care of Nora. I care about her and I would really like to help her with her feelings, but I cannot do that if you don’t let me through.

(The therapist continues with this until he is able to have the space to talk with Little Nora.)

Frequently Asked Questions About Using the Two‐chair Technique With the Detached Protector What can I do when the detached protector refuses to retreat? In practice, there is really only one major problem with this technique, that is, when the detached protector refuses to retreat. Despite the fact that the detached protector is being difficult, it is important that the therapist does not become angry with the protector. Should he do this, he runs the risk of activating the punitive parent. On the other hand, the protector can be so stubborn that the therapist must become stronger in his dealings with this mode. Should this then result in activating the

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punitive parent, the therapist should give priority to addressing the punitive mode, putting it in a separate chair. In that case, there is a chair for the punitive mode, for the detached protector mode, and for Little Nora. Although the therapist talks to the detached protector in this technique, it is important that he simultaneously talks to Little Nora in a tone of voice that is appealing to the little child mode (“I care for Nora and I know she is there behind the wall you have raised, and that she needs me to talk about her feelings…”). This will often motivate patients to lower their detached protector and to start to talk about their feelings. As soon as the patient starts to talk about her feelings, the technique has succeeded, and the therapist addresses the patient’s feelings and needs. The therapist can even take the chair of Little Nora and express her needs; that is, to be able to express her feelings and to receive understanding and reassurance from the therapist. He also states that, while the protector does protect Nora, he does not teach her anything which will help her to solve her problems. In fact the protector interferes with Nora’s development by not allowing her to feel anything at all. A more cognitive technique, addressing motivation for letting the therapist bypass the detached protector, is discussing the advantages and disadvantages of the protector with Nora (see Chapter 9, “Treatment Methods for the Detached Protector”).

Multiple‐chair technique Every now and then, the punitive mode will leave, but it is immediately replaced by the protector or vice versa. Because of this, another chair can be placed for the other mode. While this may appear to be the beginning of a child’s party game, as long as the therapist does not lose sight of the goal of these chairs (contact with Little Nora), he should be able to manage them. Keeping in mind the need to keep the lines of communication with the little child open, the therapist can add a third chair to allow the needs of the abandoned child to be expressed (see Table 5.5). This technique has the effect of giving the patient more insight into how her feelings, thoughts, and behaviors are influenced by her different modes. She will also notice that these dialogues will become more and more a part of her own internal thought processes. Nora had previously spoken about the “arguments in her head.” She has learned from her therapist that it is helpful to ignore the punitive parent in her head or to let go of the protective mode. The advantage for the therapeutic process is that she rejects the ­dysfunctional,



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while at the same time embracing the desired healthy adult side more. In any case, the therapist does not play the part of either the punitive parent or the detached protector as that would be confusing for the patient. It is usually not sufficient to get rid of the punitive and/or protective modes only once, as they will reappear for a long time in subsequent sessions. Often the therapist will notice this based upon the tone of the patient’s voice when she talks about herself. As soon as he notices a change in her intonation, he should ask if the relevant mode is at play. He should also request that she gives this mode its own chair and repeat the previously mentioned process.

Two‐or‐more‐chair technique in the final phase of therapy During the final phase of therapy, these techniques can also be applied to dysfunctional schemas and/or coping strategies that continue to cause problems. The problematic schema or coping strategy is placed into one chair and the healthy adult in the other. The patient can sit in either chair while the therapist coaches her as a healthy adult. We found out that it is extremely helpful for patients to learn to fight themselves the punitive and demanding parent modes or the detached protector symbolically placed on an empty chair (see Schema Therapy Step by Step 3.02 Detached Protector Chairwork Endphase). Similarly, it is important for patients to take the position of the healthy adult and to sooth and correct misinterpretations of their abandoned/ abused child mode, placed on an empty chair. Patients sometimes avoid doing this, as saying nice and soothing things to themselves confronts them with what they missed in their childhood, but it is necessary to develop a healthy adult mode and to heal the abandoned and abused child mode. The two‐or‐more‐chair technique can also be used to further strengthen healthy adult mode by letting the therapist play the role of the punitive parent or detached protector. The patient then tries to fight these sides from his healthy adult side and send them away. The therapist can only apply this if he makes it very clear that he is only playing a role and that what he says in this role is not what he really means.

Experiencing and Expressing Emotions BPD patients must learn to experience strong negative emotions without running away from them or behaving impulsively. Should the patient appear to not be able to experience emotions (see Chapter 2, “The detached

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protector” and Chapter 9), it is important to explain why emotions are a necessary, healthy, and functional part of human life. In doing so, the therapist explains not only that a feeling is an emotion, but also that these emotions evoke certain physical symptoms. In teaching the patient to understand emotions, he begins by explaining the most basic emotions: fear (and anxiety), anger (and rage), sadness (and dejection), happiness (and joy), and disgust. Exposure techniques as used in behavioral therapy, as well as writing letters about feelings toward persons who have maltreated the patients (without sending them) (Arntz, 2004), can be helpful in inducing and learning to tolerate and accept emotions. When cognitive diaries are used, describing emotions that are evoked in certain situations is essential (see Chapter 6 and Appendix B). As learning to deal with anger is a particularly difficult issue for BPD patients, a separate section has been dedicated to this subject.

Dealing with anger Feeling and expressing anger (Angry Nora) is an exceptionally difficult problem for BPD patients. A very small minority of BPD patients start therapy being angry with everyone and everything, including their therapist. However, most patients hold back their anger as experience has taught them that when they express it, they face very serious consequences. Every now and then there is an outburst of unexpected and uncontrollable anger. This generally serves to reinforce the patient’s fear of expressing anger even more. If, in the session, the patient is to express her anger from the standpoint of her angry child, the therapist must stimulate this. He must be very careful in how he reacts to her anger. If he is too understanding, this will temporarily subdue her anger. On the other hand, should he take this out‐burst of resentment personally, he will react with his own punitive mode. Thus, again reinforcing the patient’s belief that the expression of anger will be met with disapproval. He will also prematurely subdue her anger should he be too quick to defend himself. He best serves his patient by first allowing her the space to express anger about everything that is bothering her. In a neutral tone he must continue to ask her what she is angry at, why she is angry, and whether or not there are more things she is angry about. Only once she has had the opportunity to express all her anger can the therapist begin to empathize with her and acknowledge her right to become angry. Only then can the connection between the anger and the angry child mode be made. Meanwhile, the patient will calm down a bit and her therapist can discuss

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Expressing anger

1. Venting anger 2. Empathizing 3. Reality testing 4. Practicing assertive behavior

The therapist remains neutral and continues to ask questions. The therapist empathizes with her animosity and makes connections to the modes. Discussing what parts of the patient’s anger are justified and what parts are not. Explain why anger is normal and shouldn’t be suppressed. Using role play to practice how better to deal with a similar situation in the future.

the realistic and unrealistic components of her story. He should also educate the patient about anger. Being angry is normal so suppressing anger too long will lead to an explosion of anger later on. Because she has not learned how to deal with her anger in an appropriate manner for the future, it is helpful to try different options in role playing. In Table 5.6 we have summarized four different facets that are related to anger.

Example of dealing with anger p:

You don’t understand anything. I don’t know why I keep coming here. I called your secretary this morning to ask what time my appointment was and that stupid woman told me the wrong time. So, I’ve had to sit in your boring waiting room for an hour. t: (In a neutral tone) I can hear that you’re angry at my secretary and at me because I don’t understand you. Is there anything else you’re angry about? p: Yes, there is. You have no idea how boring your waiting room is. There’s no sunlight and only old magazines. And the people in there are nasty. They don’t even bother to say hello. t: (In a neutral tone) So you’re angry at me because you had to sit in the waiting room for an hour and you don’t like the people in there. Is there anything else that you’re angry at? p: I had an argument with my friend this morning. He didn’t want to get out of bed again. I ended up swearing at him.

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(And so on until all of her anger is out. The therapist continues to gather as much information as possible about why the patient is angry and then begins to speak in an empathetic tone.) t: I can understand that you became angry. It was stupid of me not to write our appointment in my secretary’s agenda. I can understand that Little Nora must have felt abandoned and now feels like she can’t trust me. p: I thought that even you can’t be bothered with me and that you would do this right before your holidays… (See Schema Therapy Step by Step 2.15 Angry Child—Ventilate, Empathize, Reality Testing.) The therapist then thoroughly discusses the patient’s feelings about the therapist’s forthcoming vacation. This is followed by discussing the situations in which she expressed her anger in an inappropriate manner and the therapist teaches her how to express her anger more adequately in these situations, for example, by using role play or chairwork. (See Schema Therapy Step by Step 2.16 Angry Child—Chairwork.)

If the therapist has difficulties in distinguishing the angry child from the angry protector or an angry healthy adult, see Chapter 9 treatment methods for the angry child. There are patients who do not dare to show any angry emotions. They rationalize these feelings away because of their fear of losing control and the consequences of this uncontrolled anger. The therapist tries to explain that it is this anger hoarding that causes the unexpected and uncontrollable outbursts of anger at the wrong time and (usually) directed at the wrong person. In this case, the therapist can function as model by showing the patient how to verbally express different degrees of anger, from hitting pillows via stomping his feet to telling the right person what you are angry about. He then asks the patient to do this with him. If she has trouble feeling anger, yet has the physical symptoms of anger, it is helpful to ask her to concentrate on these physical feelings. Each individual experiences different phenomena when repressing anger but some of the more common symptoms are stomach ache, headaches, and tense muscles. Some patients may even clearly



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make fists in anger and not even realize they are doing so. The therapist can ask the patient to concentrate all of her attention on the tense part of her body or pain. He then, together with the patient, investigates what these feelings mean. If she either acknowledges or recognizes these feelings, they can discuss how to further deal with them as well as allowing as much expression of them as possible. The therapist suggests that the patient practices expressing mild anger/irritation both during and outside of therapy as much as possible. This will help her to avoid hoarding these feelings. In doing this she also experiences the reactions from the “opposing” individual and generally speaking this is not as bad as she expected. More importantly, she realizes that by expressing anger at appropriate times, the chances of uncontrollable explosions of anger are greatly reduced. Another exercise is for the patient to tolerate these feelings and not immediately act them out. In doing so, she realizes that not only do these feelings dissipate in time, but she also learns more about maintaining control while experiencing strong emotions. Pain and sadness often lie behind the anger. If sufficient attention has been paid to the angry child, the therapist must therefore also investigate which feelings and thoughts of the abandoned/abused child were triggered.

Dealing with frustration When the patient also has an undisciplined/impulsive child mode the therapist should react in another way. In this case, the therapist should not let the patient ventilate, but rather set limits to the patient’s behavior in a quiet way. The therapist can confront the patient empathically with the effects of her behavior. The therapist gives psychoeducation about disappointments and frustrations. They are a part of life and everyone has to learn how to cope with them. When the patient has calmed down, he can help her solve her problems in a more realistic way (see also Chapter 9).

Experiencing and Expressing Other Emotions BPD patients often also fear losing control and becoming overwhelmed by other emotions such as fear, sadness, or joy. To discover which f­ eelings are aroused, just as previously described with anger, she can concentrate on her physical symptoms to identify them. For example, shallow, quick

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breathing accompanied by gripping the armrests of her chair can indicate that she is repressing fear or sadness. By gradually allowing these feelings into the session she will discover that they are in fact manageable and she can also try to do this outside of the therapy sessions. This can be done by consciously listening to certain types of music or watching emotional movies. It will take a long time before she is able to show these feelings to anyone else besides her therapist. Sometimes she can also try to show them to a close friend or her children. Only once she has reached the point where her healthy adult is developed, and she has developed relationships with other healthy adults is it advisable to practice these techniques outside of the safety of the therapeutic setting or good relationships.

Example of concentrating on physical symptoms in order to acknowledge feelings and naming them Nora would like to apply to work as a volunteer, but she is not succeeding. Her therapist analyses why this is the case. Nora seems to think that they simply don’t want her. The therapist asks her how this makes her feel. P: T: P: T: P: T: P: T:

I don’t know how I feel. Do you notice anything different in your body? Yeah, my stomach hurts. Concentrate on the pain in your stomach. I don’t know if I can. Perhaps it would help if you put your hand where it hurts. (Does this) It just gets worse. Just give it a try and try to concentrate on the pain and think about what this pain means. P: I think that I’m actually really scared. Sometimes I get stomach aches when things are difficult. Yeah, I’m scared that they’re going to take advantage of me if I work there. T: So it appears that the stomach ache is a signal that you’re scared. (Patient nods) T: That means that a stomach ache is a signal for you to try and find out what is scaring or bothering you.



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Experiential techniques for the happy child Simple experiential exercises can be used to liberate the happy child. Therapist and patient can together blow bubbles, blow balloons and launch them, make funny drawings, share funny stories and experiences, tell a joke, and so forth. Such exercises are systematically used in group‐ST, but can also be used in individual ST. An interesting option is to combine such exercises with addressing a dysfunctional mode. As an example, an ugly effigy can be made to represent the punitive parent, which is put on the empty chair of this mode, combated, and send away or put in fire. Or the punitive messages are blown into a balloon, after which the balloon is blown up by stepping on it. Such exercises transform negative feelings into childish pleasure, in other words convert a dysfunctional mode into a functional one, and have a liberating effect.

Letter writing The patient can learn to express her feelings by writing letters. This technique is often used in dealing with traumas, but can also be adapted to expressing emotions in different situations. The patient writes a letter addressed to the person(s) who have caused her pain in which she expresses all of her feelings of despair and/or anger. In general, this letter is never sent. This technique is not limited to negative feelings but can also be used to help the patient learn to express positive feelings. When she reads these letters aloud during her sessions, she is again helped to face these feelings. She may also choose to write letters (or emails) to the therapist about subjects she feels unable to put into words during sessions. The therapist can use these letters as a vehicle to investigate why she cannot talk about these subjects. Perhaps the protector is involved in safeguarding her from strong emotions. On the other hand, the punitive parent may feel that some subjects must remain secret. Another possibility is that the abandoned/abused child is ashamed. By treating the involvement of the modes, the patient can learn to discuss these emotions at a later stage of therapy and the need to write letters becomes less.

Frequently Asked Questions About Experiential Techniques in General What should I do if I successfully applied an experiential technique while I still have time left? After a successful application of an experiential technique it is intended that you have made contact with the abandoned/abused child. It is

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important that you take the time to validate the feelings of Little Nora and fulfill her needs in an appropriate manner. You can provide psychoeducation about what a normal parent would do and how a healthy adult would handle situations like this. If the patient still has a lot of questions about what is wrong with her, and you have still time left, you can use another experiential technique or apply a cognitive technique or make a flash card (see Chapter 6).

Conclusion In this chapter, we discussed different techniques primarily directed at feeling, rather than thinking or doing, the so‐called experiential techniques. By using these techniques the patient can manage (express feelings more and/ or more adequately) and interpret her feelings differently. Often, these techniques have important cognitive and behavioral effects. Moreover, in contrast to more rational techniques, they have an impact on the feeling level, and they address memories from early childhood, when thinking was not yet so rational. Because of this, these techniques are an important part of ST. However, it is important that these techniques are connected to the channels of both thought and action (see Table 3.1) so that the patient can put her altered insight into different behaviors. Chapter 6 describes how cognitive techniques can be added to improve the patient’s self‐image as well as her views about others and the world as a whole.

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Cognitive Techniques

Cognitive techniques can be used both to analyze and alter dysfunctional beliefs the patient has about both current and past events. In addition, the therapeutic relationship can also be analyzed using these techniques (see Chapter  4, “Cognitive Techniques and the Therapeutic Relationship”). Cognitive therapy as used in symptom‐focused treatment is not an option for BPD patients during the first phase of therapy. However, it is possible for the patient to make connections between situations, feelings, thoughts, and the associated modes (see Table 6.1). The therapist searches for connections between current situations and events in the patient’s past. For example, the patient’s abandoned child mode may cause her to panic at the mere thought that her boyfriend is leaving her with the dysfunctional belief that he will leave her forever. In this case, the therapist can explain the connections between this current situation and facts from her past, that is, when her mother did in fact leave the family for a few weeks without the children knowing why she had left or if she would return. This situation is not only incomprehensible for a young child, but also very frightening because she is threatened in her existence. Because of this, each time the patient is faced with someone “leaving” her, she is flooded with unexpected thoughts and feelings that relate to her memory of this important childhood event. However, these thoughts and feelings, while once appropriate to her childhood situation, are no longer appropriate in the present adult situation. The reactions of the angry child and the punitive parent modes can also be Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Table 6.1  Cognitive diary for modes (see Appendix B) SITUATION (What triggered my reaction?) My boyfriend went to pick something up at a shop and came home an hour too late. FEELING (How did I feel?) Angry, panicky THOUGHTS (What was I thinking?) He’s late again, he doesn’t think about me at all. He doesn’t love me. BEHAVIOUR (What did I do?) I kept checking to see if he was coming and kept calling his cellphone, which was turned off. Which mode(s) were activated? Which mode was in play in this situation? Underline the aspects you recognize and describe them. 1. Detached Protector: 2. Abandoned/abused child: I was scared he wouldn’t come back because he doesn’t love me anymore. 3. Angry/impulsive child: I was getting more and more angry because he couldn’t be bothered to call me and say why he was going to be late and he even had his phone turned off. He does that on purpose. 4. Punitive parent: He’s right to not love me anymore, I’m an impossible person to deal with. 5. Healthy adult: JUSTIFIED REACTION (Which part of my reaction was justified?) He’s never late, so I was right to be concerned. OVERREACTION (Which reactions were too strong?) In which ways did I overreact or misread the situation? I overreacted by thinking that he doesn’t love me anymore, because I didn’t know why he was late. What did I do that made the situation worse? My abandoned child side kept calling him and because I couldn’t get through to him I became more and more panicked. DESIRED REACTION How would I like to be able to deal with this situation? As he’s usually on time and not late, there must be a good reason for being late. I only need to get angry if it turns out that he didn’t think of me. What could I do to help solve this problem? I could try to distract myself by doing something else other than just waiting and worrying. If he’s still not there in an hour, I could call the police or the hospital. FEELING Less anger and fear



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traced back to experiences from the patient’s past. These explanations of connections to her past situation can be very helpful in her understanding as to why she is so often faced with uncontrollable emotions from one moment to the next. The therapist doesn’t only use specific cognitive techniques, but also gives a lot of psychoeducation about the needs of children and what parents should normally do. This information also adds to changing the thoughts and feelings of the patient on a cognitive level. After using experiential techniques it can also be helpful to have a cognitive analysis of the situation to bring structure to the experience on a cognitive level. In the description of historical role play the combination of experiential and cognitive work is explained in detail (see Chapter 5, “Historical role play”). Once therapy has progressed to the point that the patient is capable of addressing her dysfunctional cognitions without being overwhelmed by negative emotions, the therapist can begin to teach her how to recognize the various nuances of thoughts using cognitive techniques. Beginning to teach these techniques too early on in therapy can result in the patient experiencing them as punishing or pointless. Later in therapy the patient will have developed a stronger healthy adult mode and will be able to look at situations in a more balanced way. When the therapist finds the patient able to fill in the remainder of the cognitive diary for the different modes (Table  6.1 and Appendix B), the two of them can begin to challenge the patient’s dysfunctional thoughts using a Socratic dialogue (see next section) and an experiment (see Chapter 7). The most common cognitive disputation techniques are often not adequate or sufficient for BPD patients. In the example given in Table 6.1, the differences between justified reactions and overreactions can often only be put into words once one of the more complex disputation methods has been used (see further discussion). The therapist and patient write these challenges down as additional information in the cognitive diary for modes. In using this method, different types of cognitive diaries can be used. More information on cognitive diaries is available in general literature about cognitive therapy. The following are common cognitive distortions that can dominate the patient’s thought processes: Overgeneralization—This is when one thinks that if something happens “one” time it will always happen. The patient can think, for example, that if she makes a mistake, whatever she is doing will never work and that she is a failure.

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Emotional reasoning—This involves basing conclusions about oneself and others on how one feels. For example, a patient concludes that the therapist cannot be trusted because she feels uncomfortable during sessions. Personalization—The failure or success a patient experiences involves far too much of her own personal involvement, despite the fact that in reality her involvement is limited. An example of personalization is a patient who thinks that the death of a close friend is the patient’s fault, when in fact the friend died of a serious disease. Bad luck does not exist—The patient thinks that accidents and coincidences do not exist. She thinks that everything is thought out and takes place on purpose. In this manner of thinking, mistakes become lies and forgetting something becomes an example of betrayal. A person who makes mistakes and/or has setbacks, deserves to be punished. If someone makes a mistake he deserves punishment and not empathy (there is no room for understanding). An example of this is the patient thinking that it is her fault she arrived late to an interview despite the fact she left on time but was delayed due to a flat tire. Thinking in black and white—This is when the patient can only think in terms of all or nothing. People are good or bad, something is true or false, any other possible explanations simply do not exist. For example, the patient may think that someone who is unemployed has no value. Thinking like this particularly stimulates the actions of the punitive parent mode and/or the detached protector. This reasoning can be disputed in a cognitive diary or during the session with the help of a Socratic dialogue in combination with complex cognitive techniques described below. The most important cognitive problem with BPD patients is that they have the tendency to think in terms of black and white. This often leads to solutions that are not well thought out and brings along with it many conflicts as well as strong emotions. Cognitive techniques, which help to develop a more nuanced manner of thinking, are of great help in adapting black‐and‐white thinking. The most important techniques in training an individual to think in a more nuanced manner are evaluation on a visual analogue scale, multidimensional evaluation, the pie chart, two‐dimensional reproductions of a supposed connection, the court house, historical testing, and making a self monitoring circle (Farrell & Shaw, 2012). Different manners in which to encourage healthy views and to strengthen healthy schemas are flashcards and making a positive logbook. All techniques will be described briefly as elaborate descriptions of these techniques can be found in, among others, Beck (1995); Beck, Davis, and Freeman (2015); Dobson and Dobson (2018).



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The Socratic Dialogue In order to discover which reactions are justified and which reactions are too strong, the therapist and patient can discuss her thoughts with the help of a Socratic dialogue. A Socratic dialogue between patient and therapist involves allowing the patient to discover that there is more than one possible interpretation for a given event. During this dialogue the therapist makes frequent use of open questions, beginning with the words “who,” “what,” “when,” “where,” “why,” and “how.” His goal is to encourage the patient to think about her dysfunctional thoughts. Examples of commonly asked questions are:

• • • • • •

How do you know that?—What facts support this argument; which oppose it? How does that work? How many times has that happened? What do the people in your general surroundings think about this? Imagine that this actually does happen, what is really so bad about this? If this does happen, what could you do about it?

To successfully participate in a Socratic dialogue the patient must have ­sufficiently developed her healthy adult mode. This is necessary for her to be capable of thinking up alternative interpretations. This is one of the main reasons that BPD patients are not capable of a Socratic dialogue ­during the first stage of therapy. Only once the healthy adult mode has become stronger can the therapist give the patient homework assignments such as filling in the cognitive diary, defying difficult situations, and attempting alternative interpretations (see Table 6.2). Upon completing the cognitive diary in Table  6.2, the patient can continue to fill in Table  6.3. However, this is not necessary if the alternatives have become clear to her.

Evaluation on a Visual Analogue Scale When a patient thinks only in terms of black and white about herself and others, she can be taught to appreciate different nuances on a visual analogue scale. This scale goes from one extreme (i.e., stupid) to the other extreme (i.e., smart). The therapist draws a line on a board or a flip chart and writes “stupid” (0) on the left, and “smart” (100) on the right. If the patient thinks that she is “stupid” the therapist asks her to place herself somewhere on this

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Table 6.2  Cognitive diary for modes (also see Appendix B) EVENT (What triggered my reactions?) My girlfriend said that she didn’t like it when I left her waiting for half an hour. FEELING(S) (How did I feel?) Strength of feeling Scared 80 THOUGHT(S) (What did I think?) Believability She doesn’t like me anymore and will break off contact. 90 BEHAVIOUR (What did I do?) I didn’t say anything. THE FIVE ASPECTS OF MYSELF Which aspect was in play in this situation? Underline the aspects you recognize and describe them. 1. Detached Protector: Could not deal with the thought of losing her and made me pull away. 2. Abandoned/abused child: Fear of abandonment. 3. Angry/impulsive child: 4. Punitive parent: You can’t do a thing right. 5. Healthy adult: DISPUTATION OF THOUGHTS (Ask critical questions about your thoughts.) Indications that my girlfriend no longer likes me and will break off contact: She said that she didn’t like it that I left her waiting. At first she didn’t believe that there was nothing I could do about it because my mother called and began to complain about everything. We didn’t make a new appointment to see each other. Indications that my girlfriend does like me: After we finished talking about my being late, she was friendly like she usually is. When we said goodbye, she said that we should see each other again soon. What would someone else say about this? That I shouldn’t make such a big deal out of it because I’ve known her for four years and in previous situations when she was angry with me she didn’t break off our friendship. ALTERNATIVE THOUGHTS It was logical that I didn’t like her criticism, but I don’t need to assume the worst in this kind of situation.

scale. In other words, to what degree does she believe that she is “stupid”? Generally speaking, she will choose 0 or close to 0. He follows this by asking the patient to place other people she knows on this same scale. Finally he asks her to again find a place for herself on this scale. He encourages her to first find two examples of extremes (i.e., a very smart/stupid person) and then to place ­different individuals between these extremes (see Figure 6.1). This way, she discovers that, contrary to what she thought when starting the exercise, she does not belong at the extreme ends of the scale. Nora ­completed



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Table 6.3  Continuation of cognitive diary for modes (also see Appendix B) JUSTIFIED REACTION It was unpleasant to be criticized and it is a good thing that I apologized. OVERREACTIONS (Which reactions were too strong?) How did I overreact or see things wrong? I overreacted by thinking that she didn’t like me anymore and that she would break off our friendship. What did I do to make it worse? The protector made sure that I kept my friend at a distance and because of that the evening wasn’t as nice as it could have been. DESIRED REACTION (How would you like to be able to deal with this situation?) It was logical that I didn’t like her criticism, but I don’t need to assume the worst. What would be a better way of dealing with this situation? I could have said to her that I was having trouble dealing with it and what I was really afraid of, so that we could have talked about it. FEELING Relief L C Nora A X 0 ----x------x--------x------x-------x------- 100 Smart Stupid L: mentally handicapped cousin C: friend who completed (lower) high school A: friend at university X: Nobel prize winner

Figure 6.1  Example of a visual analogue scale

the highest level of high school (in the Netherlands there are different levels of high school: VMBO (lower and average), HAVO (higher), and VWO (pre‐university)) and in the end placed herself in the middle.

