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Author Topic: Schema Therapy-Jeffrey Young, Ph.D. and Janet Klosko, Ph.D.  (Read 774 times)
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« on: December 02, 2015, 01:02:43 PM »

I found this article to be very interesting and insightful. I wish I could locate the rest of it.

Schema Therapy of Borderline Personality Disorder:
Conceptualization and Treatment
By Jeffrey Young, Ph.D. and Janet Klosko, Ph.D.

Part I:  Conceptualization of Borderline Personality Disorder

    Schemas are the memories, emotions, bodily sensations, and cognitions associated with the destructive aspects of the individual’s childhood experience, organized into patterns which then repeat through life.  For both characterological and healthier patients, the core themes are the same:  they are themes like abandonment, abuse, emotional deprivation, defectiveness, and subjugation.  Characterological patients may have more schemas, and their schemas may be more severe, but they do not generally have different schemas.  It is not schemas that differentiate characterological patients from healthier patients, but rather the extreme coping styles they employ to deal with these schemas, and the modes that crystallize out of these coping styles.
    As we have explained, our concept of modes grew largely out of our clinical experience with borderline patients.  When we attempted to apply the schema-focused model to these patients, we consistently encountered two problems.  First, our borderline patients almost always seemed to have almost all of the eighteen schemas (especially Abandonment, Mistrust/Abuse, Emotional Deprivation, Defectiveness, Enmeshment/Undeveloped Self, Insufficient Self-Control, Subjugation, and Punitiveness).  To work with so many schemas simultaneously utilizing our original schema-focused approach proved unwieldy.  We needed a more workable unit of analysis.  Second, in our work with borderline patients, we (as many other clinicians) were struck by the tendency of borderline patients to shift rapidly from one intense affective state to another.  One moment  these patients are angry, the next moment they are terrified, the next moment they are fragile, the next moment they are impulsive -- to the point where it is almost like dealing with different people.  Schemas, which are essentially traits, did not explain this rapid flipping from state to state.  We developed the concept of modes to capture the shifting affective states of our borderline patients.
    The borderline patient switches continually from mode to mode in response to life events.  While healthier patients usually have fewer modes, spend longer periods of time in each one, and the modes are less extreme; borderline patients have more modes, switch modes from moment to moment, and the modes are more extreme.  Moreover, when a borderline patient switches into a mode, the other modes seem to vanish.  Unlike healthier people, who can experience two or more modes simultaneously so that one mode moderates the intensity of the other, when borderline patients are in one mode, they seem to have virtually no access to the other modes.  The modes are almost completely dissociated.  Unlike healthier patients, it seems nearly impossible for most borderline patients to experience more than one mode at a time.

Modes in the Borderline Patient

    We have identified five main modes that characterize the borderline patient: 

1.  the Abandoned Child

2.  the Angry Child

3.  the Punitive Parent

    4.  the Detached Protector

5.  the Healthy Adult

We will summarize the modes briefly to provide an overview, and then we will describe each one more fully. 

The Abandoned Child mode is the suffering inner child.  It is the part of the patient that feels most of the schemas – that feels the pain of the abandonment, abuse, deprivation, defectiveness, subjugation.  The Angry Child mode is predominant when the patient is enraged because her basic emotional needs are not being met.  The Punitive Parent mode is the internalized voice of the parent, criticizing and punishing the patient.  When the Punitive Parent mode is activated, the patient becomes a cruel persecutor, usually of herself.  In the Detached Protector mode, the patient shuts off all emotions, disconnects from others, and functions like a machine.  The Healthy Adult mode is weak to nonexistent in the borderline patient, especially at the beginning of treatment.  In a sense this is the whole problem – borderline patients have no soothing parental mode to calm and care for them.  This contributes significantly to their inability to tolerate separation.  The therapist models the Healthy Adult for the patient, and the patient eventually internalizes the therapist’s attitudes, affects, and behaviors as this mode.  It is the goal of treatment to build the patient's Healthy Adult mode in order to nurture and protect the Abandoned Child, teach the Angry Child more appropriate ways of expressing anger, defeat and expel the Punitive Parent, and replace the Detached Protector. 
    The simplest way to recognize a mode is by its feeling tone.  Each mode has its own characteristic affect.  The Abandoned Child mode has the affect of a lost child:  sad, frightened, vulnerable, defenseless.  The Angry Child mode has the affect of an enraged child, screaming and attacking the caretaker who is frustrating the child’s core needs, or acting impulsively to get those needs met.  The Punitive Parent mode has a affect that is harsh, critical, and unforgiving.  The Detached Protector has a flat, emotionless, mechanical affect.  Finally, the Healthy Adult mode has the affect of a strong and loving parent.  The therapist can differentiate the modes by listening to the tone of the patient's voice and observing the manner in which the patient is talking.  The therapist tries to become adept at identifying the patient's mode at any given moment and responding accordingly, with strategies designed specifically for working with that mode.
    We will now describe each of the modes in greater detail.  Specifically, we will describe the function of the mode, the signs and symptoms, and the therapist's broad strategy in helping borderline patients when they are in that mode.

