Hannie van Genderen - Schema Therapy for Borderline Personality Disorder

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

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

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, “‘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.

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 10we will give separate attention to the final phase of the therapy.

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

1 starting phase and case conceptualization;

2 crisis management;

3 treatment phase: therapeutic interventions with schema modes;

4 final phase of therapy.

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

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

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

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

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

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

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