Multidimensional Evaluation Should the patient gauge her self‐image or her image of others in one dimension (e.g., I’m not nice because I have no friends), then the therapist can, together with the patient, make an inventory of what other characteristics make a person worthy. They can also make an inventory of characteristics that make a person unworthy. The patient will no doubt name dimensions that “prove” that she is not nice (e.g., no friends, difficultly making social

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c­ontacts, and fear of speaking in social situations). The therapist should write these dimensions down, while at the same time stimulating the patient to try and think of more dimensions for the “nice” category. He does this by asking her what she likes about others and then to think about which characteristics make a person “nice” (or “not nice”). Once enough characteristics and/or dimensions have been found, these are also placed onto a visual scale with 0 being one extreme (when the characteristic is completely absent) and 100 being the other extreme (when the characteristic is absolutely present) (see Figure 6.2). Subsequently the patient places people she knows on these dimensions (Figure 6.3). The last part of this method involves the patient evaluating herself on these different dimensions (see Figure 6.4). The therapist can influence the individuals the patient chooses to evaluate by also suggesting people from the popular media who the patient does not personally know but who are known publicly as being not nice (e.g., serial killers or war criminals). When this method is successfully applied, the patient will end up with a much more nuanced and positive image of herself than she started out with (see Figure 6.4). (See Schema Therapy Step by Step 2.10 Punitive Parent—Cognitive Technique.) 1. Making an abstract concept concrete 0/ -------N-------------------------------------------------------/100 Not nice Nice Nora 0/ ----------------------------------------------------------------/100 Many friends No friends 0/ ----------------------------------------------------------------/100 Can get along Cannot get along with everyone with anyone 0/ ----------------------------------------------------------------/100 Will do anything Will not do anything for others for others 0/ ----------------------------------------------------------------/100 Works well Cannot work with others with others 0/ ----------------------------------------------------------------/100 Never in a bad mood Always in a bad mood Etcetera

Figure 6.2  Thinking up different dimensions



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2. Place others on these scales (including extreme cases, e.g. public figures) 0/ ----------L----------------------------------A---------C-----/100 Many friends No friends 0/ ----------L----------------------------------A---------C-----/100 Can get along Cannot get along with everyone with anyone 0/ ---------------------------A------------------------L----C---/100 Will not do Will do anything anything for others for others 0/ --L---------------------------C-------------------------A----/100 Cannot work Works well with others with others 0/ --------------A---------------L-------------------------C----/100 Always in Never in a bad mood a bad mood Etcetera

Figure 6.3  Placing others on a dimension 3. Let the patient score herself on the scales 0/ ----------L------N--------------------------A---------C-----/100 No friends Many friends 0/ ----------L----------------------------------A------N--C----/100 Cannot get along Can get along with anyone with everyone 0/ ---------------------------A----------------------N--L---C--/100 Will not do Will do anything anything for others for others 0/ --L---------------------------C----N-------------------A----/100 Cannot work Works well with others with others 0/ -------------A----------------L-------N-----------------C---/100 Always in Never in a bad mood a bad mood 4. Translate the conclusion to the first scale 0/ --------------------------L--A---------N-------------C------/100 Nice NORA Not nice

Figure 6.4  Placing yourself on a dimension

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Two‐Dimensional Reproductions of  Supposed Connections When the patient thinks that two factors are logically connected, one can test this theory to see if there are actual correlations between these two factors. In this case, two‐dimensional reproductions are the most useful. The dysfunctional thought that “success at work leads to ­happiness” was a reoccurring subject with Nora during therapeutic sessions. If the ­statement is true that “the more successful one is at work, the happier he/she is,” all of the individuals should have a position near the diagonal line in Figure 6.5. When the patient tried to place as many people as possible in this two‐ dimensional space, the previously assumed correlation became less clear than she originally thought. She began to realize that happiness must be based on factors other than success at work. In fact the only individual who ended up directly on the diagonal line was her brother who was addicted to heroin and had never worked.

Pie Chart A pie chart can help visualize the level of influence that an event or ­characteristic has on the whole. This method is particularly helpful with BPD patients who have a ­tendency to overestimate their own personal level of involvement (or fault) in various situations that go wrong. First, the patient must think of which individuals Happy * Friend who stopped Assumed association working * Friend who never worked

Not successful in work

* Neighbour

* Acquaintance

Successful in work * Patient

* Brother

* The queen

* Well-known movie star

Unhappy

Figure 6.5  Two‐dimensional representation of an assumed association between happiness and being successful at work



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and aspects influenced the given situation or played an important role in the situation. The therapist encourages her to think of as many different aspects as possible. After this, he asks her to give each person or aspect a part of the “blame” in the pie chart. Next, all the percentage parts are drawn in the circle as parts of the pie. The patient places her pie part last and discovers that she is not fully to blame; contrary to what she first thought when she rated her share 100% (see Figure 6.6). Putting the patient’s contribution into perspective has the additional effect that the punitive ­parent side is weakened.

Courthouse Method Another method of assigning “blame” or to “discharge” a person in a certain situation is the courthouse method. This is a form of role play in which the patient takes on the role of the prosecutor and the therapist plays the part of the lawyer who makes the arguments against the prosecutor. If this method works well, the roles can be switched so that the patient becomes the lawyer 5% 10%

25%

10% 10%

10% 15%

15%

1. Father was an alcoholic and did nothing 2. He had a serious problem with his intestines 3. Child protective services reacted too late 4. Her brother made several attempts at detoxification which he messed up 5. His friends were too late with calling the doctor 6. The dealer sold him stronger drugs 7. His girlfriend had just broken up with him and he didn’t want to live anymore 8. The patient kicked him out after he stole money from her

(25%) (10%) (15%) (15%) (10%) (10%) (10%) (5%)

Figure 6.6  Nora had a brother who died of an overdose of heroin when she was 16 years old. She was convinced that it was her fault because during that time in her life, she had to take care of her brothers and sisters. After making a list of exactly who and what else were responsible, she created this pie chart.

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and the therapist becomes the prosecutor. Sometimes it is helpful to have the patient play the role of judge who makes the verdict after listening to the arguments of the prosecutor and the lawyer. This technique is similar to the two‐chair technique (see Chapter 5); however, the courthouse technique is directed at dysfunctional thoughts while the two‐chair technique is directed at feelings and modes.

Historical Testing The patient’s schemas were developed early on during her childhood. Because of this, her self‐image has been distorted for the greater part of her life. Historical testing is a method of adjusting the incorrect image the patient has of herself based on her past experiences. Often BPD patients have the idea that they are bad and difficult and that they have always been this way. The therapist can test this theory by returning to each period of the patient’s life, choosing the periods in a way that they more or less line up with normal developmental phases. The patient first collects information about normal child development for each developmental phase. Then, ­different materials such as photographs, tapes, or videos, school reports, reports from child protective services and letters are analyzed to either support or refute the argument that the patient has always been bad even when she was a child (see Appendix D). Here it is particularly important to deal with the first few years of the patient’s life. Many patients think that they were bad from the moment they were born. By actually looking at baby photographs, therapist, and patient can test this theory. Of course there is absolutely nothing to indicate that a baby in a photograph is a “bad” child. School reports and such are carefully examined in the same manner with special attention given to the teachers’ comments. When it is feasible, family, old neighbors, teachers, and caregivers are also asked about the patient. Often the patient has a great deal of trouble doing this, as she is convinced that she will be confronted with proof that she truly is “bad.” This almost never happens in actual practice. Generally other individuals in the patient’s environment knew that there was something wrong in the family, but found it difficult to intervene. All of this is very helpful in creating a more nuanced self‐image for the patient. She often develops more understanding for the small child that she once was. By doing this she can see more clearly the strong role that her parent(s) and childhood traumas played in the development of her (later) problems. It becomes easier for her to send away her punitive mode as well as to offer more support to her abandoned child mode.



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Self Monitoring Circle When a patient doesn’t understand why a situation made her upset, she can make a self monitoring circle (see Figure 6.7) about her needs and feelings. Before making the circle, the situation is described. The circle starts with “what do I feel in my body?” “what do I think?” and “what do I feel?” In many cases the thoughts will be dysfunctional and the feelings negative. The next steps are describing “which schema or mode is involved” and what the facts are “what happened” (objectively) and “what do I want?” The last

Describe the situation

What do I want?

Underlying need

Physical awareness

Choices to meet need Thoughts

Facts

Action taken

Result: Was my need met? Schema and/or mode

Feelings

Figure 6.7  Self monitoring circle (derived from Farrell and Shaw (2012))

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part of the circle is describing the subjects in the middle of the circle from top to bottom. Now the need(s) can be described (“what do I need?”) and the ways the patient could have fulfilled them (“what could I have done to fulfill these needs?”). At the end she describes what she did do in reality (“what did I do?”) and what the results were (“what was the effect of my actions?”). (See Schema Therapy Step by Step 2.12 Vulnerable Child— Circle Diary Form.)

Flashcards The punitive parent mode often rears its head each time the patient is faced with something unpleasant in her life. A flashcard serves as an aid to memory and can help her deal with the unpleasant situation. The patient writes on one side of the flashcard the viewpoint of the punitive parent (“I feel guilty, therefore it is my fault that everything went wrong. This is what my punitive parent says”). On the other side of the flashcard she writes her new, more refined/balanced/nuanced view (“I feel guilty, but that doesn’t mean that I am guilty, because there could be other reasons as to why it didn’t work out. It could be bad luck or perhaps someone else had something to do with it. Even when I made a mistake this doesn’t mean that I am guilty of everything. The punitive parent is exaggerating and I don’t need this side right now”).

Positive Logbook Another way of strengthening the newly formed schemas is by means of a positive logbook. Individuals with a personality disorder have the tendency to be very selective in their memory and only remember experiences that reinforce their old, dysfunctional schemas. Because of this, patients must make use of their logbooks for a longer time and keep track of experiences and facts that oppose their old schemas and support new ones (see Appendix C). In the beginning patients require a great deal of support when using this method as they find it difficult to think of positive things. They forget to include small, daily situations such as cooking a nice meal or an hour at the gym, despite the fact that these contribute to a positive self‐image. Most patients think that they can only write down a positive experience in their logbook if it is unusually good, such as getting a new job or taking care of someone who was sick for a whole week. So, writing an application letter for



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a job or doing the shopping for someone who is sick seldom warrants a place in his or her positive logbook. Patients also tend not to include situations in which their response was good; however, the result was not what they had wished (either by accident or due to the influence of others). For example, the patient may have told her boyfriend in a very appropriate manner that she did not like that he did not show up for their previous date. Her boyfriend then reacted in a rude manner and the patient became upset and felt that this situation should not be put in a positive logbook. It is then up to the therapist to explain that in such a situation the fact that she dared to say what she normally would not say is actually a positive action and should go into her positive logbook. If the patient is keeping a positive logbook, the therapist should ask her about it at each session. If he does not do this, her interest in the logbook will fade. Cognitive techniques in combination with experiential techniques are a powerful means for procuring change. Although the chapter on cognitive techniques is relatively short in this book, this should by no means underestimate the importance of the cognitive work within this type of therapy. Therapists with no formal training in cognitive techniques will often miss the important skills in using ST. This is particularly evident with techniques such as verbalization, making concepts concrete and disputation of schemas as well as formulating healthy, new schemas. Most importantly the therapist must be able to transfer these techniques to his patient. She needs these techniques in order to refine her thinking, and to deal with difficult situations in the future in a better way. How exactly healthy thoughts can be translated into healthy behavioral patterns is described in Chapter  7 as well as in the section “Behavioral Pattern‐Breaking” in Chapter 11.

Frequently Asked Questions About Cognitive Techniques What if the patient responds with: “I see what you mean, but I don’t feel it.”? This is a common problem in the treatment of BPD when only cognitive techniques are applied. By combining cognitive techniques with experiential techniques, the cognitive insights can be integrated at a feeling level. For instance, if the patient cognitively sees she is not to blame for a mistake, but doesn’t feel it, the next step could be to use a multiple chair technique to find out what mode is related to the non‐integration at a

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feeling level, and then to proceed to get the new insight better integrated (e.g., first fighting the punitive parent mode, and next reassuring and explain the abandoned/abused child mode that she is not to blame). Similarly, imagery work and letter writing can be used to help the patient to experience the new insight. What if the patient doesn’t comply with cognitive homework, like filling out a diary? First of all, the therapist should avoid starting a power battle (“therapy involves homework, if you don’t do homework, the treatment won’t work”). Rather, the therapist should be interested in finding out what mode might have blocked the patient in doing the homework. Next that mode is addressed with one of the indicated techniques. Don’t expect BPD patients to do regular homework. Their level of functioning is often not yet high enough to be able to regularly complete homework. Usually they need to first feel emotionally better (the needs of the Abandoned/ Abused Child are already better met; the punitive parent has already been largely silenced) and healthier (Healthy Adult is better developed), before they are able to do homework assignments on a regular basis.

7

Behavioral Techniques

Behavior does not change simply because the patient has developed new insights. Thinking differently and feeling differently does not always ­automatically translate into behaving differently. In order to learn new behaviors, new skills must also be learned. Behavioral techniques can be used when the patient lacks the skills to translate new insights into new behavior. The behavioral techniques used in the therapeutic relationship have been briefly discussed in Chapter 4. For more in‐depth explanations of these techniques, we refer the reader to the extensive body of literature on behavioral therapy as well as professional courses in behavioral therapy. The following is a summary of applicable techniques with short descriptions of their use. It is important to realize that these techniques are only useful when the patient is capable of using her healthy adult mode. When this mode is sufficiently developed, she will acknowledge that she has the right to her own opinions and needs. Attempting skills training too early, one will fail as the punitive parent mode and/or the protector mode will constantly interfere with the therapeutic process (“I can’t do this either”) and thwart the therapy. The therapist must encourage the patient to try her newly learned behaviors not only during the sessions, but also in everyday life (see Chapter 11, “Behavioral Pattern‐Breaking”).

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Experiments Experiments are the natural progression of cognitive therapy techniques discussed in the previous chapter, as they are a manner in which the patient can actively try out her newly acquired insights (see Appendix E). When she comes to the conclusion that certain dysfunctional beliefs are incorrect, she may later begin to doubt again. Testing new vs. old beliefs in experiments is one way to strengthen her new schemas while at the same time weakening her old schemas. The therapist and patient discuss what steps the patient should take to find out which of the two schemas is the most accurate. Many patients have the tendency to deal with situations by means of their protector mode and are not used to paying attention to their needs. Due to their fear of being rejected again (which happened to them often in the past), they will avoid showing their needs. An experiment can help them to focus expressing their needs more often. Both therapist and patient prepare a number of concrete situations in which the patient can do this. The patient keeps a detailed record of what happens the moment she expresses her need, feeling, or opinion. After a few experiments she makes an evaluation and discovers that the dreaded rejection did not (or rarely) occur. This conclusion can attribute to weakening her dysfunctional schemas. Because of the patient’s past and her lack of healthy experiences, it is often necessary to train her in healthy behaviors before beginning with experimentation.

Skills Training and Role Play As previously mentioned, patients with BPD lack many of the social skills that most people take for granted. They never learned the skills or when they have the skills they don’t use them because of their detached protector. This has a strong influence on how they express anger and seek affection. Before the patient faces a new situation, it is necessary to explain what the acceptable behavior is for this situation and how you apply it. BPD patients often state that they raised themselves by watching others and this was how they learned to deal with various social situations. This resulted in partially adequate or completely inadequate knowledge and utilization of social skills. By using social skills training and role‐play, these skills can be learned.



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Social skills training and role‐play can be used as a means of preparing the patient for new situations. In this way her chances of developing new and better relationships are greatly increased and she learns how to behave differently in existing relationships. Daring to express her emotions and standing up for her needs are the main points of this method.

Problem Solving Problem solving deserves special attention in treating BPD patients. These patients have the tendency to swing back and forth between being i­ mpulsive and being dependent when it comes to thinking of solutions for problems. Patients can learn to be less impulsive by practicing adding a “thinking break” into the problem solving process. By doing this, patients learn to solve problems by splitting them up into smaller parts. This is followed by thinking up different possible solutions for each individual part of the problem and writing down the pros and cons of each potential solution. The therapist encourages her to think up as many different solutions as possible. He encourages her not to disregard any possibilities because either the punitive parent or the protector influences her. Only once a thorough assessment has been made to determine the most appropriate solution should the patient try it out and then evaluate it (see Appendix G).

Discussing Dangerous Behaviors The discussion of dangerous behaviors is a recurring theme in therapy with BPD patients. At the beginning of therapy, topics include suicide attempts, self‐injury (see Chapter 8, “Suicide and Self‐Injury”), and substance abuse. This is followed by other topics, such as the patient engaging in damaging relationships, resulting in her returning to old, dysfunctional schemas. Keep pressing the patient to stop the damaging behavior and discuss alternatives that will have a similar effect on her feelings of anxiety, restlessness, and anger. For example, encouraging the patient to try alternatives such as a warm bath and a glass of milk instead of alcohol when she is stressed. In addition regular discussion of the connection between these behaviors and the different modes that influence the behavior is also very important. Applying the appropriate techniques should follow this. One should not expect a quick change in the patient’s behavior and not be surprised when the “old” behaviors return when she is faced with an unpleasant situation.

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Discussing New Behaviors Discussing dangerous or damaging behaviors—or rather what the patient should not do—should always be coupled with discussing new behaviors. The new behaviors are the positive alternatives to dysfunctional behaviors and are feasible for the patient. There is little to be gained from advising the patient to avoid her boyfriend, who so blatantly neglected her, if no attention is given to the question of whom the patient should turn to for help and how she should ask for help. The patient has difficulty successfully assessing others while at the same time she also has the predisposition to pick the wrong individuals as a sort of confirmation of her own dysfunctional schemas. Only once the patient has developed a (strong) healthy adult side will her ability to judge others be improved. The alternative behavior should not only exist of serious adult behavior but also includes playful behavior. Most patients never were allowed to play and make fun. By starting with little playful things like singing under the shower and stamping in puddles in the rain the patient can strengthen her happy child mode. The second half of therapy is geared toward helping the patient find an appropriate hobby, study, or employment. Making new friends and developing close relationships (or relationship therapy to improve an existing relationship) is part of this process. Creating new and more intimate relationships is particularly difficult for patients who were abused as children and are generally distrustful of others. The abandoned/abused child must practice gradually exposing more and more of herself. She needs support in learning to express her needs and showing affection toward friends. Physical affection such as a hug is often particularly threatening for BPD patients as their past experiences with this type of affection were often in connection with force, sex, or punishment. Because of this, the therapist and patient carefully research which individuals can be trusted during this difficult behavior‐changing process. In using psychoeducation and advising the patient, the therapist is much less constrained than in other forms of therapy. He does this from a reparenting perspective and looks to support what is best for the patient. Slowly he allows her more and more autonomy over her own life, in the same way that a parent gives a teenager more responsibility. Treatment is considered complete when the patient has built up a relatively strong social network and is involved in daily activities that are beneficial to her as a person.



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Without applying behavioral techniques, the cognitive and experiential techniques often remain without grounding in the present life. The major fault with many therapies is that, while insight is developed, it is not actively put into use. Because of this, behavioral techniques are an indispensable part of ST as they put cognitive and experiential theory into practical use. The following chapter focuses on a number of methods and techniques geared for specific situations.

Frequently Asked Questions About Behavioral Techniques How do you know what is the right moment to start with behavioral techniques? The patient can start with learning new behavior in the first phase of therapy by stimulating the happy child. If this will work depends on the influence of the punitive parent. If this part “spoils” all the efforts to try something new, the therapist should pay a lot of effort to silencing the punitive parent. When the patient is able to play the role of the healthy adult in different situations outside therapy and during a session it is advisable to start with behavioral pattern breaking. The therapist can test the ability of the patient to perform new behavior by role‐play about a current situation or imagery about a situation in the near future. When in the later phases of therapy the patient has still not made healthy decisions and did not make steps in areas like friendships, partner, hobbies, and education or work, it is indicated to put these issues on the agenda and empathically confront the patient with the necessity of change to develop a more satisfying and healthy life. Of course, it may then become apparent that a specific mode constitutes a barrier to the change, and then the mode should be addressed along pushing the patient to make decisions and try out things.

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Homework BPD patients do not do homework in the “usual” manner of homework assignments in behavioral therapy. This is usually more the result of ­inability than of unwillingness. Because of this, it is better to recommend rather than require homework, while accepting when the patient does not succeed. It may be interesting to look into which mode is influencing the patient not to do her homework. The therapist can use certain tools to help the patient to engage in homework and/or to report what interfered with doing it (e.g., see Appendix F). During the sessions following a homework assignment, it is important to ask the patient regularly about her homework assignments even if she does not bring this subject up. The contents of the homework should always be connected with what has taken place during the session and can be related to any of the following subjects: Listening to recorded sessions—At the beginning of therapy, the therapist asks the patient to listen to the recorded sessions. Although this may appear to be a very simple homework assignment in theory, the actual practice of it is not simple. The patient may be afraid that she has said the wrong thing or perhaps sounds strange, which may result in activating her punitive side. Because of this, she avoids the assignment as much as possible. At other times she does not dare to listen to a session during Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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which strong or unpleasant emotions are involved when she is at home alone. The detached protector stops her from doing so out of fear she may experience an overflow of emotions while at home and without the support of her therapist. Or she is afraid of activation of the punitive mode. However, listening to these recordings can have a strong reinforcing effect of the therapy session. It is impossible to remember everything that took place during a session; therefore, re‐listening to the session allows the patient to retrieve more information. In addition, a patient often only discovers what the therapist meant upon relistening to a session recording. Sometimes this meaning is completely opposite to what the patient originally thought took place during the session (also see Chapter 3). Because of all of these reasons it is highly recommended that the therapist regularly enquires as to whether or not the patient is listening to the recorded sessions and how the patient experiences this (i.e., what modes were activated). Later in therapy, he asks occasionally, especially after a session in which the client became very emotional. Making special recordings—The therapist can choose to make special recordings about specific subjects. Common subjects for such recordings generally involve offering support to the abandoned child and refuting the punitive parent. The patient can then listen to these recordings as often as she finds necessary (see Schema Therapy Step by Step 2.14). Reading flashcards in situations where they are appropriate (see Chapter 6). Writing letters to individuals from the patient’s past (and not sending them) (see Chapter 6). Making a cognitive mode diary (see Chapter 6, “The Socratic Dialogue” and Appendix B). Keeping a positive logbook and if desirable asking the patient to read this aloud to herself (see Chapter 6 and Appendix C). Meeting friends and asking for affection from others (see Chapter 7). Relaxation and meditation/mindfulness exercises—The main reason therapists advice patients to do relaxation exercises is that they offer alternative forms of coping with strong emotions. They also have an added effect of replacing the need for the detached protector mode. There are many different types of relaxation and meditation/mindfulness exercises that are helpful in achieving this goal. The therapist should check whether the patient uses such techniques more to detach from emotions, which is actually a detached protector strategy, than to accept emotions, which is a healthy adult strategy. Early in treatment the patient’s healthy adult mode might not yet be strong enough to do such exercises in a healthy way.



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Doing things that the patient enjoys or is good at—By participating in activities that she is either good at or simply enjoys, she experiences success and hopefully satisfaction. These experiences are helpful in fighting her punitive side and strengthening the happy child. She also learns to discover her needs and how to take care of herself. In other words, the healthy adult learns to take care of the patient. Comforting—The patient must learn to comfort herself, if necessary, by means of a transitional object. This transitional object can be something she buys for herself (a stuffed animal) or something small that the therapist gives to her (a key ring or a card with something positive about the patient written on it). Experiential techniques can also be used as homework, for instance imagery of comforting and soothing one’s abandoned/ abused child (see also Chapter  9), and placing the abandoned/abused child symbolically at an empty chair and saying comforting things to it, from the healthy adult mode. Expressing anger about small issues (see Chapter 5, “Dealing with anger”). Two‐chair technique—The patient may try this technique at home, for instance when she discovers that her punitive parent mode is activated, placing it symbolically on an empty chair, combating the mode, and sending it away (see Chapter 5). Imagery rescripting—The patient may also try this at home. This is only advisable once the patient’s healthy adult side has developed to the point at which she can support and comfort the abandoned child. Before the therapist suggests that she tries this at home, it should have taken place successfully a few times during sessions. (However, the patient can practice in earlier stages with the help of a recording of an imagery rescripting during a session.) Trying out new behaviors (see Chapter 7). Trying out new activities, such as a new job, a new study, or different social contacts (see Chapter 7). (Example of several kinds of homework see Schema Therapy Step by Step 3.10).

