Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

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СКАЧАТЬ 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:

      How are you doing?

      P:

      (in an angry voice) Bad.

      T:

      Why is that, did something bad happen?

      P:

      No, I did something stupid and now everything is ruined.

      T:

      So, things are not going well with you?

      P:

      No, I'm hopeless and now I'm bothering you as well.

      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.

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).

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 СКАЧАТЬ