The Abandoned Child Mode

In our previous chapter on modes, we introduced the Vulnerable Child mode.  As we noted, we believe this mode is innate and universal.  The Abandoned Child is the borderline patient’s version of the Vulnerable Child, in this case specifically characterized by the borderline patient's focus on abandonment.  In the Abandoned Child mode, patients appear fragile and childlike.  They seem sorrowful, frantic, frightened, unloved, lost.  They feel helpless and utterly alone, and are obsessed with finding a parent figure who will take care of them.  In this mode, patients seem like very young children, innocent and dependent.  They idealize nurturers and have fantasies of being rescued by them.  They engage in desperate efforts to prevent caretakers from abandoning them, and at times their perceptions of abandonment approach delusional proportions.

The extreme youth of the borderline patient’s Vulnerable Child explains much about the borderline patient’s cognitive style.  Healthier patients have Vulnerable Child modes that are older (at least four years old, probably older), while borderline patients have Vulnerable Child modes that are younger (three years old or even younger).  In Piagetian terms, the Vulnerable Child mode of healthier patients is in at least the concrete operational phase of development, while the Abandoned Child of the borderline patient is in the preoperational or even sensorimotor phase of development (reference**Being cool (click to insert in post).  In the Abandoned Child mode, borderline patients usually lose object permanence.  They cannot summon a soothing mental image of the caretaker unless the caretaker is present.  The Abandoned Child lives in an eternal present, without clear concepts of past and future.  This increases the patient’s sense of urgency and impulsivity.  What is happening now is all that there is, was, or ever will be.  The Abandoned Child is largely preverbal, and expresses emotions in actions rather than words.  Emotions are unmodulated and pure.  There is a cognitive split between “good” and “bad,” both in the self and in significant others.  The boundary between self and others is not fixed, so that the child believes that thoughts and feelings occur outside as well as inside the self.  The Abandoned Child is egocentric, and thus prone to ideas of reference and lack of concern for other people’s needs or feelings.  Rather than viewing the world logically and rationally, the Abandoned Child engages in magical thinking, and cannot always tell the difference between what is imaginary and what is real.  (In a related point, different modes are typically different ages in borderline patients.  For example, the Detached Protector can grow into an adult while the Vulnerable Child remains infantile.  Like the Vulnerable Child, the Angry Child is generally very young.  The borderline patient often attributes to the Punitive Parent the power and knowledge young children ascribe to their parents.)   

The Abandoned Child carries the patient’s core schemas.  The therapist comforts the child in the grip of these schemas, and provides a partial antidote to them in the limited reparenting of the therapy relationship.  When borderline patients are in the Abandoned Child mode, the therapist's broad strategy is to help them identify, accept, and satisfy their basic emotional needs for secure attachment, autonomy, genuine self-expression; spontaneity and play; and realistic limits.