Pharmacological Therapy There is no medication recommended by clinical guidelines as a treatment of BPD. Nevertheless, there are a number of medications commonly ­prescribed for BPD patients. As these medications are commonly used we

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have a few comments on this subject. We often see BPD patients with ­unintentional results of pharmacological therapy such as addiction and medicine abuse. The prescribed medications are often used in combination with alcohol and/or over‐the‐counter medications (e.g., pain killers) for suicide attempts. Antidepressive medication is useful in treating serious depressive symptoms. However, there is no convincing evidence that antidepressants are helpful for BPD, not even for the affective or impulsive problems these patients have (Stoffers et al., 2010). SSRIs may even hinder psychological treatment of BPD, although this should be rigorously tested (Giesen‐Bloo et  al., 2006; Simpson et  al., 2004). For sleeplessness, antihistaminics are to be preferred above benzodiazepines, because of the risk of habituation and addiction, as well as the negative impact of benzodiazepines on sleep quality, especially on the phase of sleep when memories are consolidated. Psychological treatment needs good consolidation of recent experiences in long‐term memory. Should anxiety‐reducing medication be indicated, we recommend neuroleptic agents over benzodiazepines. It is our experience that benzodiazepines can actually heighten emotions during crises, when in fact they are prescribed to mute or numb these emotions. This has probably to do with the disinhibitory effects benzodiazepines have, similar to the effects of alcohol. The risk of acting out and losing inhibition over behavior and emotions increases rather than decreases, in particular when benzodiazepines are used in combination with alcohol. This often results in an increase of self‐harm and/or suicide attempts. With patients that are affected the risks should be discussed including reasons to terminate the use of these kinds of medication. This will be done in close contact with the primary physician and psychiatrist. In general it is recommended that medication be used sparingly and for short periods of time. Learning to deal with one’s emotions, as well as being open to receive support and understanding is impaired when the patient’s emotions are numbed. The change brought about by experiential techniques is an essential part of therapy. Psychopharmacia subdue the emotional life and this is not helpful in bringing about deeper personality changes, which are the ultimate goals of Schema Therapy. Preliminary empirical data indeed suggest that patients using medication have fewer benefits from therapy than patients not using medication (Giesen‐Bloo et al., 2006; Simpson et al., 2004).



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Crisis During the beginning of treatment, BPD patients may experience episodic crises, as both objective and subjective factors can cause the patient to become overly upset. Most crises are caused because the patient makes things worse than they actually are. This is due to her dysfunctional ­schemas being unknowingly activated and the patient ending up in one of the dysfunctional modes. This is further exasperated by her fear of strong ­emotions and the punitive attitude toward needs and emotions. The therapist must try to release the patient from these crises as quickly and often as possible. This is of extreme importance in strengthening the therapeutic relationship and is an excellent moment to change the modes. During a crisis, emotions that are normally suppressed by the detached protector during the sessions are openly expressed. The therapist can make contact with the abandoned/abused child during the crisis and can comfort and reassure her. Should the angry child be in the foreground, the therapist could give her the opportunity to vent her rage. In case the punitive parent mode fuels the crisis, which is often the case, the therapist should not ­hesitate and put this mode on an empty chair, combat it, and send it away. The expression of emotions is encouraged and it is not advisable to look for practical solutions for the patient’s problems at this time. It is of great importance that the therapist shows the patient that he can handle strong emotions and offers her support and comfort.

Example of handling a crisis Nora calls her therapist in a panic because she is about to be evicted for not paying her rent, which was partially due to her roommates. T: I understand that you are shocked that your landlord is ­threatening to evict you. And you are angry that he suddenly walked into your flat. That makes perfect sense and is very understandable. Tell me the rest. Nora tells the entire story. The therapist interrupts her every now and then to make short comments that reinforce his sympathy with her situation.

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T: I hear that your landlord was very agitated. That is very difficult for you because that reminds you of your father who was also agitated very often. I can understand that you clammed up and at the same time felt very frightened inside. Don’t panic. I will support you because I know it is not your ­mistake. It is good that you phoned me, because I do understand you and your feelings. You are doing your best and you do not deserve this, etc., etc. Once she has calmed down, he tries to make connections with the modes. T: Now that I’ve heard the entire story I can understand why you feel so abandoned. The punitive side is no doubt arguing that this is your own entire fault, which is completely false. What you need is support. When you were young, you got yelled at when something bad happened to you, but that’s not going to happen here. P: But tomorrow I’ll be out on the street with nowhere to go. The therapist must suppress his impulse to look for a practical solution to this problem and continues to support her. T: I understand that you don’t know where you’re going to go tomorrow because you’re very upset. What did your roommates say when the landlord was there? P: They were pissed off and said that they would pay the rent back within a month. T: Thank goodness you’re not on your own! It’s good to hear that you have support in this difficult situation. If necessary the therapist offers an extra session or opportunity for phone contact later in the week in order to ensure that she receives the necessary support during this crisis. The therapist tries to link what is going on now and the activation of one or more modes, as well as experiences from her past that may possibly play a role. Most importantly, the therapist must show the patient that he is there for her and will not abandon her. He must ensure that she does not hurt



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herself or others while in this panicked state. He further encourages her to find others in her circle of family/friends to support her emotionally. Only once she is calm does he attempt to find practical solutions. However, usually the patient has already thought up solutions she is capable of following. There is a serious risk that the therapist starts to make suggestions on what to do (on a practical level), which will be experienced by the patient as a sign that she is rejected in her emotional needs and criticized because she didn’t do what is necessary. The risk is especially high when the patient in her hopelessness explicitly asks the therapist what she should do. Therapists should resist the inclination to give any practical suggestion, not even an emotion regulation technique, until the patient is calmed down through feeling understood and emotionally supported by the therapist, and ­liberated from any punitive messages from their punitive parent modes. If the patient is intoxicated (e.g., pills or alcohol) or has attempted to kill herself, this method is not applicable and the help of qualified medical staff must be called into play. Should this be the situation, the therapist can only begin to analyze the crisis once it is finished.

Suicide and Self‐Injury When a patient expresses the desire to commit suicide or threatens to harm herself (self‐injury), the therapist shifts all attention toward this, in particular to the mode that is driving this. Together with the patient, the therapist attempts to discover from which mode these suicidal or self‐injury desires come. In general, each mode maintains different “reasons” for self‐injury or suicide attempts. The protector commits these behaviors as a way of ­suppressing strong emotions such as sadness and fear. It is as if the patient prefers physical pain to psychological pain. For her, the latter is unbearable. The punitive parent uses suicide and self‐injury as a form of punishment for the patient’s faults and shortcomings. The angry child shows the same behavior in order to punish others around her for what they have done to her (see Chapter 9). After the therapist has determined which mode is at play, he then intervenes using the appropriate method for that given mode. Once these harmful behaviors have disappeared, he should begin each session by asking the patient if she still has the desire to harm herself, which mode was causing this and work with that mode. He has to continue to do so until he is certain this is no longer an issue.

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Self‐injury and other self‐destructive behaviors During the first few months of therapy, self‐injury, when already present, might be difficult to prevent. The reason for this is that the patient has not yet developed ways to deal with the mode underlying the self‐injurious or self‐destructive behavior. The standard strategy is to find out with the patient what modes are driving the behavior, and address the mode with the standard techniques—perhaps adding homework like flashcards and listening to short recordings with messages from the therapist. During this period, the therapist can make agreements with the patient in order to help prevent the most damaging of these behaviors, by replacing them with less damaging actions that have strong sensory stimulus (e.g., cold showers, holding ice cubes, and running fast). However, this should never be the dominant strategy, which is detecting the underlying mode and addressing it with appropriate techniques. The therapist can insist that the patient call him first before engaging in self‐damaging activities. The therapist attempts to curtail other forms of self‐destructive behavior such as periodic drug abuse, again by exploring what the underlying mode is and addressing the mode with appropriate techniques. In the case of serious drug addiction, sometimes the help of a detoxification center is necessary before ST can take place. In the end, this behavior will be reduced as limited reparenting and addressing the underlying mode reduce the influence of the modes that are responsible for these behaviors. The therapist may have to resist using formal limit setting to control self‐damaging behavior, as it may be too early to win the battle. Often the therapist has to tolerate self‐damaging behavior, while continuously encouraging the patient to stop.

Suicide When a patient is suicidal the therapist can temporarily increase the frequency of the sessions. This can be done either by adding an extra session or adding a few telephone sessions either at the discretion of the patient or planned. During these sessions, the therapist explores together with the patient what mode is underlying the suicide attempt and uses the appropriate technique for that mode. Meanwhile the therapist offers her as much support as possible. If the patient agrees, he makes agreements with individuals in her surroundings who are prepared to care for her on a temporary basis. It is important that he avoids including family members in these



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agreements, if they are the source of the problem. Further, the therapist consults with colleagues and may consider temporarily medicating the patient. Should all of this prove unsuccessful, the therapist can organize a crisis hospitalization, either voluntary or involuntary. It is impossible to continue with therapy when the therapist is constantly worried about whether or not the patient will commit suicide. If the frequency of these suicide attempts, in spite of the extra efforts of the therapist does not decrease, it is necessary for him to set limits on this behavior. When necessary he should organize that the patient is hospitalized in a psychiatric clinic or hospital (see Chapter  4, “Setting limits”). If hospitalization is ­inevitable the therapist tries to keep contact with the patient in order to continue the treatment after the suicidal behavior has diminished considerably. When the therapist doesn’t make an attempt to limit continuous ­suicide threats, there is a very high risk that he will overstep his own ­personal limitations and become discouraged with the therapeutic process and prematurely end treatment.

Trauma Processing The processing of childhood traumas is an important part of ST. This takes place after the patient has achieved enough safe attachment to the therapist. Imagery rescripting is generally used for trauma processing. This method is also used earlier in therapy to investigate the origins of the different modes by using childhood experiences to trace the patient’s dysfunctional interpretations and during the phase of changing dysfunctional schemas. Because of this, imagery rescripting will be a trusted method when it comes into use with trauma processing. If the patient does not bring up the trauma, the therapist should suggest this topic and ensure that it does not disappear from the agenda. This is a difficult phase of the therapy and timing is very important (just before the therapist’s holidays would not be a good idea). The patient must also have a relatively stable living situation (i.e., not in the middle of moving or a divorce). Further she must have support from someone outside of the therapy sessions. Even when all of these conditions have been met, the patient may not want to deal with her childhood traumas. She needs an acceptable explanation as to why it is important for her to work through these traumas. The single most important reason is that her basic feelings of abandonment, inferiority, and distrust are direct results of her

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childhood traumas. The constant reminders of these traumas serve to ­reinforce her dysfunctional schemas. In addition, the side effects from these traumas (e.g., nightmares and concentration problems) will continue to plague her until the traumas are properly dealt with. The trauma treatment described here differs from imaginary exposure in the sense that the key feature is not exposure to the trauma memories, but rather the rescripting. In phase 1, memories of the moment just prior to when the actual trauma took place are recalled (“just before mother started to hit me with a stick”). And in phase 2 a timely intervention takes place (“mother’s hand is pushed away and mother is put out of the room” = rescripting). In other words, the rescripting is what should have taken place at that time to protect the child. It is important that the dysfunctional, childlike interpretation (“I deserved to be hit because I was bad”) changes into a functional interpretation (“I was not a bad child and no child deserves to be beaten with a stick because she makes a mistake; my mother had a mental health problem that led her to hit me when she felt frustrated”). It is recommended in the later phases of trauma‐focused imagery rescripting that the patient should be encouraged to stand up for herself using her healthy adult mode. When she succeeds in stopping the violence or abuse, this will further reinforce the feeling that she is capable of solving her own problems. Once trauma‐focused imagery rescripting is finished, the patient will need time to assemble her emotions and discuss the conclusions. Therefore, it is important to schedule enough time for this type of session. An imagery rescripting session is generally followed by a more cognitive directed session. The patient can complete her cognitive diary as a homework assignment, focusing on the topics of guilt and shame. The therapist can make himself available on the phone, outside of sessions, should the emotions become overwhelming once the patient has returned home. He does this to try and help avoid a crisis.

Frequently Asked Questions About Processing Traumas How should I deal with strong emotions in processing traumas? Patients experience very strong emotions during these sessions. Because of this it is necessary that the therapist is well versed in dealing with traumas and is able to deal with these strong emotions, as it is his job to support her during this process. If the therapist cannot handle intense emotions, he will have to seek self‐therapy or supervision



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How should you deal with the question of whether something actually happened? The therapist must take care not to suggest memories of events that did not take place. If the patient is unsure as to whether or not an event actually took place, the therapist must emphasize that whether an event is factual or not is not of the greatest importance here. For this method the focus is how the patient experienced this event (factual or not) and how the conclusions she drew, based on this, influenced the ­development of her dysfunctional schemas. Several guidelines recommend to not use information obtained during such sessions against perpetrators in a legal sense. In Chapters 4–8, various therapeutic methods and techniques used in ST were discussed. When possible, the appropriate phase of therapy and the mode for which the technique is intended was given for the ­different techniques. However, this is not sufficient to go by or treat the different modes in the most appropriate manner. Because of that, Chapter  9 discusses the techniques for each different mode separately.

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Each mode demands a different, unique approach. Some of the previously mentioned techniques are better suited to certain modes than others. This is further complicated by the fact that the different modes are constantly interchanging with each other, both during sessions and out of sessions. One mode influences the other without the patient appearing to have any control over them. The therapist should try to name the modes he observes during sessions as they occur. Similarly, when the therapist discusses important problems that recently occurred, it is explored what modes were triggered and how they influenced the patient’s feeling, thinking and ­behaving. Eventually the patient will also learn to differentiate between the different modes, both during and outside of sessions. Not all of the ­ ­techniques we have described in Chapters 4–8 are recommended for use with all of the modes or during each phase of therapy. Because of this we describe which techniques in the field of feeling (experiential techniques), thinking (cognitive techniques), and doing (behavioral techniques) can be used with which mode and how to adapt the therapeutic attitude toward each mode. We have also included information about pharmacotherapy and which obstacles the therapist may face, while reacting to one of the modes. However, even this is not enough to adequately put this therapy into practice as the modes continually change requiring the therapist’s attitudes and methods to also continually change as necessary. In the section “A Simultaneous Chess Play in a Pinball Machine” later in this chapter, we Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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describe how the therapist can best deal with the quick and constantly changing modes during therapeutic sessions.

Treatment Methods for the Detached Protector First there has to be an agreement that the detached protector is dominating the patient’s functioning, either in the here‐and‐now, or in a recent problem that is addressed. The treatment techniques for the detached protector are also largely applicable to the angry protector, the bully and attack mode, or the self‐aggrandizer. What is important that you notice it in the session and point it out to the patient. Usually this is done in a tentative manner (“Is it possible that you are (were) in your detached protector mode?”). Alternatively, the patient can be asked what mode she thinks she is (was) in at the moment. If the patient denies that she is in the detached protector mode while it is clear to the therapist that this is the case, the therapist can also respond more directly and explain why he thinks so. Then you explain the development in childhood and empathize with its adaptive value. You don’t send the protector mode away but negotiate with it with the aim that the protector takes a step aside to allow contact between the therapist and Little Nora. What is important is that it becomes clear what the triggering events are that activated the protector mode. There are different techniques we can use: You can review pros and cons of detaching in the present and motivate patient to reduce this protection. You can do imagery exercises. You can do a multiple‐chair technique in which we practice dialogues between the detached protector and the healthy adult.

Therapeutic relationship In the beginning of the therapy the therapist must often deal with the detached protector. It is one of the most difficult modes to break through. The patient doesn’t trust the therapist yet and she is frightened of the strong emotions of the abandoned/abused or angry child. She also fears punishment and/or humiliation from the punitive parent. The therapist must regularly reassure the detached protector that he will protect Little Nora against the punitive parent. And he promises that he will support her and help her



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deal with too strong and often unpleasant emotions. He encourages her to express her emotions step by step. When the therapist is aware of the fact that the patient is in the detached protector mode he has to point it out to the patient. He speaks to the patient, implicitly to her healthy adult side, about the detached protector in a friendly voice and empathizes with its adaptive value. He explains the origin of the detached protector in childhood and acknowledges that this side was a survival strategy then. He also explains that a detached protector is less useful in the present, especially in therapy. During each session, the therapist must continually try to bypass the detached protector even if this takes a great deal of effort. While the patient is in her detached protector mode, it is not possible for the therapist to reach the abandoned child with limited reparenting (see Chapter 4). At times the protector can even become aggressive (angry protector mode) or even attack the therapist (the bully and attach mode), or putting him down by denigrating him (self‐aggrandizer), often as a result of the patient not having enough trust in her therapist. Because of this, the protector is prepared to do, and does, anything and everything to ensure the therapist does not get near the abandoned/abused child. The protector does this with the aim of protecting the patient from further abuse. This means that the therapist must have patience and continue to earn the patient’s trust in him. He must make it clear that the fact that she does not trust him is understandable. He must express empathy with her, let her know that learning to trust someone takes time, ­particularly if one has a past of putting their trust in untrustworthy individuals. The therapist can choose to increase the frequency and/or length of the sessions in trying to bypass the protector because usually the protector will back down in this situation. The therapist must be aware of the fact that he has to treat his patient very carefully, keep his promises, and start each session on time. Trust develops slowly and ­vanishes very quickly. Outside of the session the protector can show their side by means of self‐ injury or suicide attempts. To an extent, physical pain protects the patient from emotional pain. In this case, all attention must first focus on reassuring the patient that the emotional pain will be healed in the treatment and that the therapist will help the patient to achieve this. The therapist must ensure that he is easily accessible to the patient in this situation and that a crisis center is available when he is not. If possible, he should handle the crisis himself (see Chapter 8).

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Feeling One of the best methods for bypassing the detached protector is the two‐ chair technique. The therapist asks the patient to sit in a different chair, be as it were the detached protector, and from this position put into words why the protector is needed. While in this other chair the patient can put her fears into words without immediately becoming emotional. Then, the therapist can have a discussion with the protector. During this discussion he emphasizes that the protector had a functional role in Little Nora’s past when she was unable to escape her difficult situation, and that it is still has a function, when Nora feels overwhelmed and does not know how to deal with her emotions. However, now, in the treatment situation, Nora’s situation is different and she can allow Little Nora to be protected by the therapist and he will teach her how to handle emotions in another (more adult) way. The therapist reassures the detached protector than he will not reject, abandon, or abuse Nora for expressing her emotions and needs, and asks the detached protector permission to talk with Nora about her emotions, problems, etc. When the relationship between therapist and patient is strong and trusting, the patient often becomes emotional by this reassurance and moves into the abandoned/abused child mode. The therapist can then point out the mode switch and ask her to return to her original chair and continue the discussion with the abandoned/abused child. When the protector agrees that the therapist continues with the abandoned/abused child, he asks her to return to her chair even if she is not visibly emotional. Another possibility is to avoid the protector altogether by asking the patient to close her eyes and imagine Little Nora and ask her how she feels. If this is successful, then the therapist can try to reach the abandoned/ abused child in this manner and encourage her to express her feelings. If this is not successful, the therapist can also apply imagery by asking the patient to go back in fantasy to the moment last week where the detached protector became activated. Lastly, the therapist can ask the patient when the detached protector was activated, and then discuss the difficult situation that triggered the detached protector. While validating the use of the detached protector to deal with the difficult situation, the therapist focuses on the feelings involved and explores them. This strategy often leads to bypassing the detached protector.



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Thinking The detached protector has advantages (in the short‐term) and disadvantages (in the long‐term). The therapist and patient can investigate these pros and cons and can write them down on a white board. In practice, it is the patient who will think of pros and the therapist must help to find cons. The therapist always starts with the pros because these are much more obvious for the patient. In fact, she is right in the short‐term while her life still is full of difficulties and terrible feelings (so the detached protector makes her feel less bad). The therapist points to disadvantages in the here and now (such as loneliness and making no progress in life) and in the long‐term (e.g., no healthy relationships, no effect of treatment, etc.). He must explain why it is in her best interest to learn to deal with her feelings and emotions. This is an important skill for future intimate relationships and/or having children. Further it will help her with her general development as a person (see Table  9.1). This cognitive technique helps the patient to lessen the detached protector mode. Table 9.1  Examples of the pros and cons of the detached protector Pros

Cons

I feel quiet I don’t feel the urge to cut myself I don’t have conflicts with other people I don’t have to talk about difficult issues in the session I don’t have to try new things like working or studying

I feel empty If I suppress my feelings too long, I’ll end up hurting myself I am lonely because I don’t connect with other people (or my therapist) I cannot start a new relationship when I stay detached I don’t learn how to handle emotions, so I should better not raise children. Otherwise they’ll get the same problems as I have I don’t learn how to overcome my problems If I don’t find new work or a training course, I will never get a normal income If I stay in the detached protector mode, my life will be boring I won’t find out what I like and dislike.

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The other cognitive techniques described in Chapter 6 are less useful in the first phase of therapy. This is because what appears to have changed on a cognitive level is often not assimilated at an emotional level. The new insights will not sink in, as the detached protector blocks connecting the new insights to the emotional level. In the last phase of therapy the patient could use a cognitive diary when the detached protector gets in the way outside the session.

Doing The patient must learn to spend less time in the protector mode both during sessions and outside of sessions. She can only be successful in doing this outside of sessions once she is able to do so during sessions. Further, the patient also needs to build‐up trust in others outside of the therapeutic framework. The therapist encourages her to share her feelings with others more and more often. If she has little contact with others, he can encourage her to participate in activities where she is likely to meet people regularly. Once she has developed relationships with a few good friends, it is helpful to invite them for one or more sessions to stimulate the patient by encouraging her to practice expressing her emotions toward them. Some patients can benefit from activities for the happy child. When they are able to do some relaxing or funny things (like going to the swimming pool and going down the slide instead of doing exercises) or dancing. If the patient can really make fun she is not in the detached protector.

Pharmacotherapy The use of psychopharmacology has been suggested if the patient’s level of fear and panic, or other emotions like anger or sadness, reaches a point that she can no longer tolerate. However, there are at least two reasons to be extremely careful with the use of psychopharmics during ST. First, there are indications that pharmacological agents interfere with the emotional and cognitive change processes during treatment, so that recovery is delayed (Giesen‐Bloo et  al., 2006). Secondly, their application might actually strengthen the detached protector mode, the opposite ST aims for. BPD‐ patients have a tendency to view even normal emotions as pathological, and both from the detached protector and the punitive parent modes believe that the best solution is to shut off emotions. Prescribing medication when emotions are high might reinforce such views. It is recommended to explore why the patient feels the emotions should be dealt with by medication (in other words, by a chemical agent that strengthens the detached protector),



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for example, whether she fears loss of control (detached protector), ­activation of the punitive parent mode, or intolerable feelings of abandonment (abandoned/abused child). The therapist can then try an appropriate technique instead of referring the patient to a psychiatrist. Should everything go well, after about a year the protector will be much less present. Further, the times that the protector is present, it will be much easier to set him on the sideline.

Frequently Asked Questions About the Detached Protector How do I know that my patient is in the detached protector or is really too tired to talk about her difficulties? If the patient appears tired or sleepy, it is almost impossible to get through to her. The therapist must first find out if this is due to an actual lack of sleep and if so, which mode is responsible for her insomnia. Once this is established, the therapist and patient can work together to improve her sleep patterns. However, if there appears to be no physical explanation for her being tired, it is more than likely the result of the detached protector. In this case the therapist can try different methods to “wake her up” such as opening a window, talking louder or even (gently) shaking her. Often it is helpful to begin with a difficult subject, which is more likely to force the patient to become more alert. It can also be helpful to explore when this state started and discuss whether this is related to any difficult situation around that time. What should I do when the patient dissociates? When the patient’s “absence” begins to take the form of a dissociative state, the therapist can attempt to remove her from this state by means of concentration exercises such as controlled breathing, focusing on a certain point in the room, and having her describe where she is and with whom. He continues to reassure her that he will protect her from her punitive side. While doing this the therapist tries to discover what made the patient so frightened that she went into this dissociative state. He further tries to connect the results of this search to traumatic experiences from the patient’s past. Can psychotic symptoms be part of the detached protector? Large amounts of stress combined with serious fear can result in short‐term psychotic symptoms. These psychotic symptoms often have a paranoid

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content. For example, the patient may think that her therapist is about to hit her, or she sees him looking at her in an aggressive manner. In these situations, it is as if the therapist becomes the abusive parent. In mode terms, a suspicious overcontroller mode is activated. Thus, this is a more active and overcompensating mode than the detached protector mode. When not present on a more regular basis, this paranoid suspiciousness is often related to an intense threat experienced by the abandoned/abused child mode. Just as when a patient becomes dissociative, the therapist must also slowly, and in detail, reassure her and try to bring her back to reality when she shows psychotic symptoms. As the stress levels decrease, these psychotic symptoms will also decrease. The therapist does not need to worry about a full‐blown psychotic episode based on these symptoms. Temporary use of antipsychotic drugs is sometimes indicated. What can I do when the detached protector turns into an angry protector, a bully and attack mode, or a self‐aggrandizer? Sometimes the patient becomes even more disturbed when the therapist pushes too much to decrease the detached protector and the patient becomes angry with the therapist or even attacks him verbally. She can also disagree with the therapist in a condescending way (the self‐aggrandizer). The therapist must inquire what he said or did to disturb the patient and at the same time be aware of the fact that this is again a survival strategy. So do not take it too personally but go on with your strategy to bypass these protectors. How can I distinguish a detached protector from a healthy adult? At times the therapist does not know whether or not he is dealing with the protector as the patient makes apparently sensible statements while at the same time asking the therapist to come up with practical solutions for her situation. He may think that he is dealing with the healthy adult. To clarify the situation the therapist can ask his patient about her feelings. If she appears to have a flat emotionless reaction, then he knows he is dealing with the protector. Looking for practical solutions while the patient is in the protector mode is seldom a good idea, as this mode is not focused on the needs of the vulnerable child and healthy adult modes. On the other hand, if she responds in a nuanced manner, then the therapist knows he is dealing with a healthy adult mode. When the patient is in the healthy adult mode or even when she is in the abandoned/abused child mode, if the patient feels that she has enough



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s­upport from the therapist it is possible for her to think of practical solutions herself without the detached protector. What can I do if the patient doesn’t want to talk with the therapist when she sits in the chair of the detached protector? If the patient refuses to talk to the therapist when she is sitting in the chair of the detached protector (or one of the other coping modes), the therapist can also suggest that the patient sits next to him and that he talks to the empty chair. He can then ask the patient, who is sitting next to him, what the detached protector answers. This technique is similar to how the therapist can deal with the punitive parent in an empty chair. The difference is that he does not send the detached protector away.

