Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

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Figure 3.2 Mode model with schemas and historical roots Nora

      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

      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 the mode that is “talking” from the tone of voice of the patient in combination with the content of the story (Table 3.2) (see ST step by step 2.17 and 5. Examples of modes).

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

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

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