Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

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Figure 3.1 Case conceptualization Nora

       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 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:

      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.

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 modes. He further explains how each schema СКАЧАТЬ