Treatment Methods for the Abandoned/Abused Child Therapeutic relationship As discussed in detail in Chapter  4, building a trusting therapeutic ­relationship with the patient is a continuous point of interest from the start of therapy onwards. When the patient is in the abandoned/abused child mode, the therapist can support and comfort her. Further he can help her discover different healthy options for meeting her needs while respecting the needs of others. It is not necessary to think up practical solutions for her problems at this point, but rather for the therapist to empathize with the feelings, needs and rights of the patient. It is of particular importance for the therapist to be supportive in a warm and understanding manner. His patient should clearly hear this in the tone of his voice and mannerisms. During difficult periods in the patient’s life, the therapist himself can either call her or allow her to call him or write an email or text message between sessions as extra support. He can also record an audio flashcard in which he says nice things about the patient (see Schema Therapy Step by Step 2.13 Vulnerable Child—Audio flashcard). The purpose of this is also that the patient learns to feel empathy for the little child she once was. As therapy progresses, the healthy adult mode will offer more and more of this needed support to the abandoned/abused child mode. Because of this, the extra attention (e.g., between‐session telephone calls) will become less necessary.

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Feeling Virtually all experiential techniques are helpful at this stage of therapy. Using experiential techniques gives the abandoned child the opportunity to express her feelings. These techniques, in particular imagery rescripting and historical role play, also show her that it is perfectly normal to ask for and receive help and support when one is dealing with difficult situations. Later in therapy she will learn to integrate this attitude into her healthy adult mode and will not require the therapist’s support as often. To encourage this, it is good to stimulate the patient to play the role of the healthy adult, who takes care of the abandoned/abused child in imagery rescripting. For most BPD patients this is not possible until the final phase of therapy. When patients were forced by circumstances to take over the role of parent(s) during their childhood, the therapist must take care not to expect the patient to take the role of healthy adult too early in therapy. The patient must first have a period during which she can be a child and experience the care of the therapist before growing up and becoming a healthy adult. In historical role play, the third phase, in which she must try out different behaviors, will be the most difficult as she will have to think of alternative behaviors that she does not yet possess because her personal experience is very limited. The therapist can help by modeling options before the patient herself tries them.

Thinking By using cognitive techniques, the patient can learn what a normal childhood involves. She can incorporate what she missed during her own childhood as well as learn how to fulfill her needs in the future. The patient can read about general childhood development to increase her understanding of normal development. Furthermore, the therapist can suggest that she learns about the universal rights of children to get an idea of what normal standards actually are. The therapist can make flashcards or recordings in which he says positive things about the patient and asks her to read or listen to these at home. One of the most important mistakes the patient makes when she is in the abandoned/abused child mode is concluding that simply because things happened in a certain way, they will always happen in this way. She has an inadequate perspective of time. The concept of (very bad) things becoming less painful over time can help her become less anxious and sad.



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Another cognitive technique to reassure the abandoned child that she is doing well is making a positive logbook (see Chapter 6).

Doing The therapist shows the patient that he appreciates her by speaking in a friendly and respectful manner to her. He also regularly praises her to show his recognition of her as a person as well as her efforts to learn how to do things in a different manner. The patient must also learn to give herself compliments. Sometimes it is necessary for a patient to temporarily break off contact with her parents or other individuals who have a damaging influence on her life. This is especially necessary if the parents continue to respond to the patient in the same dysfunctional manner as when she was a child. In this case it is best to limit contact to a minimum until the patient has developed an adequately strong healthy adult mode. Once she has done this, she can decide for herself whether or not she wants to retain contact with her parent(s) and in which way. Limiting contact, even briefly, is very difficult for the patient. She often feels frightened she will be plagued by feelings of guilt (punitive parent mode) or end up feeling even more alone in the world (abandoned/abused child mode). She will trivialize the negative influence of her parent(s) and may even become angry with her therapist (angry protector or bully and attack mode). Where there was “only” emotional abuse or neglect, instead of physical or sexual abuse, the patient will be particularly reluctant to reduce contact with the parents. The therapist must therefore be cautious when dealing with this topic and discuss both the pros and cons. This requires a strong, safe therapeutic relationship and possibly the therapist making extra time for the patient. An important catalyst for a temporary break in contact with the parents is often that despite having two sessions a week, therapy is not progressing due to the daily negative influence of the parents. (The same may hold for partners and friends). As described in the section on the protector, the patient can practice sharing her feelings and asking for and receiving support from new contacts. Self‐practice with imagery work, for example, soothing the abandoned child, might be helpful to make it through this difficult period. Box 9.1 offers instructions for the patient for a soothing imagery exercise for the abandoned/abused child mode.

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Box 9.1  Imagining comforting your abandoned/abused child mode When to use this imagery: when you are feeling emotionally vulnerable, sad, anxious, etc., or having an intrusive memory of negative events from your childhood. Steps: 1. Close your eyes and take a moment to notice the thoughts you are having and the emotions you are experiencing (including where you feel these emotions in your body). This will help you to know how to best comfort your inner child. 2. With your eyes closed, imagine your child self being beside you or in front of you and imagine giving them a hug. You may wish to say or whisper to her reassuring words to help sooth her and assure her that she is safe/loved/capable, etc. If you are struggling with this image, perhaps focus on just taking your child self ’s hand. After a minute or so, try changing perspectives, such that you become the child receiving the hug from your adult self, and hearing the reassuring words being whispered to you. Before you finish the image, move back into the adult self ’s perspective. Sit with this image for 30 s to 5 min in total—stop once you feel your child self has been soothed. 3. Take a moment to ground yourself back to your present surroundings. First become aware of your body sitting in the chair, next become aware of the sounds inside and outside the room, then open your eyes and look around, noticing the objects around you. 4. After this it is best to change the activity you are doing so that your mind does not go back to thinking about negative things. At least go get yourself a glass of water or splash your face with water before returning to the physical space you were in. Note: This exercise was developed by Georgie Paulik. Reprinted with ­permission of the author (Paulik, Steel, & Arntz, 2019).

Frequently Asked Questions About the  Abandoned/Abused Child When does limited reparenting become too much? The therapist can become too good a parent. Too much extra care for the patient can result in the therapist overstepping the boundaries of the



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therapeutic relationship. Young, Klosko, and Weishaar (2003) defines the boundaries for the therapist as follows: “The therapist has no contact with the patient outside of the work relationship and does not make the patient too dependent upon him or satisfy his own needs via the patient. This is about ‘limited’ reparenting not actual parenthood.” So limited reparenting doesn’t mean your helpfulness knows no bounds. Therapists should be alarmed when they become a means of soothing and the patient becomes difunctionally dependent on them. It is important to keep in mind that functional parenting involves frustration for the child (not all needs of the child are (immediately) fulfilled; the child needs to make challenging and often frightening steps to mature). Similarly, limited reparenting should involve frustrating the patient in a functional way to help patients to develop in a healthy way. When does limited reparenting become too little? The therapist can set himself too far away from the role of a parent and find the patient’s behavior childish. He must be willing and able to accept at least part of the patient’s problems as from a young child who does not have the ability to deal with these problems on her own. The therapist must be willing to put extra energy and time into treatment. He must see the patient not as greedy, but rather as someone who is in need of certain things. In doing so, he must find a balance between “too much” and “too little” in regard to fulfilling her needs. It is helpful for the therapist to tell the patient that her needs are ­normal, and he understands them but cannot always be 100% able to meet them immediately or in the way the patient expects or even demands. By doing so, he does not disregard these needs or insist that the patient repress her emotions (something the punitive parent would do). But he also sets limits to unreasonable demands and to demands that are not unreasonable, but the therapist is not able or willing to meet. This will help the patient to build up frustration tolerance.

Treatment Methods for the Happy Child Therapeutic relationship The therapist doesn’t have to be serious all the time. He can take the advantage of the opportunity when it is possible to laugh about a funny story of the patient. Or he tells a story out of his own experience. Sometimes stories about his own or other children can illustrate how children make fun.

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Feeling At the end of an imagery rescripting exercise it is important that the therapist does something playful with the child, or let the child play with other children. After he has protected and comforted the abandoned/abused child, he suggests doing something playful together (or with other children). The patient will very rarely suggest this, because her parents usually did not propose her to play. So playing together will give the patient a totally new experience.

Thinking Educating the patient about the natural need of children to play, the playfulness of adults, and the use of playfulness is usually indicated. It might be important to explain that therapy is not only about reducing away the negative, but also about helping patients to find the positive (joy, happiness, spontaneity, creativity, connecting, etc.). Other cognitive techniques are usually not indicated for developing the happy child. When the patient says that playing is useless and a waste of time, this will be the voice of the punitive or demanding parent. So silencing the punitive parent is of course a very good way to make room for the happy child.

Doing Using real children’s games like blowing balloons or bubbles or tug‐of‐ war can also be applied in therapy (see Chapter 2). In the later phases of therapy, patients can be stimulated to try out new activities and hobbies, so that patients discover what they like and what makes their life more rewarding.

Frequently Asked Questions About the Happy Child What can I do when the patient thinks playing is silly? When the patient says playing is silly, he is probably talking with the voice of the punitive or demanding parent. In that case the therapist has to switch to fighting the punitive parent. Another problem can be that the therapist is not used to paying attention to the happy child himself, because he has learned that therapy is a serious business. In that case he should ask for help from his colleagues (especially expressive, art, and psychomotor therapists).



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Treatment Methods for the Angry Child Therapeutic relationship The angry child requires a safe therapeutic relationship. Within certain boundaries the angry child should be able to express her anger (see Chapter 5, “Dealing with anger”) and also learn appropriate assertiveness (see Chapter 7, “Skills Training and Role Play”). This entire topic of anger is usually faced later on in therapy, as the patient does not dare to express these emotions early in therapy out of fear of the punitive parent mode or rejection by the therapist. At times, the patient is so frightened of her own aggression that she does not show up for the session at all. In this case the therapist can call her at the time she should have had her session and discuss her fears with her. He can try to reassure her that he will not be shocked or punish her when she becomes angry, but rather help her express her anger. If the patient fears becoming uncontrollable and accidentally hurting the therapist, they can agree that if she loses control, she can temporarily leave the room only returning once her rage has diminished. A better method is to show her how to vent her anger safely by, for example, hitting a pillow. The therapist demonstrates this by actually physically hitting a pillow and shouting. In doing so he encourages her to do the same, always keeping a pillow close at hand should her anger flare up. In this way the patient gets the message that anger, no matter how strong, can be safely released. However, the expression of this anger must take place in a nondamaging manner. This allows many patients enough security to express their anger more and more often. A special case is when the patient is angry toward the therapist, from the angry child mode. It is often very difficult for therapists to deal with strong anger, reproaches, and accusations directed to them as a person. Therefore, the following ventilating technique is recommended. As soon as the therapist feels that it is from the angry child mode that the patient is angry at him, he switches into using this technique. Contrary to the usual rule that the mode should be tentatively labeled, the therapist postpones checking with the patient what mode is related to the anger. However, it is good to acknowledge that you understand that the patient is angry at you. Therapists should then try the best they can to behave like a neutral “complaint officer,” a neutral professional who documents all the complaints the person has. The therapist takes a piece of paper and writes down the complaint and reads it to the patient to check whether he accurately noted it. Before dealing with

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the complaint, he asks the patient whether there are any other issues she is angry about. He writes down the next issue, and repeats reading the two issues to the patient to check whether he correctly understood the patient. Next he asks whether there is something else the patient is angry about toward the therapist, writes it as literary as possible and reads all the issues to the patient to check whether what he wrote down is accurate. This procedure is repeated until all the issues that the patient is angry about are noted. It is important to write down the accusations of the patient as literary as possible, and postponing any discussion, interpretation, defending, empathizing, etc. The idea is to profit from this usually unique moment, when the patient can no longer suppress the angry child mode, and to (finally) give the patient the opportunity to ventilate anger in a safe context. Non‐neutral actions like empathizing, apologizing, defending, correcting, or interpreting will either lead to the patient starting to suppress the anger again (and triggering the punitive parent mode) or to escalation. Usually, after all the anger is ventilated, the patient is calmed down and the therapist can choose among a range of possibilities, including:

• • • •

• • •

Empathizing: the therapist indicates that he can understand that the patient is angry because she has also been treated badly or unreasonably or because many things went wrong. Reality testing: help the patient find out what was correct and was incorrect in the accusation. Explaining the real reason of the therapist’s behavior, apologizing when indicated, etc. Educating the patient about anger (normalizing it and explaining its function) and about the effects of too long suppression of irritation and anger (a small trigger can lead to a difficult to control explosion of built‐ up anger), and motivating the patient to work on earlier expression of anger and irritation. Sharing the impact of the initial anger of the patient and motivating the patient to work on earlier and more appropriate expression of irritation and anger, and building appropriate assertiveness. Exploring whether the patient has similar anger problems outside therapy, to motivate the patient to work on better dealing with anger and/or to detect the shared schema that is triggered. Underneath the angry child’s anger there is usually a “vulnerable” emotion of the abandoned/abused child mode. After fully ventilating all the anger built‐up against the therapist, it is often worthwhile to explore the v­ ulnerable



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feelings and next choose an appropriate technique to process these. Common examples are feelings of rejection, neglect, and abandonment. It should be stressed that all the anger toward the therapist should first be fully ventilated before one of these possible next steps can be taken. Also keep in mind that usually there is an understandable reason why the patient stands up for her rights, even if a lot of the accusations is based on misinterpretations or on exaggerations. Furthermore, this ventilation technique does not work with angry coping modes, like the bully and attack mode, the angry protector mode, and the self‐aggrandizer. The therapist should be certain it is the angry child mode that drives the anger toward him—usually this can be felt because there is a feeling of being hurt by the therapist with the patient fighting for recognition of her emotional needs. In contrast to the coping modes, that want to create a distance to the therapist, the angry child mode wants connection and her needs to be met by the therapist. Lastly, as this is a very difficult technique, therapists are urged to practice the technique in role‐plays before starting ST with BPD patients.

Feeling If the patient is unable to get in touch with her feelings of anger, it is the job of the therapist to help her (see Chapter  5, “Dealing with anger”). When using imagery rescripting situations from the patient’s past, in which she was very angry but was not able to do anything about this anger, the therapist makes sure that the person who threatens to punish the child if angry, cannot harm the patient. He can do this by, for example, creating an unbreakable see‐through wall or bars separating the angry child from this person. Another possible solution is that he ties up or holds back the person. By doing this he gives the angry child or healthy adult the opportunity to express her anger. If she is unable to do so, the therapist can also do this for her. Another experiential technique is to place the person to which the anger is directed symbolically on an empty chair and to let the patient ventilate the anger to the chair, as if the person is sitting on the chair. This will help the patient to normalize anger, and become to feel safer with this unpleasant emotion, while it offers an antidote to the usual internal response of the punitive parent mode. After ventilating, usually the abandoned/abused child mode becomes apparent. The two‐chair‐technique can be used when fury of the patient is cooled down a little bit. In one chair the patient can ventilate why she is angry and

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in another chair she can express the pain or anxiety that is behind it. The therapist or the healthy adult can help the patient to realize that being angry is normal, but you have to learn how to express it appropriately. After applying experiential techniques, it is important to discuss an emergency plan with the patient and decide on different alternatives for dealing with the punitive parent mode should it return and seek revenge outside of the sessions because of the venting of anger. Sometimes, soon after participating in this type of exercise, the patient will feel the need to hurt herself or possibly attempt suicide as punishment for expressing her angry emotions. Should this threaten to happen, the patient can call her therapist or other health care workers. If, however, the therapist has doubts about her ability to actively call for help, he can check up on her by making telephone appointments and asking how she is doing during these calls.

Thinking BPD patients often have a number of irrational thoughts surrounding feeling and/or expressing anger. These irrational thoughts are excellent material for treatment with cognitive therapy. Observing how ordinary individuals deal with anger is helpful in building an understanding of how to express anger in a normal way. Looking at the pros and cons of expressing vs. suppressing anger can be also very helpful.

Doing First the patient must practice expressing mild irritations and anger during sessions and later outside of the sessions (also see Chapter 7, “Skills Training and Role Play”). This can take the form of an experiment in combination with challenging dysfunctional thoughts. If she appears to have problems with anger and restlessness at home and cannot directly place where this anger comes from, it is likely to be residual anger from her past which is not yet ready to be processed. Physical activity is helpful in getting rid of this unrest. Some patients find hitting a pillow or boxing bag helpful while others use sports as a form of release. While one patient may prefer using sports to release this anger, another patient might frantically clean the house. The therapist can use the following session to explore aspects that elicited this rage.

Pharmacotherapy Anger leads to insomnia in some patients. Occasional use of antihistaminics or antipsychotics can help break this cycle as the patient runs the risk of exhaustion, and when she is overly tired her ability to deal with



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the punitive parent mode is compromised. The use of benzodiazepines is not recommended as they have the side effect of unbridling the patient and can actually increase the chances of uncontrollable fits of rage. Antihistamines or melatonin may be better alternatives as sleep medication.

Frequently Asked Questions About the Angry Child Mode How can I prevent “revenge” or punishment by the punitive parent mode? One should not underestimate the risk of punishment by the punitive parent for expressing anger, particularly once the session is completed. The therapist must never forget to talk about this possibility at the end of a session in which the angry child was present, and make a plan of action with the patient how to deal with this. How can I prevent that I get angry with the angry child? The angry child can evoke more negative reactions from the therapist than the other modes. Because of this, the therapist must take care to keep his own reactions under control particularly when the angry child’s aggression is directed toward him. He must do his best to view the patient as a child in the middle of a tantrum, stomping her foot in anger. Should he not succeed in controlling his own anger and respond to her attack with a counterattack, the patient will no doubt begin to feel rejected (abandoned child). Another risk is that the therapist wants to pull away from the patient because he cannot stand her anger. This is not to say that the therapist should not set limits to the patient’s aggressive behavior. While he must tolerate her feeling angry, he need not tolerate all forms of expressing this anger. In doing so he does not reject her anger, but rather sets limits to behavioral expressions that are not acceptable, such as damaging property of the therapist. What can I do when I get afraid of the anger of the patient? If the therapist actually does become frightened of his patient, he must investigate whether he is dealing with an angry child, an angry protector, a bully and attack, or even a predator mode. In either case, he must ensure that the necessary boundaries and limitations are clear in order for him to feel safe again. On the other hand, there are therapists who are too afraid of anger anyway. In this case they have to explore the origins of this fear and learn how to cope with anger in a better way.

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How can I distinguish an angry child from an angry protector or an angry healthy adult? An angry child is always more or less out of control and is most of the time angry about more than one subject. As a therapist you can feel the sadness behind it. It is not difficult to see that the anger is about something that has hurt the patient or gave her the impression that she was treated unjustly. If the patient is in the angry child mode and the therapist reacts in a good way the anger will diminish within between 5 and 10 min. When the patient is in an angry protector mode the therapist feels as if he is pushed away, because this a protector mode. If the therapist lets this mode vent the anger, it will go on till the end of the session. The best way to end this anger is to treat the mode similarly as is done with the detached protector mode, that is, understand it as a survival mechanism. An angry healthy adult is more balanced, and it is clear toward whom the anger is directed. If the patient is angry at the therapist, they can discuss what has happened and solve the problem. Most of the time the anger will drop soon. Can the angry child mode lead to hurting oneself or others? Angry Nora can also turn toward self‐injury and suicide as a way of showing anger. In this mode she does not intend to punish herself, but to take revenge on those around her who have unjustly hurt her. In rare cases the patient may also threaten to kill these individuals who have wronged her. When a patient threatens suicide and/or murder, the therapist is put under an enormous strain and must set very clear boundaries and enlist the involvement of a colleague (see Chapter 8, “Suicide and Self‐Injury”).

Treatment Methods for the  Undisciplined/Impulsive Child When the patient also has an undisciplined/impulsive child mode the therapist should react in another way. In this case he should react more directly and confront the patient in an empathic way. In this case, the therapist should not let the patient ventilate, but rather set limits to the patient’s behavior in a quiet way. He must refuse to comply with the patient’s demands and explain at the same time that disappointments and frustrations are part of life. When the patient has calmed down, he can help her solve her ­problems in a more realistic way (see also Chapter 5).



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Therapeutic relationship The most important technique to deal with the impulsive child mode is probably empathic confrontation, which heavily relies on the therapeutic relationship. With this technique, the therapist on the one hand expresses empathy with the intentions underlying the impulsive actions of this mode, while simultaneously confronting the patient with the need for change (see Chapter  4). The same applies more or less to the undisciplined child mode. If the patient has not learned to handle frustrations and perform boring tasks, she reacts like a child who does not feel like it and prefers to play. Therapists have to keep in mind that usually the intentions of the impulsive or undisciplined actions are okay. For instance, the patient wants a good experience, wants to feel loved, and rebels against the miserable life that she leads as a result of the messages from the punitive parent mode. Or she reacts as a child who has been pedagogically neglected and has not learned how to perform difficult or boring tasks such as housekeeping or administration. Thus, the therapist expresses understanding and even sympathy and praise with the need to have positive experiences, to feel loved and appreciated, or the need to play and supports the rebelliousness against the punitive parent mode. Next, the therapist confronts the patient with the way she tries to get these needs met and how she rebels against the punitive parent. The impulsive actions have a high risk to create new problems, thus fuelling the punitive parent mode, and won’t lead to a sustainable solution for what the patient tries to accomplish. For example, the wish to find true love won’t be met by impulsive sex with people one doesn’t know and who are not interested to invest in a long‐term relationship. Moreover, the impulsive actions are risky and create disappointments, which will lead to further punitive messages from the punitive parent mode, and to emotional pain for the abandoned/abused child (repetition of early experiences). After the empathic confrontation, the therapist can either choose to work with the underlying feelings of the abandoned/abused child mode, or to work on functional (non‐impulsive) ways to get emotional needs met, or to channel the rebellious impulses of the patient toward combating the punitive parent mode, or toward protesting against maltreatment in the past though imagery work or through historical role play. Limit‐setting in the strict sense (Chapter  4) is reserved for impulsive actions that the therapist feels that are not tolerable in the short‐term.

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Feeling The multiple‐chair technique can be used to explore how different modes feel and think about the emotional needs that gave rise to the impulsive/ undisciplined actions. After the rebellious background of an impulsive action has become clear to the patient, experiential techniques like imagery rescripting, drama rescripting, and empty‐chair technique can be used to channel the rebelliousness to the issue, person, or mode it should be directed to.

Thinking The pros and cons technique can be used to consider whether an impulsive action tendency should be acted out, or not. This also applies to the lack of action on the part of the undisciplined child, which means that important tasks are left behind. It is advisable to help patients to learn to consider alternatives. Flashcards can be used to help patients to reconsider impulsive or undisciplined actions and to consider alternatives.

Doing When functional ways of how emotional needs can be met have become clear, the patient can be stimulated to try them out. When protest against (previous) maltreatment is an important issue, the therapist can help the patient to channel the protest toward the original person, for example by writing letters (don’t let the patient send them), or confronting the person in a well‐prepared meeting (this can take place in a therapy session so that the patient feels emotionally supported). Sometimes it is necessary that the patient distance herself from the people that create the rebellious feelings in the patient, and to find more healthy people (see angry child mode). Patients who have not learned to perform boring but useful tasks have to learn problem solving techniques in order to solve their problems step by step.

Frequently Asked Questions the  Undisciplined/Impulsive Child How can I tell the difference between ADHD and the undisciplined/ impulsive child? It is not always easy to find out whether there is also a diagnosis of ADHD. One has to use the proper diagnostic instruments to discover whether the patient had ADHD from her childhood. If there is also a



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diagnosis of ADHD, it is advisable to treat this problem as much as ­ ossible before the treatment for BPD. If the patient has already learned p to cope in a better way with her impulsivity (sometimes with the help of medication) then ST works better.

Treatment Methods for the Punitive Parent Therapeutic relationship The therapist protects the patient as much as possible from the punitive parent mode. This mode is very dangerous because of the fact that the patient wants to punish herself can lead to destructive behavior such as self‐injury and suicide or stopping therapy. During therapy the therapist tries to create as safe a situation as possible and makes sure that he is reachable in the event of a crisis (see Chapter 8, “Crisis” and “Suicide and Self‐ Injury”). Despite all of his efforts, the patient will at times interpret comments from the therapist as punitive. Most often the therapist is not aware of this; however, when the patient suddenly changes from one mode to another (to the punitive parent or protector), there is a large chance that the therapist said something “wrong.” The therapist should not take this personally but be aware of the fact that it is the punitive parent mode that reacts as if the therapist acted wrongly. He can ask the patient if this is the case and try to explain what he actually meant by his comments. Usually it is necessary that this is made part of combating the punitive parent mode symbolically placed on an empty chair (see below). It is possible, however, that the therapist did indeed react in a punishing way. This is most probably due to falling into the trap of acting out negative counter‐transference and he must repair this situation. The therapist is the role model of a good parent (who also makes mistakes at times) and takes a completely opposite stance to that of the punitive parent. It is always important to point out that when the origins of the punitive parent mode are addressed, it is not about the caregiver as a whole, but about specific behavior of the caregiver that was experienced as punitive by the patient as a child. Forgetting to address this might create unnecessary resistance in the patient and might lead to problems in the therapeutic relationship.

Feeling The primary experiential technique to address the punitive parent mode is the empty chair technique (see Chapter 5). When the therapist discovers that the punitive parent mode is activated, he checks with the patient whether he

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is correct and if so, he symbolically puts this mode on an empty chair, and combats the voice (take care that the patient does not sit on the chair of the punitive parent when combating it!). Usually several rounds are necessary before the voice is silent. The therapist can step up the power with which he fights the punitive parent step by step by speaking louder or standing up. He must also use different arguments in the beginning to prove that the punitive parent is wrong. If this doesn’t work it might help to put the chair outside the room to set limits to the destructive influences of this mode. Later in treatment the therapist coaches the patient in fighting the punitive parent mode herself, after which she also starts to practice this at home. In imagery rescripting the therapist rescripts early memories related to this mode and combats the punitive caregiver. Later in treatment the therapist teaches the patient to fight against this punitive caregiver herself in imagery rescripting. This can also be achieved using historical role play. A hard‐confrontational manner is the best method for dealing with a punitive parent whose behavior toward the patient is clearly cruel and derogatory. The therapist does not only talk in a louder voice but also interrupts the parent should he refuse to listen. He uses a more formal type of language in dealing with the punitive parent by referring to him or her as Mr. or Mrs. X (name of parents). When the punitive parent is more demanding and critical in a negative sense toward the patient, the accent of the disputation should lie in pointing out the parent’s own failings and rigidity. The critical/demanding parent appears more or less reasonable and only stops when the parent’s own shortcomings are pointed out. One aspect he has definitely failed at is raising his daughter in a loving and accepting way. This is a particularly helpful method if this critical side is connected to one of the parents. The therapist, who should have enough information about this parent, gathered during intake interviews, can offer convincing examples. Another possible variation on this theme is that of the guilt‐inducing, complaining parent. This a sort of punitive parent that insists that all attention be focused on him/her and holds Little Nora responsible for the parent’s unhappiness. Should Nora attempt to go her own way, she is punished and reproached. The patient herself finds her parent pitiful and feels responsible for the parent’s happiness, and therefore cannot directly disagree with the parent. In this case the therapist is not very strict with the guilt inducing parent mode but is more resolute in dealing with it. In imagery he tells this parent that (s)he must seek help for him/herself and must not rely on Little Nora to solve his/her problems. If the guilt inducing parent refuses to seek help, the therapist can actively send this parent to a clinic or calls a



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virtual colleague who takes this parent away. The main issue is that Little Nora doesn’t have to take care of her father or mother anymore. As with all experiential techniques, the therapist should not start an extended discussion with the punitive, demanding, or guilt inducing side, because doing so would only be an admission that this side is partially correct. The punitive parent is not a person who is capable of thinking in a nuanced manner, but rather a mode that will attack even the slightest faults and mistakes. Thinking about things in a distinctive, refined manner is part of a healthy adult’s schema, not that of a punitive parent mode.

Thinking When the patient has negative thoughts about herself and realizes that this is due to the punitive mode, she can try to make a balanced judgment of herself using a cognitive diary with the help of her healthy adult side. The punitive parent will judge the patient in a very black‐and‐white manner. Thoughts like “I am evil, dumb and ugly, and everything is my fault” are common. Techniques that can be used in this situation are multidimensional evaluation, the pie chart and the courthouse method (see Chapter 6). In addition, the patient can ask other people who are close to her for help and advice by asking them for their point of view on, for example, a mistake that she has made. Keeping a positive logbook and historical testing are other methods that provide arguments opposing the punitive parent mode. Developing healthy adult norms and values is also a way to reduce the influence of the punitive parent as the patient is afraid that no norms and values will be left if she lets go of the excessively strict standards of her parents. A healthy adult knows that if you do not have to sacrifice yourself to the interest of others and that meeting your own needs is not selfish. The therapist should help her to develop more flexible and more reasonable norms without forcing his own ideas upon her. These new values and norms belong to the healthy adult.

Doing The patient can do a number of things to rid herself of the punitive parent mode, for example:

• •

Listen to a recording during which the therapist sends the punitive ­parent away. Read through flashcards with statements as to why the punitive parent is incorrect.

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Visit friends and ask for support and affection. Relax using meditative or relaxation exercises. Do things that the patient enjoys doing or is good at. Do all kind of things the happy child likes and behave “naughtily” in the (incorrect) view of the punitive parent mode. Learning to comfort herself, if necessary, using a transitional object. Have a schema dialogue at home between healthy and punitive modes.

For further information about these forms of homework, please refer to Chapter 8, “Homework.”

Frequently Asked Questions About the Punitive Parent What can I do if the punitive parent comes back after the session? The punitive parent can return after a session in which he was silenced and seek revenge. The therapist must not underestimate this. Different measures for dealing with this situation have been described earlier in this chapter under “Treatment Methods for the Angry/Impulsive Child.” What can I do if the punitive parent damages the therapy directly? The punishing side sometimes causes the patient not to do what is good or healthy for her, but rather to do the complete opposite. This comes from the thought that she does not deserve to be happy. It is often also an unconscious attempt to provoke punishment from her therapist. This often leads to the patient not showing up for sessions. In this case the therapist must call the patient and convince her that he will not punish her, even though things have gone wrong. Further he must encourage her to attend the next session. If the patient is not available on the telephone, the therapist should send her a text message, email or letter in which he expresses his concern for her well‐being and invites her to the next session. Why do some patients keep on defending their parents? The patient can also become protective of her parents (“they couldn’t help it; they had bad childhoods themselves”). The therapist explains that it is important to silence the punitive parent as this mode is damaging for the patient. He repeats that by rejecting the punitive parent, the patient is not rejecting the parent as a whole, or as he or she is now, but rather that part of the parent’s behavior that was not good and was punishing during the patient’s youth.



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Actual understanding the parent or forgiveness only takes place at the end of therapy, or after it has been completed, and becomes the choice of the patient as a healthy adult. The patient must first learn to silence the punitive parent mode in her own head.

Treatment Methods for the Healthy Adult Therapeutic relationship The therapeutic relationship changes slowly but surely from that of a ­parent– child relationship to that of a relationship between two adults. The patient becomes more and more autonomous and is able to find solutions to her problems without the help of the therapist. From the very beginning of therapy, the therapist searches for contact with the healthy adult, even if these moments are few and far between. In particular when dealing with aggressive and impulsive behavior, the therapist seeks contact with the healthy adult directly and tries to end this behavior in order to continue with therapy.

Example of talking with the healthy adult when the patient wants to stop therapy Nora is threatening to stop therapy because her boyfriend broke up with her and now life has no meaning. t: Nora, I understand that you’re having a very difficult time right now, but I want to talk to your healthy adult side. What I want to say is that you shouldn’t stop therapy now because you will end up having more problems. I understand that right now you feel like it’s going nowhere, but you also felt this way when we began therapy, but you stuck it out. Right now, everything may seem hopeless, but your healthy adult knows that this will pass, and I can help you with it.

Feeling Initially the Healthy Adult mode is strengthened by the experiential techniques and by psychoeducation. During the execution of the experiential

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techniques, the therapist always gives the example of how he acts as a healthy adult. The patient internalizes all those messages and develops a new perspective about what is healthy and normal. If the therapist notices that the patient shows more healthy behavior more often, he can also discuss with her how she can recognize the healthy adult. If the patient is confronted with a difficult situation, the therapist may ask her to think of another situation in which she has solved something well through her healthy adult. He asks her to describe what her attitude, thoughts and feelings were then. He then asks her to apply these skills to the current difficult situation (see Schema Therapy Step by Step 3.06). In the last phase of the therapy, the patient is capable of expressing and sharing her feelings with others. This is easily observed during therapy sessions as her feelings are expressed without any deterrents. The stories she shares with the therapist show her ability to deal with emotions and feelings in her relationships with others. When she is faced with strong emotions, she is capable of researching which one of her old schemas is at work. She can offer alternative healthy schemas to counter these old schemas on her own.

Thinking The cognitive techniques are all aimed at developing and strengthening the healthy adult, because they are looking for a more realistic and nuanced view of reality. In the second phase of therapy, the therapist will actively provide psychoeducation about how the healthy adult deals with problems or difficult situations in four steps. 1 Pay attention to your emotions and be kind and accept what you feel. To learn to dwell on the emotions, many patients need to build in a moment of rest. If they are in danger of being flooded, they can briefly withdraw from the difficult situation and, for example, read their flashcard with instructions for the healthy adult. 2 Be aware of the coping or parent modes that want to interfere. The healthy adult contains these modes so that they have as little influence as possible. 3 What do you really need in this situation? The patient examines what she needs in terms of her basic needs (such as security, recognition, appreciation, consolation, etc.). 4 What can I do to fulfill this need? What the patient can do naturally depends on the situation. What many patients have to learn is that sharing



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emotions can often be an important first step. Also taking the time to first find out what exactly is going on can be useful. In more threatening situations it is necessary that the patient also learns to be assertive and able to defend herself (see Schema Therapy Step by Step 3.07 and 3.08). If the patient knows what to do, it can still be difficult to perform the action. So, the following section describes how she can learn that. At the end of therapy, the healthy adult is capable of studying the underlying thoughts of threatening negative feelings or impulsive behavior and disputing them. She can think about herself and the world as a whole in a nuanced manner and is competent in having a Socratic dialogue (see Chapter 6) in her head without having to write everything down in a cognitive diary.

Doing At the start of therapy, the patient cannot yet practice new behavior. So it is not wise to expect much behavioral change at that stage. But as the healthy adult develops more, the therapist can teach her to take small steps to practice healthy behavior (see Chapter 7). Later on in therapy, the patient can prepare for future situations through an imagination about a situation in the future (see Schema Therapy Step by Step 3.09). After such an imagery exercise, the therapist gives her homework to try this out in reality. At the end of therapy, the patient participates in different sorts of activities appropriate to a normal adult lifestyle such as maintaining friendships and building a relationship. She either works or studies or has some other meaningful way to fill her days. The healthy adult makes the final decisions as to those individuals from her past she wishes to maintain contact with and those she chooses not to.

Frequently Asked Questions About the Healthy Adult How do I know if the healthy adult is present? During the first half of the therapy the therapist may sometimes think he is talking to the healthy adult while in reality he is being faced by the protector. Especially when dealing with patients whose protector has a strong tendency to rationalize and trivialize, the therapist can be led to believe that the pathology he is dealing with is not too serious. In this phase the

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therapist has to ask himself whether this healthy behavior is in accordance with the severity of the pathology at the start of therapy. He has to at least check the emotions of the patient to get more clarity on this issue (see earlier discussion on obstacles when dealing with the protector).

A Simultaneous Chess Play in a Pinball Machine In short, the therapist is meant to support the abandoned/abused child, teach the angry child to express her anger timely and in an appropriate manner, teach the undisciplined child frustration tolerance, the impulsive child to get needs met in an organized and functional way, make the detached protector (or angry protector, the bully and attack mode, or the self‐aggrandizer) role less necessary, send the punitive or demanding parent away, stimulate the happy child to develop, and help the healthy adult develop and flourish. We have described per mode just how the therapist can go about achieving these goals. This systematic description suggests that in using this therapy it is possible to plan which mode one is going to work on during a given session. Unfortunately, this is not the case in actual practice. Just as the patient herself has no control over her modes, neither does the therapist. The modes pop up and switch off constantly in no particular order. At times the patient feels like the ball in a pinball machine, being constantly pushed around by others (the flippers) into different, unexpected or undesired places. Each new place the ball is shot off to represents yet another different mode for the patient. The actions of the therapist are aimed at creating calmness in this pinball machine until the patient herself learns to control where she wants the ball to go using her healthy adult mode. Each time a new mode pops up during a session, it is up to the therapist to explore this change, name the present mode and modify his therapeutic strategy. If he waits too long in doing this, he runs the risk of his efforts having no therapeutic value as well as deterioration of the therapeutic relationship or in a worst‐case scenario, the patient stopping therapy altogether.

Example of reactions to quickly changing modes Nora arrives frightened (abandoned child). She has just seen an acquaintance with whom she broke off contact in the past after they had an argument. t: (Friendly) I see that you have had quite a shock. That makes ­perfect sense seeing as you had not expected to see him.



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p: I don’t dare leave this office; maybe he’s waiting for me. t: (Reassuring) Are you afraid that he will try to hurt you? It was many years ago, don’t you think it won’t be that bad? p: (Feels the therapist thinks she is exaggerating) No you’re right, I’m exaggerating again and making too big of a deal out of the whole thing (punitive parent). t: (Is not immediately aware that this is the punitive parent) I don’t think you’re exaggerating, but I wonder if after so many years he’s still got something against you. p: No it’s true, I don’t need to make such a big deal out of this. Let’s talk about something else (detached protector). The remainder of the session is spent discussing another topic. It seems as though this was a reasonable conversation with a healthy adult. However, just under the surface, there is the recurring theme of the patient’s fear for this old acquaintance. She does not dare bring this subject up with her therapist for fear of rejection, and at the end of the session this fear reappears. p: Despite all of this, I still don’t know whether or not I’ll make it home in one piece. You can’t help me (abandoned abused child). t: (Immediately becomes defensive  =  his own pitfall schema failure) Oh, I thought you didn’t want to talk about that anymore. p: (The detached protector is activated and says): Well maybe therapy doesn’t help in this kind of situation. I was thinking about stopping therapy altogether. t: This is indeed a good topic to discuss in therapy and we can start off with it during the next session. P: (The angry protector is activated) No I will not come anymore because you do not understand me. End of session. Because the therapist took too long to realize that he was dealing with the abandoned child, the detached protector was activated. Now the therapist runs the risk of losing his connection with the abandoned child. He even activated the angry protector by not saying he does not think it is a good idea for the patient to stop. Should the patient not show up for her next session, it is very important that the therapist makes all attempts to contact her and acknowledge his mistake and convince her to continue with therapy.

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What complicates this situation is the fact that the modes are overlapping. While the one mode is actively present, the others are constantly lurking in the background. Because of this, all the modes hear what the therapist says. At times the various modes react (in silence) to what the therapist says and the patient experiences this as a sort of “war” or chaos in her head. From the therapist’s point of view, it is as if he is playing chess blindfolded with five (or more) players. Each player (mode) makes his moves on a separate board. It is then up to the therapist to keep all of the different boards in the back of his head and remember which player’s turn it is.

Example of dealing with different modes during one single intervention Nora enters the session in the punitive parent mode and begins speaking about herself in a negative manner. p: I’m such a failure, I can’t even begin that assignment. It’s due in a week and I haven’t even started! t: (Friendly) If I am hearing you correctly, I hear the punitive ­parent talking about you in a negative way. p: Of course after so many failures. t: I suggest that we set aside another chair for this mode so that I can say something to it because I don’t agree at all. (Patient nods and both of them look at the empty chair, the place for the punitive parent.) t: (In a clearly harsher voice toward the empty chair) I don’t think Nora is a failure at all. And you’re not helping by talking to her like this, you’re just making things worse. If you continue, then she will start drinking again and then become a mess. So stop it right now, then I can talk with Little Nora and find out what happened. At the moment, the therapist is playing on the punitive parent’s board. He then sets this mode in another chair and tells it to be quiet. At the same time, and on the boards of the detached protector and the abandoned/abused child, the therapist also passes on a message to them.



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To the protector he says: “If this continues, then you will become active again and Nora will start drinking.” To the abandoned/abused child, he says: “I want to help you, so I am telling the punitive parent to stop and the protector to stay away.” If all goes well, Little Nora will immediately feel the therapist’s support. Should he succeed in silencing the punitive parent for the remainder of the session, then Little Nora can continue to talk to the therapist, and he can continue to support her and help her solve her problem. If all of this is going as planned, then the protector will hear this on its own separate board and realize that it is not needed at this time.

When playing chess blindfolded it is evident that sometimes the player (the therapist) will win, sometimes he will lose, and sometimes it will end in a draw. In ST the therapist must not lose his match against the punitive parent because then he loses the matches with the other modes as well. When this happens, the abandoned child’s board is filled with fear and sadness, the angry child’s board is filled with rage, while the protector’s board senses that something is not right and grows stronger. Playing chess in the dark like this is often a game of hit and miss for the therapist. The therapist must develop a talent so as not to fall into his own traps (modes). Should this appear to be happening, he must take the time to analyze this with a colleague and then continue where he left off. Surprisingly enough it is often possible to analyze what went wrong together with the patient. Both he and the patient can agree to recognize this situation sooner should it arise again. In short, BPD is so complicated that in addition to vast knowledge and skills, the therapist must also remain patient, be flexible, and possess the ability to put things into proper perspective. Good, regular peer supervision is therefore absolutely indispensable.

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Schema Therapy in Day‐Treatment and Inpatient Settings Schema therapy for patients with BPD is not only applied in the outpatient mental health care system, but also in day‐treatment and in full‐time clinical settings. Within those clinical settings, other professional groups besides psychotherapists carry out their practice. For optimal effects, the whole treatment package as well as the treatment milieu should be based on a coherent ST approach. The next paragraph discusses how nonverbal ­therapies and ST have been integrated. We are aware of three uncontrolled studies documenting the effects of (short‐term) inpatient ST for BPD (Reiss, Lieb, Arntz, Shaw, & Farrell, 2014), but not of any controlled study in the nonforensic day‐treatment/inpatient setting. We also see an increase in the application of ST in the forensic sector, especially for the most complex personality disorder (PD) patients in high security forensic hospitals ­ (Bernstein, Arntz, & de Vos, 2007; Keulen‐de Vos, Bernstein, & Arntz, 2014). An RCT comparing ST to Treatment as Usual for high security forensic patients with PDs demonstrated superiority of ST in a number of primary and secondary outcomes (Bernstein et al., 2020). One of the most recent developments is the application of ST to children and adolescents (Loose, Graaf, & Zarbock, 2013). ST with children and adolescents is more comprehensive than in adults because children and adolescents go through different stages of development and they usually Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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still live with their parents at home. For this, the integration of ­developmental psychological and system‐oriented theories with ST is necessary. Schema therapists who work with children and adolescents find in the book of Loose, et al., answers to their questions how they can adjust the ST techniques to the fact that children cannot be seen separately from their ­parents. Children with serious pathology often have parents who themselves also have a personality disorder. Particularly if one of the parents has a BPD, it is strongly recommended to pay extra attention to the upbringing of the children at an early stage and to provide extra pedagogical support. In some (extreme) cases it might be necessary to separate the child from the parents, for instance if the parent’s behavior remains detrimental for the child despite attempts to change it. ST for adolescents with BPD has not yet been formally tested. Pilot studies suggested positive effects though (Geertzema, personal communication, 2019; Renner et  al., 2013). Another recent ­development is the application of ST for the elderly with BPD. This group is usually excluded from clinical trials, and often from psychotherapy, but the clinical impression is that treatment is possible, and that ST is a good ­possibility (Khasho et al., 2019; Videler et al., 2017). The application of ST in groups and with couples in the outpatient s­ etting has also seen a significant development in recent years (Atkinson, 2012; Simeone‐DiFrancesco, Roediger, & Stevens, 2015). Within the context of this book, we will shortly discuss nonverbal therapies, group therapy for patients with BPD, and couples therapy with couples where one of the ­partners has BPD.

Schema Therapy and Nonverbal Therapies Nonverbal therapies include art therapy, drama therapy, dance therapy, movement therapy, and musical therapy. Nonverbal therapists in particular have developed their skills with regards to ST in recent years and have ­integrated this approach into their methods. Nonverbal therapists find the mode model attractive as they can readily connect it to their methods. Patients often appreciate nonverbal therapies with their experiential methods, as they offer them connection to and understanding of their modes. Nonverbal therapies have specific techniques that can trigger modes that might be difficult to access in verbal therapies. In general, it is felt that psychotherapeutic ST should also be offered to help patients integrate the experiences offered in nonverbal therapy. If all therapists, the nonverbal



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and the psychotherapists, use the same language and base their approach on the same model, nonverbal therapy can be a great help especially for more complex patients. Muste, Weertman, and Claassen (2009) and van Vreeswijk, Broersen, and Nadort (2012) describe the application of ST within day treatment and inpatient settings in the Netherlands. One RCT documents the powerful effects of a nonverbal therapy which was partially based on the ST model for patients with PDs (Haeyen, van Hooren, van der Veld, & Hutschemaekers, 2018). Note that quite some nonverbal methods and techniques have been integrated in group‐ST along the Farrell and Shaw model.

Group Schema Therapy Since 1989, Farrell and Shaw have been focusing on developing ST in groups, comprised exclusively of patients with BPD, in outpatient and inpatient settings. The effects of this group schema therapy (GST) appeared to be even greater and achieved over a shorter period than with individual ST (Farrell, Shaw, & Webber, 2009). A pilot study in the Netherlands, in which a combination of weekly group ST sessions and weekly individual ST ­sessions was given, also showed very promising effects (Dickhaut & Arntz, 2014). Another pilot study of the combination of group and individual ­outpatient ST in a sample of highly complex BPD patients that required frequent hospitalization showed very strong effects on reduction of hospitalization and strong effects on BPD severity and secondary outcomes (Fassbinder et  al., 2016). Because of these promising results, the most important aspects of this group therapy will be described in this chapter. An international multi‐center study under the direction of Arntz and Farrell started in 2010, with the aim of comparing GST with treatment as usual and exploring whether the combination of individual and group‐ST or mainly group‐ST should be the treatment of choice. First results were available when this book was finalized. These indicate superior effects of GST compared to treatment as usual, especially for the combined individual‐group ST, when main outcome (BPD severity), treatment dropout, and most secondary outcomes are considered (Arntz et  al., 2019). This matches with preferences of most patients and many therapists (Martius, 2019). The following description of this group‐ST is largely derived from the workshops led by Farrell and Shaw and their description thereof in their publications (Farrell & Shaw, 2012; Farrell, Reiss, & Shaw, 2014; Farrell et al., 2009).

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GST is an integrative form of group therapy, which combines aspects of directive group therapy with aspects of psychodynamic groups, but has a unique way of handling the group dynamics. The group is led twice a week by two psychotherapists who adopt a parental role (see Chapter 4, “Limited Reparenting”).

The advantages of group schema therapy There are various general advantages to group therapy that are frequently mentioned in the literature: universality, altruism, recognition, interpersonal learning, behavioral imitation, existential factors, emotional catharsis, repetition of the primary family situation, and the opportunity to obtain information from different people (Yalom & Leszcz, 2005). GST has various additional advantages that contribute to the group process, in which patients with BPD are able to achieve improvements in a relatively short period of time. The clearly defined structure of group therapy enables a safe climate to be formed relatively quickly, in which the abandoned/abused child can feel safe. The advantages of group therapy over individual therapy are hypothesized to be the following:

• • • • • • •

Mutual support and appreciation between group members. Patients with BPD might tend to not fully believe the positive feedback they receive from their therapist (“you’re only saying that because you’re paid to do so”); they are far more likely to accept the same feedback from their peers. More opportunities to experiment with expressing emotions and new behaviors with different people. Patients can learn to develop trust in other people by bonding with other group members (with whom they will feel relatively at ease because of their mutual understanding) and the two therapists. Emphatic confrontation by group members in response to undesirable behavior might be more effective than confrontation by a therapist. Strengthening of the limited reparenting effect, because besides “two parents,” there are now also several “brothers and sisters” in the group. More opportunities during role play to have different people play different modes. Vicarious learning from each other.

Tasks and roles of the therapists The therapists work together as a good “parents.” This means that they try to balance individual needs and collective needs of the group like parents han-



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dle sibblings in a family. They attempt to connect with every patient. They have a quiet, friendly, clear way of talking, similar to the style of a friendly teacher in the first years of primary school. This way of talking comforts the patients and creates a friendly atmosphere within the group. Being a good parenting couple also means that the therapists take turns leading the group process; therefore the roles of therapist and co‐therapist change regularly. When one therapist focuses his attention on one of the group members, the other therapist ensures that the rest of the group remains engaged in some way (both verbally and nonverbally). The co‐therapist ensures that the therapist doesn’t pay too much attention to a single group member and helps him when a difficult situation arises due to conflict or misunderstanding. GST can sometimes be schema‐triggering for the therapists themselves. Working with two therapists makes it easier to support each other in these situations. Both therapists strive to divide their attention as evenly as possible across the group. The therapists also ensure that there is sufficient structure within the group so everyone can feel safe. Good collaboration between the therapists is crucial and, if they work together well, the two therapists will complement each other, giving the patients two role models. The therapists prepare a theme for each session, but they should also be flexible enough to react should another theme arise at the start of a session. As in individual therapy, there can be an unexpected shift in modes, which means that the interventions will have to be adjusted accordingly.

Therapy phases The first 8–10 sessions are more structured than the later sessions. These involve extensive explanations and psychoeducation regarding the characteristics of BPD and ST (mode model) and the basic needs of children. The focus is centered on creating an atmosphere of bonding and safety within the group. The therapists continually strive to translate individual experiences and feelings into themes that are important for the entire group. Even if there are differences, they look for aspects that might be useful to the entire group or for topics where group members with a different experience can still contribute and help other group members. Another important aspect is learning to cope with stress and life‐threatening behaviors. The group members can provide support to each other and give tips. The entire group practices finding a safe haven through imagery so everyone can make use of it after a difficult exercise. The next phase involves working with the modes. This is the longest phase of the therapy and lasts approximately a year. The frequency of the

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sessions can be reduced in the second year. As in individual therapy, the focus will initially be on minimizing the detached protector and combating the punitive parent to give the abandoned/abused child room to develop into a healthy adult. The angry/impulsive child will also have room to vent their rage, but this is only possible in a group setting if the other group members (with the aid of one of the therapists) continue to feel safe. If this is difficult to achieve, the patient can temporarily leave the group together with one of the therapists and vent her rage outside of the group. The patient and the therapist need to return to the group before finishing the session. Attention is also paid to the happy child in every group session. Whatever happens during the first part of the group session, the therapists always reserve enough time at the end of the session to play a game. The final phase consists of ending the therapy and letting go of the therapists. In this phase, patients increasingly go out and undertake individual activities outside of the group. Patients also increasingly experience differences between them, which might sometimes create conflicts, but if handled appropriately this will stimulate individuation and learning to collaborate safely despite being different.

Differences between working in a group and individual therapy Working with modes is in many ways like working in individual therapy and the use of the various techniques is also similar (see Chapters 6–11). However, there are several important differences, which we will discuss here to globally explain how GST progresses with BPD patients. For a more detailed version of this group therapy, we refer you to Farrell and Shaw’s books (Farrell & Shaw, 2012; Farrell et al., 2014). Group rules  General group rules such as rules regarding attendance, confidentiality, mutual respect, and leaving the group, naturally also apply to GST. However, unlike with psychodynamic groups, GST group members are allowed to meet or contact each other outside the group. In many cases, this can lead to additional mutual support and help. However, the agreement is that if a crisis occurs, patients should contact one of the therapists or another caregiver and not go to a fellow group member. If a patient asks someone else in the group for help, the patient also needs to try and do something with the advice given. Therapists should check and take care that there is no systematic exclusion of one or several group members.



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Working with the happy child mode  Group therapy makes much more use of working with the happy child mode. Patients do need support and comfort, but they also need an opportunity to play and have fun. Some patients even need to learn what playing and having fun actually are. Initially, attention is given to what patients enjoy doing and which hobbies they may have had as a child. What did they play with and who did they play with? Did they have a special stuffed toy or doll? What did they miss and what does Little Nora need now in that regard? By talking with each other about this, information can be collected and exchanged about the activities that make the patient happy and the inhibiting effect the punitive parent has on this. Imagery centered on enjoyable moments from the past is also useful. Subsequently, each group member is encouraged to think of something that they enjoy doing. This can be preparing a meal together for one member, for example, and playing a game for another member. Each and every group member has the opportunity, at some stage, to do something that they really enjoy doing.

Use of techniques derived from nonverbal therapies A group setting presents far more opportunities to make use of games simply because there are more participants and patients will dare to participate more readily when they see others doing the same. The therapists regularly think of games that are aimed at breaking through or weakening dysfunctional modes to reach the abandoned/abused child or the happy child. Making music together, making something together—such as a doll representing the punitive parent, which can then be thrown away—or exercises borrowed from movement therapy are welcome additions to other known techniques. Below is a description of a few examples of integration of nonverbal ­techniques in GST per mode. Creative therapy with all modes  In creative therapy, the patient can create an image on paper or with other materials to symbolize the modes. This helps her to discover what the modes look like, what has caused these modes and why they are hard to change. These images can be used in the group to show each other how an individual experiences his or her modes. Detached protector  With the detached protector mode, the understanding of emotions can be strengthened through grounding exercises. The patients

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learn to concentrate on certain emotions within their bodies and learn to deal with difficult emotions, keeping the detached protector at bay. The presence of multiple people in the same space usually has a heightened effect on these emotions. Each exercise, in particular those with the happy child, helps break through the detached protector mode. If they succeed in allowing more emotions in, the patient will be more open to receiving support and comfort from the other group members and they will notice that they have more to gain from this than from “hiding away” in the detached protector mode. Abandoned/abused child  When one of the patients is in the abandoned/ abused child mode, they occasionally find it easier to accept comfort and support from their peers than from the therapists. Therapists are more readily associated with professionals that are just paid for being kind than are the group members. Group members are usually very loyal and supportive to each other, and as soon as they notice that one of them is in the abandoned/abused child mode, they will support that group member. Patients occasionally can and are allowed to get physically closer to each other than therapists can or may. Exercises derived from nonverbal therapies are seen as less threatening when everyone joins in than when a patient is alone with the therapist. The fear of abuse or punishment in a patient group with the same problem is significantly reduced. Angry/impulsive child  For people who have difficulty expressing their rage, seeing someone else who does dare to get angry can be very stimulating. However, patients can become too fearful if someone expresses real, violent anger, especially when directed to a group member. It is of the upmost importance that one of the group therapists immediately sets limits to such expressions of anger or aggression. The safety in the group should have priority. Techniques drawn from movement therapy or drama therapy can be used to evoke anger. One example of this is a competition in which patients, two by two, stand with their backs against each other and try to push each other across the room. There are countless other exercises used within nonverbal therapies which can help to stimulate anger such as throwing balls, hammering, kicking, or punching cushions and scratching on paper. There



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are also techniques that allow patients who have trouble controlling their anger to practice this. The co‐therapist can protect patients who are afraid of people who are angry, for example by taking them aside and letting them look at the angry patient from a distance. He can let patients hide behind a row of chairs or cushions while they watch how the other therapist gives the angry patient the chance to vent her rage and to explore how this anger ties in with her past, without punishing her for expressing these emotions. If at a later stage more adequate means of expressing anger are practiced, the entire group can join in. Punitive parent  Group members can form a unified front against the punitive parent, both in imagery and in role play, causing him to stop more effectively. During imagery rescripting with one of the patients, the therapist may ask if the entire group will gather around the patient to protect her from the punitive parent. The messages that the group members send to combat the punitive parent can also be noted down on cards. In addition, an audio file can be made, which the patient can then use when her punitive parent becomes active again. Moreover, the group can make a doll that symbolizes the punitive parent. The doll is made from a piece of cloth on which characteristic sayings of the punitive parent from each group member are written. This allows the group members to discover what the punitive parent looks like to the other members. A second doll can then be made on which all the positive things about each patient are written, or the positive things can be written on the back of the punitive parent to combat them. These types of dolls can then be used in other exercises (see the techniques outlined below). Healthy adult  The healthy adult not only develops on the basis of the model shown by the therapists, but also by the group members who can show each other that it is normal to express emotions and needs, that everyone is allowed to make mistakes and that everyone has strengths and weaknesses. Using techniques from nonverbal therapies, the expression of emotions can be practiced using both verbal and nonverbal methods. It is striking how many patients can represent the healthy adult mode with regard to others, while they are not able to do so with regard to themselves. Expressing healthy adult views to each other is helpful for both the messengers and the receivers. In a group setting there are more ways to convey what a healthy adults does than in an individual setting. The group

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members can go out and arrange to do things together which strengthens the healthy adult. Group members can do a lot of things together, but starting a sexual relationship with a fellow group member is discouraged until the members involved have adequately strengthened the healthy adult. Activities with fellow group members can have a healing effect because patients with BPD are far more accepting of each other than of other people in their surroundings. One exercise derived from creative therapy is making an identity bracelet with beads. Each group member is given a number of different beads. Everyone takes turns giving a bead to another member and explains which positive characteristic of that person is symbolized by that bead. The patient threads the beads into a bracelet and writes down on a card what was said with each bead. This bracelet contributes to creating a personal identity.

Developing identity Developing an identity occurs primarily through feedback experienced by trying out things and through feedback from important people in one’s life (especially parents, and peers during adolescence). Patients with BPD did not develop a positive identity because of punishment, negative criticisms and abandonment. They have difficulties with trying out new things, as their punitive parent mode is activated when it is not a success, and because their detached protector mode causes inactivity and avoidance. In a group setting, the identity development process can develop faster because constructive feedback comes from the group members as well as from the therapists. In the last phase of the therapy, the group functions as a group of adolescents who are all searching for their own identities and are busy with the process of individualization and breaking away. They help each other to develop their healthy adult by exploring together what they think is important in life and what sorts of relationships they would like to have. Letting go of the therapists and the therapy occurs much more easily if the patient experiences being a part of a group.

Adjusting schema therapy techniques for use in a group setting All the techniques, which have been described in the earlier chapters, can be applied in a group setting. However, some adjustments will need to be made, a description of which will follow in the next few paragraphs. The group always starts creating a secure bond by standing in a circle together with the therapists. The therapists speak a few welcome words in



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which they emphasize that this is a safe place to discuss everything and to share your needs and feelings. All group members are connected by a strip of a fleece blanket. Each group member can also use this strip during the other exercises if they want to feel more connected to the therapist or a group member. Because every patient needs to be addressed during a group session, it’s not customary to work too long with any one patient. The techniques are often applied in an abbreviated form (7 min at the most) or are regularly interrupted so that experiences can be shared with the rest of the group, allowing everyone the opportunity to take away something of value for themselves. The therapist also invites group members to say supportive or helping things or do other things to satisfy the needs of the abandoned child during rescripting The patients are stimulated as much as possible to join in during these exercises, but if someone is unwilling or unable to join in, then it will help if they are actively observing so that they can learn something along the way. The co‐therapist has an important role in engaging all the group members through words, gestures, and eye contact. Imagery rescripting  In the first phase, each group member learns to create their own safe haven, which they can use at the beginning or the end through imagery rescripting. For patients who have trouble visualizing a safe place, it might help to hear which safe places others use to draw inspiration for their own safe haven. The therapists can also help by suggesting a safe place. One example is to create a sort of “safety bubble” around you where you can decide what you want to let in or keep out. The connection between the group members can also be symbolized because everyone sits in a circle and holds a strip of a fleece blanket that connects everyone to each other. Once a safe haven has been found, the therapists will ask the patients to imagine that they’re a small child for a couple of moments, to make contact with the abandoned child. Everyone opens their eyes and describes what they experienced or felt. If someone reacts more strongly than the others, she will be asked to close her eyes again and return to the abandoned/ abused child to explore what her needs are at that moment. The group members can indicate if they recognize that need or if they have also experienced situations in which their needs have not been met. The therapists then stimulate the group members to think of as many ways as possible in which the need of the child can be met and allow all the group members to

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help with the rescripting. The therapist can also involve the group members in the rescripting by asking the patient to hold a fleece blanket and letting another group member hold the other side of the fleece blanket. If the patient is almost overwhelmed by emotions, the other person can pull on this strip to make contact. In a later stage of the therapy, all the group members can be asked to close their eyes again and imagine that they find themselves in the same situation from the past as that one patient. If it concerns abusive situations, the other group members may keep their eyes open and not join in or intervene; the therapist will do so instead. But sometimes participants are strong enough to take part in the imagined rescripting—remember that the group as a whole is a powerful means to protect the child and confront the perpetrator. In any case, they can draw indirect benefits from the rescripting because they see how the therapist ensures that the patient remains safe and supported. After the rescripting is complete, rescripting of a different situation with a different patient can take place or the group can move on to another technique. Role play  When doing role play in the present or the past, as many group members as possible are used to play various roles. When doing role play for current or future situations, group members can assist in thinking of and demonstrating various reactions. The patients are often better able to demonstrate helpful behavior during a role‐play situation, even though they may not be able to apply this to their own situation. Certain skills, particularly with regards to expressing emotions, are more effectively practiced in a group setting than in individual therapy. For historical role play, the advantage is that complex situations from the past can be simulated with multiple participants filling the various roles. Simulating being shut out by a class at school, for example, where the roles of the classmates and the teacher can be acted out, provides significantly more information and gives more room for alternative interpretations. The main advantage is that this type of role play ensures that the patients come out of the detached protector mode and further develop their healthy adult role by applying the healthy adult role to support someone else’s abandoned child. Two‐or‐more‐chair technique  With the two‐or‐more‐chair technique in a group setting, there is no empty chair; something is placed on the chair, which represents the mode that needs to be worked on, or one of the therapists plays



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the mode. The doll representing the punitive parent, which we described ­earlier, can be draped over the chair so that the entire group can focus on the doll. The doll can then be thrown away or stuffed in a closet to symbolize that he’s gone and needs to stay gone. Because there are two therapists, one therapist can easily sit in the punitive parent chair without having the group feel as if they’re being abandoned. The other therapist can then combat him (together with as many patients as possible) and stand up for the rights of the abandoned/abused child. Cognitive and behavioral techniques  Cognitive techniques are more readily applied in group therapy than in individual therapy because the patients have less trouble identifying the healthy adult with regards to another group member than they do with their own healthy adult. In individual therapy, the therapist himself needs to supply the healthy perspective, but he is not often readily believed or trusted because he is not “one of us.” Another advantage of a group setting is that a situation and the underlying schema can be analyzed from different perspectives, so that the nuances are highlighted at an earlier stage. In situations where a number of group members have the same schema, a nuance immediately has a broader effect on the group at large. Behavioral techniques can similarly be applied more readily because there are many more possibilities to practice with multiple people within a safe environment. As with cognitive therapy, some patients can apparently show the healthy adult with a certain amount of skill when they’re playing someone else’s role but are unable to do so when they play themselves.

Difficulties with GST The role of the therapist in group therapy is, in several respects, more complex than during individual therapy. The therapists need to complement each other to be able to cooperate as effectively as possible. Because the roles of the therapist and co‐therapist constantly change, the therapists need to be flexible in their reactions. Just as with any parenting couple, this can naturally lead to tension between the therapists. In addition, group therapy can impact multiple schemas and different schemas of the therapist at the same time, which is unlikely to occur in individual therapy; it is not always easy to deal with such a situation. At the same time, the necessary schemas can be triggered among the group members themselves. The two therapists need to work well together to support each other and keep the group process under control.

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In a group setting, the group members, just like siblings in a family, will compete for the attention of the therapists. Given that patients with BPD have many needs, the therapists will often have the feeling that they are not doing enough to help them. The patients do get less attention from the therapist than during individual therapy sessions, but that is compensated for by the fact that the members can gain support from each other and experience how it feels to provide support to someone else. Some issues are better dealt with in individual sessions, such as the processing of severe trauma that is too intimate or too shocking. A minimal number of individual sessions is therefore recommended even when the primary format is group‐ST. A situation that many group therapists find very difficult is when a participant gets aggressive or behaves inappropriately in some other way. The therapists should react immediately, setting firm limits and if this does not work, requesting the participant to leave the group for a moment until he/ she is cooled down. If the therapist hesitates with setting limits, safety is endangered and trying to repair this the next session is very difficult (the experience of threat and powerless therapists is consolidated in memory and not easily changed). Group therapists should practice in role plays with how to intervene when such situations happen. A commonly occurring schema with BPD patients is mistrust. This means that therapists need to have a good sense of honesty and justice to be able to treat all the group members as fairly and equally as possible to develop a sense of mutual trust. Support and help from a good peer support group, in which other group therapists and, if parallel individual ST sessions take place, also the individual therapists take part, is essential to bring this form of GST to a fitting conclusion.

Summary GST with patients with BPD, as developed by Farrell and Shaw (and coworkers) (2009, 2012, 2014), differs from directive and psychodynamic group therapy in several significant ways. Elements from both forms of group therapy and individual ST are integrated into a functioning group therapy model for patients with BPD. There are important differences between individual ST and GST. For GST, the techniques used in individual therapy, which are described in Chapters 6–8 need to be adjusted. We have discussed the various methods and techniques involved in less detail than in the chapters regarding i­ ndividual therapy,



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but we assume that this chapter, in combination with the earlier chapters, offers some initial insight into this form of group therapy. For the treatment of BPD, GST is usually combined with individual ST. If the individual ST is not provided by a GST therapist, the individual and group therapists should have regular peer supervision to keep each other informed about how patients develop and to prevent “splitting.” Patients are informed that all information is shared between therapists, so they cannot demand confidentially. However, a group therapist will never share information from individual treatment in the group without explicit consent from the participant. Lastly, it should be noted that when a semi‐open format is used for GST, the approach should be adapted to the fact that at specific (planned) moments participants leave the group, while the next session new participants enter. Specific rituals can help to structure these moments and channel the feelings (and hence the modes) that are triggered.

Schema Therapy for Couples Since 2007, Atkinson (2012) has been applying schema therapy for couples. The primary inspiration for this was the Emotion‐Focused Couple Therapy by Johnson (2003a, 2003b, 2004) and the couples therapy described by Gottman (1999), Gottman and Silver (1999), and Gottman and DeClaire (2001). As far as we are aware, no literature is available with regards to ST with couples, married, or otherwise, where one partner has been diagnosed with BPD. Research into this form of therapy when one or both partners have BPD is therefore unknown to us. We have nonetheless decided to devote a paragraph in this book to the topic. Based on the existing literature (Atkinson, 2012; Simeone‐DiFrancesco et  al., 2015), a course and workshops led by Atkinson and Roediger, and discussions carried out by a group of couple therapists at the community mental health center of Maastricht, we will describe ST with couples where one of the patients has been diagnosed with BPD.

Indication for Schema therapy with couples where one partner has BPD If the request for treatment primarily focuses on relationship issues, couples therapy forms a suitable initial course for therapy. It is not unusual to occasionally invite the partner to individual therapy sessions with patients with

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BPD, but the objectives are usually limited and there is no full couples ­therapy where both partners work on their schemas and modes. In a married couple where one of the partners is diagnosed with BPD, it is usually not easy to convince the other partner that they also need to look at their own issues. The counseling is generally limited to a couple of conversations primarily involving psychoeducation on the issues regarding the patient and advice on how to deal with this. If the relationship issue is at the forefront and is also the primary request for treatment from the patients, then it is possible to look at the pathology of both partners. The choice to start with ST for couples is not only dependent on the request for treatment from the patients but also on the therapist’s assessment of whether couples therapy has a chance of succeeding given the extent of the pathology of the partners. Unlike in conventional couples therapy, individual sessions can be provided next to the sessions for the couple. This is especially indicated when one partner has, or both partners have severe psychopathology, such as BPD. In these individual sessions the focus is on working on the individual problems of the patient, for instance with experiential techniques for specific schema modes—and not on the couple issues. Thus, this combination of formats is similar to the combination of group and individual ST. If other relationships outside of the couple relationship, violence, substance abuse, or irreconcilable objectives are involved, then couples therapy is not the first choice (Atkinson, 2012). Frequently, a patient with BPD has a relationship with a partner with narcissistic issues (Solomon, 1998), an avoidant personality disorder, or an obsessive–compulsive personality disorder. People with a personality disorder are generally more than likely to place the blame for problems on others, in this case, they place the blame for the problems on their partner with BPD. However, it is no coincidence that they have chosen a partner with BPD. If we look at the commonly occurring schemas with patients with BPD and their partners, we notice that it often concerns schemas that complement each other’s shortcomings. Some examples are:

•

A man with unrelenting standards/hypercriticalness and emotional inhibition schemas can offer structure to a woman with BPD with regards to abandonment/instability and mistrust, and/or abuse. He chooses a partner with BPD because she can express her emotions forcefully, and that brings the partner more in touch with his own feelings. Although this man can offer structure and stability, his schemas can also lead to an overly‐critical attitude, which in turn reinforces the punitive parent mode of the woman with BPD.



•

•

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A man with an entitlement schema can offer a woman with BPD safety and structure to a certain degree, as long as she agrees to be the “lesser” party in the relationship (from her defectiveness/shame schema). This man chooses a woman with BPD because he needs a partner who looks up to him and admires him, confirming his feelings of superiority. As soon as the woman with BPD solves her problems and strives to achieve a more equal position, tensions arise and the man will try to degrade her, strengthening her punitive side and damaging her abandoned child side. A man who is very caring given his self‐sacrifice or subjugation schema (not infrequently a partner who is a social worker or caregiver by profession) can be caring for the abandoned child but perpetuates the issues in part by treating the woman as the weaker party. This man chooses a woman with BPD to have someone with whom he can satisfy his need for recognition by caring for the weak. If the woman is to recover and develop a healthy adult who needs less support, this partner loses his role in the relationship and this may mean the end of the relationship. A man who has a strong avoidant coping strategy and has comparable schemas to his partner (such as abandonment/instability, emotional deprivation, defectiveness/shame, or failure) is a stabilizing factor for a woman with BPD because he never displays strong emotions. He chooses a woman with BPD because she expresses her emotions more often (albeit somewhat strongly) which allows him to experience his emotions safely and vicariously through his partner. But if things get too intense, he will avoid the situation and be confirmed in his avoidant coping strategy. These partners avoid intimacy, heightening the pain of the abandoned child and perpetuating each other’s detached protector.

(The roles of the man and the woman can naturally be reversed in these examples.) Therefore, to make couples therapy possible, it is very important to motivate both partners to work on their relationship issues and to examine their own modes and schemas.

The advantages of couples therapy In couples therapy, emotions come to the surface much more quickly than in individual therapy because the partners easily trigger each other’s schemas and modes through certain actions or reactions. The advantage of this is that the therapist has to devote much less energy to breaking through the detached protector. If the therapy is successful, and both partners are able

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to break through old patterns and comfort and support each other’s abandoned child, then the recovery process may be quicker than with individual ST. The patients, after all, will encounter more corrective experiences because they see each other daily as opposed to the once or twice a week that they see the therapist. Moreover, positive reactions can have a much deeper and more lasting effect when the reaction comes from the partner, the person who is the most important influence in the patient’s life at that moment. This process of mutual confirmation and support cannot be expected if the choice of partner has a pathological origin. If both partners develop as healthier adults, they may discover that they are no longer a matching fit and this means that the relationship cannot last. The advantage of ST as opposed to other forms of couples therapy is that the use of a schema‐therapeutic frame of reference makes it easier for patients to understand what is going on inside them and how that leads to relationship issues. Once patients understand that their issues are linked to clashing schemas or modes, the tendency to blame each other for everything diminishes and a more relaxed and open atmosphere develops in the relationship. The creation of a safe relationship gives both partners room to discuss the individual aspects of their issues and to recover with each other’s help. The advantages of couples therapy mean that it could potentially lead to quicker results than individual treatment. Atkinson states that ST for couples where one of the two partners is diagnosed with BPD lasts approximately 1 year. What still needs to be researched is whether the recovery from BPD after a year is comparable to 3 years’ individual treatment or 2 years’ Group Schema therapy and if the mentioned results are directly related to the improved relationship.

The therapeutic relationship The therapist should have completed at least a basic education as a couples therapist and as a schema therapist to be able to apply ST to relationship issues. He should also have a thorough knowledge of personality disorders other than BPD, as he will discover that modes other than those found in BPD will play a role here. He needs to be able to have a supportive relationship on equal footing with both partners, and that is quite a challenge when dealing with extreme personality disorders because the therapist’s schemas are triggered not by one, but by two people and their interactions with each other. A good peer support group is therefore essential.



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The role of the therapist in ST for couples is, as with individual therapy, to help both partners, from a limited reparenting position, to understand and change their schemas and modes. If one of the partners threatens the abandoned child of the other because he is in the angry child mode, the punitive/critical parent, or in an aggressive overcompensating mode (for a further explanation of other modes, see Arntz & Jacob, 2017; Jacob, van Genderen, & Seebauer, 2015; and Young, Klosko, & Weishaar, 2003), then the therapist will protect the abandoned/abused child mode. If one or both partners isolate themselves from their emotions by remaining in a coping mode, the therapist will try to bypass this mode and involve this partner more with the session. This might especially be a challenge in case of strong overcompensating modes, such as the self‐aggrandizer mode, the perfectionistic overcontroller mode, or the bully and attack mode. Through the application of different techniques, the therapist initially fills the role of the healthy adult to show how they can support the abandoned child using this perspective.

Case conceptualization The therapist draws up, together with the patients, a case conceptualization of each individual’s issues and works at the same time at clarifying how both partners’ schemas and modes react with each other and how this leads to a cyclic process creating a downward spiral in the relationship, a so‐called mode sequence (see Figure 10.1). This mode sequence illustrates that different situations can lead to the same escalation, both from the perspective of the woman (start upper left) as from the perspective of the man (start upper right). The therapist lists the problem with the help of the techniques illustrated in Chapter  4 and asks both partners (preferably independently of each other) to fill out a schema questionnaire and mode questionnaire. There is a significant chance that the results from the questionnaire do not give an adequate overview of the pathology. Reasons for this can be that both partners are trying to “prove” that they are not the source of the problems and/ or they are trying to create the impression that their pathology is not as serious as their partner’s. That’s why other methods used to map out the problems involved are at least as important as the questionnaires. Atkinson (2012) advises having one or two conversations with the ­partners together and two individual conversations, followed by a final communal conversation. Our experience is that the partner can also be

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Schema Therapy for Borderline Personality Disorder He comes home and finds the house messy (OC)

She has forgotten to do something (B)

He thinks she doesn’t take him into account(VC)

He responds critically (OC)

She takes this as abandonement (AC) and starts to drink (DP)

He notices that his criticism is wrong (VC) and withdraws (DP)

She feels hurt (AC) and starts to automutilate (PP)

Figure 10.1  Example of a mode sequence in a couple: wife is diagnosed with BPD and the husband has obsessive–compulsive personality disorder. (S = Situation; AC = Abandoned/abused Child; VC = Vulnerable Child; DP = Detached Protector; OC = Overcontroller; PP = Punitive Parent)

­present during the conversation when the individual life history and causes of the schemas and modes of one of the partners is discussed. This can even provide a positive contribution to both partners’ understanding of each other’s schemas and modes, as well as the origins of these in their respective childhoods. If the therapist carries out individual consultations, the rule naturally applies that the contents of these conversations are not allowed to be kept secret from the other. If patients do tell secrets, then they need to tell their partner within 1 month or the therapy will be discontinued. The therapist attempts, based on events outside the session, but especially based on the interactions within the session, to determine which typical patterns occur in the relationship. One of the ways in which to achieve this is to ask the couple to discuss a problem for which they have no clear solution for about 15 min, without having the therapist intervene. The therapist will then try to explain to the partners which patterns he sees and explain which modes play a role.



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According to Atkinson, (2012), there are five mode sequences, which are related to the three different coping strategies:

• • • • •

Fight/flight loop: One partner attacks from the punitive side or the angry child and the other seeks refuge in the detached protector. Fight/fight loop: Both react critically toward each other; both are in the punitive or critical parent mode and/or the angry protector or angry child mode. Fight/freeze loop: One partner attacks (for example, from the punitive parent mode) and the other freezes up and reacts submissively (as a compliant surrenderer). Freeze/freeze loop: This occurs with couples who both do not or no longer dare to ask the other to fulfill their needs (both shift in the compliant surrender mode). Flight/flight loop: Both partners lead largely separate lives and no longer have any emotional contact; both partners are in the detached protector mode.

Once they recognize the pattern, patients will start to realize that their reactions are usually caused by their own modes being triggered by the other’s actions. They also start to see how these actions and reactions cause the situation to spin out of control, without them having the power to react differently. They will see not only their own impotence but also that of the other. The therapist not only verbally clarifies the relationship problem but also does so visually with a drawing of a vicious cycle showing the couple’s specific modes. They can take these insights with them in the form of one or more flashcards about the relationship, which they can use as an aid to better understand their problems at home. Besides the information gained from conversations and the case history, he uses imagery with regards to the case conceptualization and possibly a two‐or‐more‐chair technique (see Chapter 5: Imagery; Two‐or‐More‐Chair Technique) to clarify the development of these schemas and modes.

Adjusting schema therapy techniques for couples therapy All the techniques, which have been described in the earlier chapters, can be applied in couples therapy. Only slight adjustments are needed. It is essential for the therapist to ensure that both partners remain involved with the process, as with other forms of couples therapy. They need to learn how

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to fulfill each other’s needs for attention, love, and support in a positive manner (using the healthy adult mode). Imagery rescripting  The therapist lets one of the partners do an imagery exercise in order to rescript situations that have contributed to mode development. Initially, the therapist will be doing the rescripting and the partner will have a more observing role. Nonetheless, the imagery of one partner will evoke emotions with the other. It can trigger the same modes (he will also come into his abandoned child mode) or it can call up empathy from his healthy adult mode. The therapist ensures that the imagery involving one person doesn’t take too long and involves the partner as soon as possible by asking him about his experiences and possibly asking him to contribute to the rescripting. It can be very healing when not only the therapist but also the partner stands up to the punitive parent present in the imagery and soothes the abandoned/abused child. The further along in the therapeutic process, the more the partner is involved with rescripting. The experiences from imagery of a past event can subsequently be linked to a recent situation. By having one partner relate her experiences of a recent conflict during an imagery exercise and at the same time linking it with events from the past, the observing partner is able to better “hear” and deal with what the other has to say about the situation. It makes a significant difference whether you hear “You didn’t hear me and that’s why I threatened you with divorce because I think you’re an uncaring …,” or hear, “You weren’t listening to me, and I thought you didn’t care because the situation made me think of my father who was never interested in me. That’s why I forgot to ask why you didn’t hear me and immediately threatened to file for divorce.” If one of the partners nonetheless is in danger of reacting in a punitive or critical way to the abandoned child of the other partner, the therapist protects the abandoned child by making the partner stop that behavior. He explains that it would be a repetition of the initial damage if the partner continues to persist, and ties in the activation of this (punitive parent) mode with the abandoned child of this patient. Role play  With ST for couples, both historical role play and the current role play techniques can be applied. In the historical role play, there are more opportunities to have the partner also play the role of a parent if the situation allows it. Particularly in current situations, doing role play with role reversal can lead to new insights (see Chapter 5: Role Play).



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Two‐or‐more‐chair technique  With the application of the two‐or‐more‐chair technique, the same additional possibilities apply as with imagery. Partners can initially learn from each other that certain behavior is not representative of the partner as a whole, but stems from the activation of a mode. In the second instance, the partners can help to combat each other’s dysfunctional modes by fighting these modes together (in the case of the punitive or critical parent) or to bypass them (in the case of the protector or other coping modes). Cognitive and behavioral techniques  Use can be made of cognitive techniques from the beginning of ST with couples. Case conceptualization makes significant use of cognitive techniques through the discussion of the validity, or rather invalidity, of the dysfunctional cognitions and to explain these using the schemas and modes. Partners produce one or more flashcards about their relation patterns and collect increasing amounts of information about healthy forms of intimacy. They can also read about it in books such as Reinventing Your Life, written by Young (1999) or The Seven Principles of Making Marriage Work by Gottman and Silver (1999), or Breaking Negative Thinking Patterns: A Schema Therapy Self‐help and Support Book by Jacob et al. (2015). As the schemas and modes are cured, there is more room for behavioral change. The therapist discusses, in concrete terms, the fields in which the relational link can be strengthened, and in doing so can draw from those exercises that are also used in other forms of couples therapy.

Difficulties with ST with couples The difficulties with using ST in relationship issues, which Atkinson (2012) describes, are in fact the same as those found in other forms of couples therapy. He identifies the predominance of somatic complaints, addiction, and secrets as the main stumbling blocks. Moreover, he warns against the risks of triggering the therapist’s schemas and losing track of the therapy situation. One risk in a couple where one partner has a BPD diagnosis and the other doesn’t is that the therapist potentially goes along with the partner’s perception that he or she does not have any problems. The therapist may reinforce the punitive parent in the patient by giving her the feeling that it’s her fault. Sometimes the necessary experience is required when dealing with patients with personality disorders to see the dysfunctional patterns and identify the part both partners play in them.

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Summary In ST for couples, both partners can learn to support each other’s a­ bandoned child and develop their healthy adult and happy child modes further. If this succeeds, then ST for couples may provide faster results than an individual ST for BPD or two individual therapies for both partners. Whether that is truly the case remains to be seen; as far as the authors of this book are aware, research has not been conducted on this aspect of ST yet. The ­published literature regarding ST with relationship problems has been scant so far, but with the information from this chapter, we hope to give a first impression of the possibilities of ST for couples in general and with BPD.

11

Final Phase of Therapy

Behavioral Pattern‐Breaking Once the schema modes are no longer actively present, there may still be remnants of schemas and/or coping styles that must be dealt with. “Even if patients have insight into their Early Maladaptive Schemas, and even if they have done the cognitive and experiential work, their schemas will reassert themselves if patients do not change their behavioral patterns” (Young, Klosko, & Weishaar, 2003, p. 146). Moreover, behavioral patterns may be tackled. For example, Nora had the tendency to put difficult things off by rationalizing that these things were not that important. For descriptions of schemas and coping styles please refer to Appendices I and J (see Schema Therapy Step by Step 4.01–4.17 Examples of Schemas). Together with her therapist, the patient makes a list of behaviors that still need to be altered and puts them in order of importance. Included in this list are also important decisions she still has to make, such as choices regarding education or employment. If she avoids mentioning an important ­subject, the therapist can press her to add this to the list. The behavioral techniques will be used very often during this phase of therapy to learn new skills and solve problems (see Chapter 7). The therapist can make more use of empathetic confrontation to encourage her to finish this last part of the therapy (see Schema Therapy Step by Step 3.01 Empathic Confrontation, End of Therapy). He encourages her to observe Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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the advantages and disadvantages of the last changes she has to make during this last phase of therapy. Not only practicing new behaviors but also doing homework becomes more important in this final phase of the therapy than it has previously been (see Appendix H) (see Schema Therapy Step by Step 3.11 Healthy Adult, Dealing with conflict). Experiential techniques will still be very useful to help to change old behavioral patterns. The two‐or‐more‐chair technique can be used to start a discussion between the old dysfunctional behavioral pattern and the healthy adult. Imagery rescripting with future situations in which the patient is the healthy adult, who tries to handle difficult situations, can be very helpful to anticipate the real situation. It can give the patient more self‐confidence and lowers the threshold to act differently toward old and new relationships (see Chapter  5 and Schema Therapy Step by Step 3.08 Future Imagery—Mode awareness and mode management and 3.09 Future Imagery—Behavioral Change).

Ending Therapy The last phase of therapy often involves some kind of mourning process when the patient must accept the fact that her parents will not change and that she will not be able to return to childhood and experience the things she missed from them. The patient searches to find a new, mostly less intensive, relationship with her parents and with other family members. The patient also can discover that her partner has not changed and starts wondering if she still wants to continue the relationship. The therapist can decide to have some sessions together with the partner of the patient or refer them to a relationship therapy or refer the partner to a colleague for individual therapy. The patient will also slowly begin to let go of her therapist and begin to stand on her own feet. The frequency of sessions is reduced. As the therapist has often been the only person she could trust in her life for a long time, this process is not easy for her and requires a great deal of effort. The patient’s fear of abandonment will arise again and has to be dealt with. Because the therapist also has a strong bond with his patient, this process of saying goodbye may also be difficult for him. The therapist must take care to offer his patient the space and the trust to move on her own. He does this in the same way that a parent would when his child grows up and moves on. Patients often continue to maintain contact with their therapist particularly when important events occur in their lives (e.g., wedding, birth of a child,



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or a difficult event like death of a parent or a relationship crisis). In general, the therapist responds with a card. When the patient experiences serious difficulties, she might return to the therapist for help. Usually, a few booster sessions suffice. In line with the limited parenting concept, it is important that the bond between patient and therapist remains, even when treatment is formally stopped. According to Young, therapy is only finished when the patient has found a good (healthy for her) partner (Young, personal comments to author). In one study we nevertheless observed successful cases who did not (yet) have an intimate partner. 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. This time‐limited ST covers a period of 24 months, with an intensive first year, after which the session frequency is gradually reduced. The recommended structure is to offer in the first year two sessions a week, either individual ST or once a week individual and once a week group ST. In the second year, the session frequency is gradually decreased. In case of pure individual ST, in the first 6 months of the second year, the frequency is decreased to once a week. In the third quarter of the second year, the frequency is further reduced to once every 2 weeks, after which sessions once per month follow for the last quarter of the second year. In case of combined individual and group ST, the reduction of sessions depends on whether or not the group has a closed or a (semi‐)open format. With a closed format, both the individual and the group ST go to a once every 2 weeks frequency in the first 6 months of the second year, after which the group goes to monthly sessions for the last 6 months, while the individual sessions are offered once every 2 weeks in the third quarter of year 2, and monthly in the last quarter of the second year. In case of a (semi‐)open group format, the group has a steady frequency of once a week for 1.5 year, after which the patients leaves the group. The individual sessions reduce to once every 2 weeks in the first 6 months of the second year, then to once every two weeks in the third quarter and to once per month in the last quarter of the second year. Table 11.1 provides an overview. Essential in this time limited approach are the following. First, the schedule of sessions over the 2 years of treatment should be discussed with the patient before treatment starts. Second, the patient should be repeatedly reminded of the schedule, and related to what should be dealt with in treatment (e.g., experiential work on memories of childhood abuse and neglect in the first year; behavioral pattern breaking in the second year). Third, both

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Table 11.1  Overview gradual reduction of session frequency 24 Months of treatment Format

Months 1–12

Months 13–18

Months 19–21

Months 22–24

Only Individual ST

2 × per week

1 × per week

1 × per 2 weeks

monthly

1 × per week 1 × per week

1 × per 2 weeks 1 × per 2 weeks

1 × per 2 weeks monthly

monthly

1 × per week 1 × per week

1 × per 2 weeks 1 × per week

1 × per 2 weeks NA (finished)

monthly

Individual and Group ST combined: closed group Individual component Group component Individual and Group ST combined: (semi‐) open group Individual component Group component

monthly

NA (finished)

therapist and patient should be prepared that frequency reduction usually creates anxiety, and triggers the abandoned/abused child mode. Fourth, the rationale of time‐limited treatment and gradual reduction of sessions should be repeatedly discussed with the patient. As discussed previously, the core idea is that time‐limited treatment stimulates patients to try out what has been learned during treatment on their own, which will lead to further growth, especially of the healthy adult mode and the trust that they can manage on their own. Fifth, the evaluation of treatment should be postponed to a follow‐up 1 year after the 2‐year treatment finished. Then it is possible to get an idea of the real effects of treatment—not contaminated by being in treatment. The fact that the evaluation is postponed to 1 year after the 2‐year course also helps patients to overcome their anxieties and try things out for a year. In most cases we have seen at the 3‐year evaluation that the 2 years were enough, that BPD‐manifestations further reduced and functioning improved, and that patients reported (by hindsight) to be helped by this structure as it stimulated them to develop further and discover they were actually capable to deal with difficult issues themselves.

12

Conclusion

Until relatively recently, many therapists were convinced that the only achievable goal for BPD patients was a bit of stability in their lives. The therapy we have described in this book looks like yielding much better results than a simple, stable life. In many patients, significant and serious changes in their personalities appear to take place. In the study by Giesen‐ Bloo et al. (2006) it appeared that 52% of patients no longer met the criteria for BPD upon completion of ST, and almost 70% improved reliably. These individuals have satisfying relationships with others and are capable of regular employment or have found other meaningful activities to fill their days. Later trials, often involving a group‐ST component, showed similar or even better effects (Boog, Goudriaan, van de Wetering, Franken, & Arntz, 2019; Dickhaut & Arntz, 2014; Farrell, Shaw, & Webber, 2009; Fassbinder et  al., 2016; Nadort et  al., 2009). What remains unclear from research is exactly which patients are more likely to benefit from ST and which are not, although one study indicated that high hostility is related to dropout from treatment, and high levels of burden because of dissociative symptoms is related to less chance of recovery (Arntz, Stupar‐Rutenfrans, Bloo, van Dyck, & Spinhoven, 2015). However, these predictors don’t seem to be specific for ST as they are also found with other approaches such as Dialectical Behavior Therapy (DBT) and TFP. A study aiming at finding patient‐related characteristics that predict whether ST or DBT is a better treatment option for the patient has just started (Wibbelink, 2018). Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Individuals who have had BPD in the past might retain a certain amount of vulnerability regarding situations that are similar to their childhood traumas (e.g., loss of a partner). The clinical impression in the situation of a need for help is that a few sessions are enough to help the former BPD patient get back on track. It is recommended that the patient receives help from her own former therapist during this crisis. He knows her well and it will be easier for him to identify which schemas have become active and reassure her. He is also well aware of how she overcame her problems in the past and knows which healthy coping strategies are most likely to work for her and helps her to activate these strategies. Future scientific research must investigate which factors play a role in possible relapse. Interestingly, none of the patients that recovered from BPD had relapsed at the 1‐year follow‐up in the studies so far. Longer‐term follow‐up studies are needed to investigate how resilient these patients are in the long term. An important development the last decade has been the use of group‐ST. Using a specific way of dealing with the group dynamics, group‐ST might offer an important experience for patients with BPD. Early trials suggested good results (Dickhaut & Arntz, 2014; Farrell et al., 2009; Fassbinder et al., 2016), and it has even been claimed that proper use of group‐ST catalyzes change processes central in ST. For instance, corrective experiences offered by other group members might feel more convincing than offered by professional therapists, who are “paid for the job.” As another example, repeatedly experiencing safety in the group while sharing vulnerable emotions of the abandoned‐abused child mode might promote generalization over people compared to individual ST. An international multi‐center study under the direction of Arntz and Farrell started in 2010, with the aim of comparing GST with treatment as usual and exploring whether the combination of individual and group‐ST or mainly group‐ST should be the treatment of choice. First results were available when this book was finalized. These indicate superior effects of GST compared to treatment as usual, especially for the combined individual and group‐ST, when main outcome (BPD severity), treatment dropout, and most secondary outcomes are considered (Arntz et al., 2019). This matches with preferences of most patients and many therapists (Martius, 2019; Tan et al. 2018). Nevertheless, several major issues related to the application of group‐ST for BPD have to be resolved. First, apart from the aforementioned studies on group‐ST, no RCTs have yet compared group‐ST to other treatments. Thus, we need more research about the effectiveness compared to other

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treatments. Second, the cost‐effectiveness of group‐ST should be ­documented. At the moment when this text was written, two other RCTs were running that address several of these issues. One RCT compares the combined individual and group‐ST format to DBT in terms of effectiveness and cost‐effectiveness (Fassbinder et  al., 2018). Another RCT not only compares the combined individual and group‐ST format to DBT, but also aims to find predictors for selecting the optimal treatment for a specific patient (Wibbelink, 2018). Returning to individual ST, experience has shown that therapists using ST tend to find working with BPD patients enjoyable. They develop a better understanding of their patients and experience more possibilities to help them. This is not to say that this is easy work and that a therapist can start helping 10 different BPD patients at the same time using this method. For individual ST, the maximum number should remain somewhere between four or five patients who have progressed to the point where the most ­problematic aspects are dealt with.

Appendix A

Brochure for Patients: Schema Therapy for People with Borderline Personality Disorder

What Is Borderline Personality Disorder? People with borderline personality disorder (BPD) have problems with mood swings. They experience problems in almost every aspect of their lives because of these mood swings, particularly in their relationships. Often, they do not know who they are or what they want. These individuals also have a tendency to act in very impulsive ways. They often experience outbursts of anger/rage and crises are not uncommon. Individuals with BPD do not know why their moods swing in this uncontrollable manner. Molehills quickly become mountains and the result is often frightening or makes them angry. While many people with BPD are intelligent and creative, they are seldom able to succeed in developing these talents. Often their education remains incomplete and they work far below their abilities. They run the risk of hurting themselves. Research has shown that the suicide risk in this group is higher than in other personality disorders. Further, in an attempt to numb overpowering emotions, these individuals often abuse various substances (e.g., drugs and/ or alcohol).

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What Is Schema Therapy? Schema therapy is a form of therapy that involves a combination of cognitive behavioral therapy and elements from other types of therapy. These are all directed not only at the current problems the patient is experiencing but also at addressing the patient’s past and the sources of these problems.

Description of BPD from the Perspective of Schema Therapy Schema Therapy assumes that people developed ideas about themselves, the other people, and the world around them during their childhood. These ideas are called schemas. Schemas tell people how to deal with the different situations that they encounter. If during your childhood you had little support or direction, in other words you were emotionally neglected, you don’t learn important information about yourself, others, and the world around you. If one adds to this emotional, physical, and/or sexual abuse, the chance is even greater that normal development is disrupted. The result is that you do not experience yourself as a whole, because you have developed different sides of yourself that manifests themselves at different moments. These different sides are referred to as schema modes or schema states. Most individuals with BPD have five schema modes: the abandoned/abused child, the angry/impulsive child, the punitive parent, the detached protector, and the healthy adult. People with BPD have two modes that are characteristic of their childhood abuse and/or neglect. These schema modes express a behavior that is childlike with very strong, often uncontrollable emotions and absolute ideas. The other three modes have to do with more adult characteristics. The punitive side and the detached protector, while appearing to be helpful, are actually not helping at all as their frequent presence interferes with the development of the healthy adult. There is also a sixth mode, the happy child mode. This mode is not dysfunctional, and it is mostly very underdeveloped. So, during therapy one of the goals is developing a playful happy child mode.

The abandoned and abused child When you are in this mode, you feel abandoned, helpless, frightened, and threatened. You think that at any given moment terrible things will happen. There is no one you can trust and there is no possibility for help.



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The angry and impulsive child If you are so angry that you lose control of yourself, then the angry child is active. You feel that you have been unfairly treated and wronged so that direct frontal attack is the best defense. You may also feel very frustrated because your needs are not met and you feel your life is miserable. You might then become very impulsive in wanting to satisfy your wants and needs as a rebellion against an unjust world.

The happy child When you’re making fun and playing games or do anything else you enjoy without thinking of your adult duties, you’re probably in the happy child mode. You feel happy, carefree, relaxed, and cheerful. You do not think so much, you just act and have fun and you laugh or at least smile.

The punitive side This side puts the opinions of one (or more) of your childhood caregivers who mistreated you into words. The punitive side does not approve of showing emotions and thinks that you deserve to be punished for all of your mistakes, even accidents. This side gives you the feeling that you are bad, dumb, lazy, and ugly. At times these feelings can be so strong that you may feel you should not even exist. The punitive side directs itself against all of the child modes.

The detached protector Both the child sides as well as the punitive side carry along with them very strong emotions, which can at times be unbearable. The protector helps you to avoid these feelings. Sometimes this makes you feel empty or “nothing.” At other times substances (drugs, alcohol) are abused to push these feelings away. The detached protector shuts you off from others so that no one can hurt you.

The healthy adult This side can handle emotions and solve problems well. But as many things in your childhood have gone wrong, you have not sufficiently developed this side and it is often not present when you need it most.

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Goal of Schema Therapy The goal of schema therapy is to strengthen the healthy adult and develop the happy child. In addition, the other child sides learn to deal with intense emotions without being scared of feeling completely lost or scared of an outburst of rage. The punitive side is not needed any more and will be replaced with normal, nuanced values and norms. The detached protector is gradually less necessary as the punitive side disappears and you are not suddenly overwhelmed by your feelings anymore.

What does the therapy consist of? The therapy consists of a number of different ways to accomplish the ­aforementioned goal.

Relationship with the therapist The therapist helps you learn the things you could not learn in your childhood. The therapist tries to support and understand you instead of punishing you so that you learn to trust a person. Since this trust was destroyed to a great extent in your childhood, this is an important experience.

Experiential techniques In your childhood, the experience and expression of emotions was ­suppressed and dealt with in a disturbed way. Experiential techniques are used to learn to feel again in a healthy way. The therapist can, for instance, ask you to close your eyes and go back to the situations in the past. He asks you what you actually would have wanted to happen at that time, and he helps you to express your needs (in your imagination) and to stop the ­maltreatment. This way you learn that your emotions and needs were ­normal, but the reactions to them were not.

Cognitive techniques Cognitive therapy is concerned with the thoughts and ideas about yourself, other people and the world, which developed from negative experiences in your childhood and the rest of your life. Evidence for and against this way of thinking will be looked for. This way you acquire more nuanced perspectives.



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Behavioral techniques Not only your emotions and thought must be changed, but also what you do as a result. Behavioral techniques usually consist of exercises to try out a new behavior. If, for instance, you have never learned to express your opinion, you practice this skill first with the therapist and later in situations outside of therapy.

What you can expect? A combination of the described techniques will lead to a more positive image of yourself, finding out who you can and cannot trust, and the best way of tackling problems. The different sides of you will cooperate more and you develop into a healthy adult. Since the problems have been there for a long time and your development is disturbed in many ways, this therapy will ask a lot of you and take around 2 years (or longer if necessary). Try to talk about problems with your therapist by following and persevering with the therapy so that you will eventually be much better.

Appendix B

Cognitive Diary for Modes

ACTIVATING EVENT (What caused my reaction?) FEELING (How did I feel?) THOUGHT (What was I thinking?) BEHAVIOUR (What did I do?) THE SIX ASPECTS OF MYSELF Which aspect was in play in this situation? Underline the aspects you recognize and describe them. 1. 2. 3. 4. 5. 6.

Detached protector: Abandoned/abused child: Angry/impulsive child: Happy child Punitive parent: Healthy adult:

JUSTIFIED REACTION (What part of my reaction was justified?) OVERREACTION (What part of my reaction was too strong?) In which way did I overreact or see things that were not there? What did the different aspects of myself do to make things worse? DESIRED REACTION What would be a better way for me to view this situation and to deal with it? What could I do to solve this problem in a better manner? FEELING

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

Appendix C

Positive Logbook

Try to write down one or more small (or large) activities or experiences that contribute toward a positive image of yourself and others. All of this information can be used to weaken the punitive mode and strengthen the healthy adult mode. Date: Subject: Date: Subject: Date: Subject: Date: Subject: Date: Subject: Date: Subject: Date: Subject:

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

Appendix D

Historical Testing

Write down experiences that took place in the different phases of your life that prove that the punitive parent is wrong and that support the little child. 0–2 years 3–5 years 6–12 years 13–18 years 19–25 years 26–35 years 36–50 years and older Summary:

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

Appendix E

Experiments

Instructions for the therapist Planning an experiment: 1 Decide with the patient whether or not it is useful to find out if an idea is tenable. 2 A theory can only be tested if it is falsifiable. 3 If desired, formulate alternative theories. 4 Together with the patient, decide upon a concrete situation in the near future, in which the idea is likely to play a role. 5 Together with the patient, decide upon concrete behaviors that clearly test the idea (i.e., which can lead to falsification). 6 Allow the patient to predict where the behaviors from no. 5 are likely to lead to, based upon the to‐be‐tested idea. 7 Beforehand, agree upon which concrete results, based on the aforementioned behaviors, will serve as evidence for or against the accuracy of the idea. 8 Beforehand, agree upon where and when the patient will try out these new behaviors and exactly what she must pay attention to. One should expect a great deal of fear regarding her anticipation of this exercise. 9 Remember this is an experiment and an experiment cannot fail!

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Evaluation of the experiment: 1 Do not forget: an experiment cannot fail! However, it is possible that it was not executed, wrongly executed, or wrongly designed. 2 Allow the patient to blow off steam after this exercise and empathize with the courage she has shown by attempting to execute it. 3 Ask the patient to retell the situation, behavior, and concrete consequences of the experiment. 4 Based upon the concrete results of the experiment, discuss whether or not the predictions were correct. Be careful to avoid misinterpretations. 5 Summarize the results and, together with the patient, re‐evaluate the tested idea. Pitfalls: 1 Essential components of the new behavior were not executed. 2 The experiment cannot offer a decisive answer to the idea. 3 The idea is incorrectly formulated and does not accurately represent the patient’s theories. 4 The patient rejects the results. Search for the reasons and watch out for misinterpretations. Invite the patient to set up a decisive test. 5 The therapist got too involved in a specific outcome of the experiment. Date: The original thought to be tested for credibility The alternative thought to be tested for credibility Behavioral experiment: What am I going to do and how am I going to do it? Which results support the original thought? Which results support the alternative thought? Result: How did the behavioral experiment go? Which results appeared to support the original thought and which appeared to support the alternative thought? Credibility of the original thought: Credibility of the alternative thought: What have I learned from this experiment? Which mode has changed because of this and how has it changed?

Appendix F

Homework Form

Description of the homework assignment I want to do: When will I do this homework assignment? What potential problems can I think of when it comes to doing this assignment? 1. 2. 3. Possible solutions to these problems: 1. 2. 3. Results: Effects on the modes: Which problems appeared that I did not think of beforehand and how did I deal with them?

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

Appendix G

Problem Solving

What is the problem? What do I want to achieve? Which modes are likely to interfere with my solving this problem? 1. 2. Which thoughts are likely to interfere with my solving this problem? 1. 2. What alternative thoughts help me to solve this problem? 1. 2. What solutions can I think of for this problem? 1. 2. 3. 4. 5. 6. List pros and cons for each solution Which of these solutions do I choose and why? How did I deal with it?

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What was the result and did I achieve my goal? What influence did the result have on the modes? Eventually: Which other solution will I try? Result:

Appendix H

Changing Behavioral Patterns

Description of the behavioral pattern I want to work on: In what kind of situations does this behavior often appear? What do I do in these situations that results in things not going well? Which mode, rule of life, or thought plays an important role here? What are the arguments against this mode, rule of life, or thought? What is a new behavior that would be more goal‐orientated in this situation? How did it work out when I tried out this new behavior? Formulate a new and healthier rule of life:

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

Appendix I

Eighteen Schemas

In this appendix the 18 schemas as described and summarized by Young, Klosko, and Weishaar (2003) are listed and described briefly. We refer to this book for a detailed explanation on the meaning of the schemas and schema therapy. In accordance with Young et al., this appendix will refer to the patient in the feminine form and refer to the therapist using the masculine form. The 18 schemas are organized in five themes, shortly introduced before the schemas are described.

Disconnection and Rejection The patient expects that she cannot rely on the security or predictability of her surroundings. Further she assumes a lack of reliability, support, empathy and respect from others. She comes from a family in which she was treated in a cold, rejecting manner. She was lonely and had no emotional support; at times she even lacked basic care. Her parents (caregivers) were unpredictable, uninterested, or abusive.

Abandonment/instability The patient expects that she will soon lose anyone with whom she has an emotional attachment. She believes that all of her intimate relationships will eventually end. Important others in her environment are seen as unreliable and unpredictable in their ability or willingness to support her or in their Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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devotion to her. They will either die or abandon her. In either case, she will end up alone.

Mistrust/abuse The patient is convinced that others will, in one way or another, eventually take advantage of her. She expects others to purposely hurt her, cheat on her, manipulate, and/or humiliate her. She believes that she will always have the short end of the stick.

Emotional deprivation The patient thinks that her primary emotional needs are either not met or inadequately met by others. These needs are related to physical care, empathy, affection, protection, companionship, and care. The most common forms of emotional deprivation are as follows:

• • •

Deprivation of Nurturance: No attention, warmth, or companionship. Deprivation of Empathy: No one listens to you, understands you, or can share your feelings. Deprivation of Protection: No one gives you advice or direction.

Defectiveness/shame The patient feels that she is intrinsically incomplete and bad. As soon as others get to know her better, they will also discover this and no longer want anything to do with her. She thinks that no one will find her worthy of loving. She is overly concerned with the judgment of others and is very conscious of herself and her inadequacies. These feelings of being incomplete and inadequate often result in strong feelings of shame. Defectiveness/shame can be related to both inner (“negative” desires and needs) and outer (undesirable physical appearance or being socially inadequate) aspects of the self.

Social isolation/alienation The patient has the feeling that she is isolated from the rest of the world, is different from everyone else, and does not fit in anywhere.



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Impaired Autonomy and Performance The patient expects that she is incapable of functioning and performing on her own and independently of others. She comes from a (clinging) family from which she cannot break free and in which she is overly protected.

Dependence/incompetence The patient is not capble of taking on daily responsibilities and cannot do so independently. She feels extremely dependent upon others in situations that require her to make decisions on simple daily problems or to attempt anything new. She appears completely helpless.

Vulnerability to harm or illness The patient is convinced that at any given moment, something terrible could happen to her and that there is absolutely nothing she can do to protect ­herself from this impending disaster. She fears both medical and psychological catastrophes as well as other types of adversity. She takes extraordinary ­precautions to avoid disasters.

Enmeshment/undeveloped self The patient is overly involved with and connected to one or more of her caregivers. Because of this over‐involvement she is unable to develop her own identity. At times the patient has the idea that she does not exist without the other person and often feels empty and without goals.

Failure The patient is convinced that she is not capable of performing at the same level as her peers with regard to career, education, or sport. She feels stupid, foolish, talentless, and ignorant. She does not even attempt to succeed at things as she is convinced she will be unable to do so successfully.

Impaired Limits The patient has inadequate boundaries, feelings of responsibility, and frustration tolerance. She is not good at setting realistic long‐term goals and has difficulty working together with others. She comes from a family that

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offered little direction or gave the feeling of being superior to the rest of the world. The parents set few limitations and did not encourage the patient to persevere during difficult times and/or take others into consideration.

Entitlement/grandiosity The patient thinks that she is superior to others and has special, only‐for‐ her rights. She does not need to follow the “normal” rules as she is above them. She can do and get away with what she wants without taking others into consideration. The main theme here is power and control over situations and individuals. There is no empathy for others.

Insufficient self‐control/self‐discipline The patient cannot tolerate any frustration in achieving her goals. She is not capable of suppressing feelings or impulses. It is possible that she is primarily attempting to avoid unpleasantness or being uncomfortable (pain, argument, and effort).

Other‐Directedness The patient always takes the needs of others into consideration and ­suppresses her own needs. She does this in order to receive love and approval from others. She comes from a family that only accepted her given certain conditions. The needs and status of the parents took priority over the individual character of the child.

Subjugation The patient gives herself over to the will of others to avoid negative consequences. This can include the suppression of all her needs or emotions. The patient thinks that her desires, opinions, and feelings are not cared for by others. This often leads to pent‐up rage, which is then expressed in an ­inadequate manner (i.e. passive–aggressive or via psychosomatic symptoms). One can distinguish between subjugation of needs and subjugation of emotions, but they usually go together.

Self‐sacrifice The patient voluntarily and regularly sacrifices her needs for others whom she views as weaker than herself. If she does attend to her own



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needs, she feels guilty about doing so. She is overly sensitive to the pain of others. Because her own needs are not met she eventually resents those she cares for.

Approval‐seeking/recognition‐seeking The patient searches for approval, appreciation and acknowledgement in an exaggerated manner. She does this at the cost of her own development and needs. This sometimes results in an excessive desire for status, beauty, and social approval in order to achieve acknowledgement and admiration.

Overvigilance and Inhibition At the cost of self‐expression and relaxation, the patient suppresses her spontaneous feelings and needs and follows her own set of strict rules and values. The patient’s family emphasized achievement, perfectionism, and repression of feelings and emotions. The caregivers were critical, pessimistic, and moralistic while at the same time expecting an almost unachievable high standard.

Negativity/pessimism The patient always sees the negative side of things while she ignores or minimizes the positive side. Eventually, everything will go wrong even if it is currently going well. Because she is convinced that everything will eventually go wrong, she is constantly worried and hyper‐alert. She often complains and does not dare to make any decisions.

Emotional inhibition The patient always holds in her emotions and impulses as she thinks that expressing these will damage others or lead to feelings of shame, abandonment, or loss of self‐worth. This involves suppressing all spontaneous expression: anger, joy, as well as discussing problems. She emphasizes rationalization.

Unrelenting standards/hypercriticalness The patient believes that she will never be good enough and that she must always try harder. She tries to satisfy an unusually high set of personal standards to avoid criticism. She is critical of herself as well as of others

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around her. This results in perfectionism, rigid rules, and a preoccupation with time and efficiency. She does this at the cost of enjoying herself, ­relaxing, and maintaining social contacts.

Punitiveness The patient feels that individuals should be severely punished for their ­mistakes. She is aggressive, intolerant, and impatient. She is completely unforgiving of mistakes. She does not take an individual’s circumstances or feelings into account.

Appendix J

Coping Strategies

Coping strategies are mechanisms for dealing with schemas. All organisms have three manners of dealing with threat: freeze, flight, and fight. When confronted with a schema, an individual can react in any one of these ways. In this appendix we will describe briefly the three ways in which one can cope with schemas, as described in detail by Young, Klosko, and Weishaar (2003) to which we refer the reader for further reading.

Surrender (Schema‐Affirming Behavior: Freeze) The patient behaves in accordance with her schema and adapts her thoughts and feelings accordingly. This behavior confirms the schema. Behavior: The behavior is according to the schema. Thoughts: Selective information processing, in other words, only information that supports the presence of the schema is of importance. Feelings: The emotional pain from the schema is directly felt.

Avoidance (Schema‐Evasive Behavior: Flight) The patient avoids activities that trigger the schema and the accompanying feelings. The result is that the schema is not questioned and therefore no corrective experiences can take place. Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Behavior: Active and passive avoidance of all kinds of situations that could potentially activate the schema. Thoughts: Denial of situations and memories; depersonalization. Feelings: Denial or leveling off of feelings (includes self‐injury and ­substance abuse).

Overcompensation (Showing the Opposite Behavior in Order to Fight the Schema: Fight) The patient behaves completely opposite to her schema to avoid having problems from it. This results in the patient underestimating the influence of her schema and often in overly assertive or independent behavior. Behavior: The behavior is completely the opposite of your schema. Thoughts: Denial that this schema is applicable for the patient. Feelings: The patient covers up unpleasant schema‐related feelings with opposing feelings (e.g., power as a cover‐up for powerlessness or pride as a cover‐up for inferiority). However, the unpleasant feelings return when the overcompensation fails due to setbacks or illness.

Appendix K

Form for the Historical Role Play

HISTORICAL ROLE PLAY: ROLE PLAY 1 (the original situation) Patient plays herself as a child. Therapist plays the other person. Conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐100 Assumed perspective of the other person: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐100 ROLE PLAY 2 original situation: role reversal Patient plays the other person. Therapist plays the patient as a child. Alternative assumed perspective of the other person: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐100 Alternative conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐100 ROLE PLAY 3 Patient plays herself as a child but tries out new behavior. Therapist plays the other person. Alternative assumed perspective of the other person: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐100 Alternative conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐100 Original conclusion about myself: 0‐‐‐‐‐‐‐‐‐‐‐X‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐100 Implications for the future

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

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Index

abandoned/abused child, the (mode)  16, 21–22 how to recognize  22 treatment methods for  176–180 abuse  41, 42, 55, 56 acceptability ST for Patients  10 acting out  158 addiction  158, 162 ADHD  11, 188 advice  52, 206 anamnestic interview  38 anger  126–129, 181–186 dealing with  126, 127, 181 expressing 157 trouble with feeling anger  128 angry/impulsive child (mode)  20, 22–24, 45, 126, 127–129, 181–186 how to recognize  24 treatment methods for  133–6 treatment of  45 angry protector, the (mode)  17, 19, 23, 128 antidepressants 158 antisocial personality disorder  11 anorexia nervosa  11 antipsychotic medication  25 attachment (disorganised)  5, 8 autism spectrum disorders  11 autonomy  12, 27

avoidant personality disorder  4 axis‐I complaints  5 basic needs of a child  12 Beck, Aaron (Tim)  xii, 7, 8 behavioral pattern‐breaking  225 behavioral techniques  149–153, 213–223 and the therapeutic relationship  67, 68 experiments 15 problem solving  151 skills training and role play  150 see also doing benzodiazepines 158 bipolar disorder  11 booster sessions  227 borderline personality disorder (BPD)  3 brochure for patients  233–238 Borderline Personality Disorder Severity Index (BPDSI)  39 borderline personality organisation  3 boundary‐exceeding behaviour  55–57 examples of  57 sanctions for  59 BPD checklist  39 break off contact with parents  177 brochure for patients  233–238 bully and attack (mode)  17, 18, 19 burn out  52

Schema Therapy for Borderline Personality Disorder, Second Edition. Arnoud Arntz and Hannie van Genderen. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.

272 Index care 33 case conceptualisation  15, 35, 36, 40, 42 chairwork see two‐or‐more‐chair technique changing behavioural patterns  47, 169 childhood traumas  163–164 children and adolescents  201 cognitive diary on the therapeutic relationship 66 cognitive diary for modes  134, 135, 138, 139, 239 cognitive distortions  135, 136 cognitive techniques  133–148, 213, 223 and the therapeutic relation  65 cognitive distortions  135, 136 commonly asked questions  137 courthouse method  143 evaluation on a visual analogue scale 137–139 flashcards 146 historical testing  144 homework 148 multidimensional evaluation  139–140 pie chart  142 positive logbook  146–147 self monitoring circle  145 Socratic dialogue  137 therapeutic relationship  66 two‐dimensional reproductions of supposed connections  142 see also thinking comforting  157, 178 comorbidity  4, 5, 36 comorbid disorders (treating)  35 conclusions 229–231 conflict(s) (cope with)  55 connection to others  12 (contra‐) indications  11 coping strategies  6, 13, 259 avoidance 259 surrender 259 overcompensation 260 coping response  14 cost‐effectiveness 9 courthouse method  143

crisis  159–161, 206 crisis management  44 damaging behaviours  52, 53 damaging relationships  151 dangerous behaviours  151 day‐treatment and Inpatient Settings  201 dealing with anger  126, 127 defectiveness / shame  254 dependence / incompetence  255 dependent personality disorder  4 depression 11 detached protector, the (mode)  16–21 how to recognize  20 treatment methods for  168–175 development of BPD  5 development of ST for BPS  7 diagnosis  3, 11, 48 diagnostic criteria for borderline personality disorder  4 diagnostic interview  38 dialectical behavioural therapy  7, 8, 10 differences between working in a group and individual therapy  206 direct answers  64 discussing dangerous behaviours  151 discussing new behaviours  152 dissociative state  173 doing  31, 172, 177, 180, 184, 188, 191, 195 downward arrow technique  38 dropout 8 DSM‐5  3, 4, 13 dysfunctional schemas  5, 6, 13, 38, 163 early maladapive schemas  13 email  34, 50 emotion ‐focused couple therapy  215 emotional abuse  5, 117 emotional deprivation  254 emotional inhibition  56, 63, 216, 257 empathic confrontation  53, 55, 225 ending therapy  48, 226–228 enmeshment / undevoloped self  255 entitlement / grandiosity  256

Index 273 evaluation on a visual analogue scale  137 experiencing and expressing emotion  125–132 experiential techniques in the first phase 47 experiments 150 explaining the treatment rationale  43 expressing anger  126, 127 expressing other emotions  129 failure 255 feeling (methods)  31, 170, 176, 180, 183, 188, 189, 194 forensic sector  201 final phase of therapy  47, 225 flashcards 146 frustration(s)  52, 129, 179, 186, 187 function analysis of the therapeutic relationship  63, 64 giving direction  52, 53 good care  51, 52 group schema therapy  203–201 adjusting schema therapy techniques 210–213 developing identity  210 group rules  206 tasks and roles of the therapists  204 the advantages of  204 therapy phases  205 use of techniques derived from nonverbal therapies  207 working with the happy child mode  207 group ST research  9, 10 happy child mode  15, 27, 28, 207 how to recognize  28 treatment  45, 179, 180 experiential techniques  131 healthy adult, the (mode)  16, 26, 27, 45, 47, 193, 226 how to recognize  27 treatment methods for  193–196 hearing punitive voices  121 historical role play  104–112, 212, 229 rescripting 109–112

role switching  106 the original situation  105 three phases  104 historical testing  144, 443 histrionic personality disorder  4 hobby 112 homework  47, 137, 148, 155–157, 226 imagery 69–103 applications and aims of  70 instruction imagery for the case conceptualization 75–78 of childhood memories  71 of roots of modes  75 of a safe place  75–76 starting point of  71 without rescipting  75, 96 imagery rescripting  70, 71, 80–103 basic model during the first phase of therapy 80–88 basic model during the final phase of therapy  80, 89–93, 226 changing behaviour patterns  93 future situations  226 imagening the original situation  81 Frequently asked questions about Imagening conforting the abused child 178 imagery in a group  211 imagery with couples  222 by the patient as a healthy adult  80, 89 medication 102 questions during  78 rational of  72 by the therapist  81–83 therapist reassures and comforts  85, 86 therapist takes the patient to a safe place 86–88 three phases  89 two phases  80–88 variations of  90 imaginary exposure  164 impaired autonomy  255 impaired limits  255

274 Index impulsive child mode  15, 23, 24, 129, 186–188 (see also angry/impulsive child) incompetence 255 indication(s)  11, 38, 172, 215 information gathering  37–42 instruction imagery for the case conceptualization 78 insufficient self‐control/ self‐discipline 256 letter writing  126, 127, 131 life rules  12 limits exceed own  52 broken 52 personal 55 too few  56 too quickly  56 limit setting see setting limits limited reparenting  50–62 too much limited reparenting  178 listening to recorded sessions  34 measurements 8 medication  56, 102, 157–15 abuse 102 meditation exercises  156 memory  69, 70 accurate 69 wipe‐out 72 Mentalization Based Treatment (MBT)  8, 10 methods per mode (see modes) 107 mistrust/abuse 254 modelling by the therapist  46 mode(s) 14–17 changing 196 flipping of modes  46 guessing game modes  46 methods per mode  167–199 model 40 name for  43 recognize modes  45 search for the roots of  52, 53 therapeutic interventions with  44 mode model  42–43, 48 with schemas  43 not appropriate  49

mode sequence (with couples)  219–221 mood swings  44 multidimensional evaluation  139 multiple‐chair technique  80, 86, 87 multiple personality disorder  15 narcissistic personality disorder  4 narcissistic traits  12 neglect 5 new behaviors  152 negativity/pessimism 257 nonverbal therapies  202, 203, 207–210 obsessive‐compulsive personality disorder  216, 257 other‐directedness 256 overcompensation  14, 260 overvigilance 257 pathways to childhood memories 71 personal boundaries  56 personality disorders antisocial  4, 11 avoidant 4 dependent  4, 19 histrionic 4 narcissistic 4 paranoid  4, 173, 174 Personality Disorder Beliefs Questionnaire (PDBQ) 39 Personality Beliefs Questionnaire  39 personal limits  55 pharmacological therapy  157, 158, 175, 184 phases in treatment  35, 47 physical abuse  5 physical symptoms  130, 131 pie chart  142 positive logbook  146 problem‐solving  151, 93 pro’s and con’s method  168–171 psychoanalytical forms of treatment  7, 8 psycho‐education  47, 64, 135, 152 psychoses  11, 25, 121, 172 punitiveness  56, 258

Index 275 punitive parent, the (mode)  18, 20, 24–26, 45 how to recognize  26 treatment methods  115–122, 189–193 punishing voice  25, 121 quality of life  8, 9 Questionnaires 39 Beliefs Questionnaire  39 Borderline Personality Severity Index 39 BPD Checlist  39 Personality Beliefs Questionnaire  39 Schema Mode Inventory  39 The Personality Disorder beliefs Questionnaire Young Schema Questionnaire  39 Young Parenting inventory  39 relaxation exercises  156 rescripting by the therapist  83 research  8, 11, 48, 215, 227 role play  62, 70, 103–115 of a current situation  114–115 historical role play  104–112 three phases  104 and rescripting  109–112 and role reversal  62 and role switching  106 and skills training  150 and role play with couples  222 and role play in a group  212 safety  12, 57, 205 safe place  75, 79, 205 sanctions 59 schema dialogue  115, 192 schema‐focused therapy  7 schemas 12–14 dysfunctional  5, 6, 13, 24 questionnaires 39 of the therapist  53 Schema Mode Inventory (SMI)  39 schema modes  8, 14–16, 169 and treatment methods  125–144 schema state  11 schema therapy for couples  215–224

adjusting schema therapy techniques 221–223 advantage of  217–218 case conceptualization  219–221 indication 215–217 mode sequence  219–221 therapeutic relationship  218–219 schema therapy in other settings and modalities  201 children and adolescents  201–202 couples 202 day treatment and inpatient settings  201 the elderly with BPD  201 foresic sector  201 group 202 nonverbal therapies  202 self‐aggrandizer (mode)  17,18, 19 self‐appreciation 12 self‐control/self‐discipline 174 self‐destructive behaviours  162 self‐disclosure  65, 65 self‐expression  12, 27 self‐injury/self‐harm  42, 161–162 self‐sacrifice 256 self‐soother (mode)  17 setting limits  55–62 direct 55 consequences  59, 61 personal limits  55 step by step  55 steps in limit setting  60 topics 56 sexual abuse  5, 13, 41 simultaneous chess play in a Pinball Machine  196 skills training  150 sleep (lack of)  173 social isolation/alienation  254 social skills  150 Socratic dialogue  97 special recordings  156 starting phase  35 strategies 12 structure of sessions during active treatment 45 structure of treatment  33

276 Index study 203 subjugation 250 substance abuse  11 suicide  5, 8, 42, 151, 161–163 attempt  3, 42, 50, 151, 158 suicide risk  3, 8 surrender  14, 259 telephone accessibility  50 temperament  12, 13, 17 TFP See Transference Focused‐Psychotherapy therapeutic interventions with modes  44 therapeutic relation(ship)  49–68, 168–175, 179, 187, 189, 218 behavioural experiments and  67 behavioural techniques  67 cognitive techniques and  65, 66 functional analysis  64 literature on  63 non therapeutic  52 therapeutic techniques  32 therapists’ schemas  62 therapy ending of  60 phases of  29, 153 see phases in treatment  35 thinking (methods)  31, 171, 176, 180, 184, 188, 191, 194 threat(en) others  52, 55 transference‐focused psychotherapy  7, 8 transitional object  157 traumatical experiences  5 trauma processing  163–165 treatment axis‐I symptoms  5 frequently asked questions about  48 phases of  35, 44 rationale 43 starting phase of  36 structure of  33 treatment phase  44 treatment methods first phase  45 for the abandoned/abused child  175–179

for the angry/impulsive child  181–186 for the angry protector  168, 174, 186 for the bully and attack mode  168, 174 for the critical/demanding parent  190 for the detached protector  168–175 for the guilt inducing parent  190 for the happy child  179–186 for the healthy adult  193–196 for the punitive parent  136–9 for the self‐aggrandizer  168–174 for the undisciplined/impulsive child 186–189 two‐dimensional reproductions of supposed connections  102, 103 two‐or‐more‐chair technique  115–125 chair of little Noa  124, 125 final phase  125 for the demanding parent mode  119 for the punitive parent  115 multiple‐chair technique  124–125 strategies 87 with changing schemas and coping with couples  223 with groups  213 with the detached protector  122–124 using dolls or cards  120 undisciplined child (mode)  15, 23, 129, 186–188 treatment methods for  187–189 unrelenting standards  257 visual analogue scale and nuanced thinking 97–100 voicemail 50 vulnerability to harm or illness  255 ways to gather information  38 working with the modes  45 writing letters  126 Young, Jeffrey  xii, 1, 7, 8, 11 Young Parenting Inventory  39 Young Schema Questionnaire  39