The Angry Child Mode

This is the mode that professionals most often associate with borderline patients, even though it is the one that most borderline patients are in the least amount of the time.  Most borderline patients spend a majority of their time in the Detached Protector mode.  Sometimes they are the Punitive Parent, and sometimes they are the Abandoned Child.  Rarely, when they cannot hold it back anymore, they switch into the Angry Child mode.
    The Detached Protector and Punitive Parent modes operate to keep all of the borderline patient's needs and feelings suppressed -- all the needs and feelings of the Abandoned Child.  After a while, these needs and feelings accumulate, and the patient feels a growing sense of inner pressure.  The patient may say something like, "I feel something building up inside me."  (The patient may start dreaming about impending disasters, such as tidal waves or storms.)  The pressure builds, some "last-straw" event occurs (perhaps a problematic interaction with the therapist), and then the patient switches into the Angry Child mode.  The patient suddenly becomes filled with anger. 
    When patients are in this mode, they vent their anger in inappropriate ways.  They may appear intensely rageful, demanding, devaluing, controlling, or abusive.  They act impulsively to get their needs met, and may appear manipulative or reckless.  They may make suicidal threats and engage in parasuicidal behavior.  (One patient, reacting to the end of the session by switching into this mode, walked out saying, “I’m on my way to the bathroom to cut my ankles.”)  In the Angry Child mode, patients make demands with an air of entitlement that can overpower and alienate others.  However, their demands do not really reflect entitlement, but rather are desperate attempts to get their basic emotional needs met.
    When patients are in this mode, the therapist's broad strategy is to set limits, and to teach them more appropriate ways of dealing with their anger and getting their needs met.

The Punitive Parent Mode

The function of this mode is to punish the patient for doing something “wrong,” such as expressing needs or feelings.  (For a borderline patient, almost anything can be “wrong.”)  The mode is an internalization of the parent's rage and hatred of the patient as a child.  Signs and symptoms include self-loathing, self-criticism, self-denial, self-mutilation, suicidal fantasies, and self-destructive behavior.  Patients in this mode become their own punitive, rejecting parent.  They become angry at themselves for having or showing needs.  They do things to punish themselves, such as cutting or starving themselves, and speak about themselves in mean, harsh tones, saying such things as they are "evil," "bad," or “dirty.”
    When patients are in the Punitive Parent mode, the therapist's broad strategy is to help them reject punitive parental messages and build self-esteem.  The therapist supports the needs and rights of the Abandoned Child and attempts to overthrow and banish the Punitive Parent.

The Detached Protector Mode

Except for those who are very severe, borderline patients typically spend most of their time in the Detached Protector mode.  The function of this mode is to cut off emotional needs, disconnect from others, and behave submissively in order to avoid punishment.
    When borderline patients are in the Detached Protector mode, they often appear normal.  They are “good patients.”  They do everything they are supposed to do and they act appropriately.  They come to their sessions on time, do their homework, and pay for their sessions promptly.  They do not act out nor lose control of their emotions.  In fact, many therapists inadvertently reinforce this mode.  The problem is that, when patients are in this mode, they are cut off from their own needs and feelings.  Rather than being true to themselves, they are basing their identity on gaining the therapist’s approval.  They are doing what the therapist wants them to do but they are not really connecting to the therapist.  Sometimes therapists spend a whole treatment with a borderline patient, never realizing that the patient is in the Detached Protector mode nearly the entire time.  The patient does not make significant progress, but rather just floats from session to session, feeling nothing and attaching to no one.

Signs and symptoms of the Detached Protector mode include depersonalization, emptiness, boredom, substance abuse, binging, self-mutilation, psychosomatic complaints, “blankness,” and robot-like compliance.  Patients often switch into the Detached Protector mode when their feelings are stirred up in sessions in order to cut the feelings off.  When patients are in the Detached Protector mode, the therapist's broad strategy is to help them experience emotions as they arise without blocking, reconnect to others, and express their needs.
    It is important to realize that one mode can activate another mode.  For example, a patient might express a need in the Abandoned Child mode, and then switch into the Punitive Parent mode to punish herself for expressing the need, then switch into the Detached Protector to escape the pain of the punishment.

Hypothesized Origins of Borderline Personality Disorder

Biological Factors

    In our observation, the majority of borderline patients have an emotionally intense, labile temperament.  This hypothesized temperament may set a biological predisposition to developing the disorder (***reference).
    There is evidence of gender differences.  Three-fourths of patients diagnosed with borderline personality disorder are female (Gunderson et. al., 1991 ***G).  This might partly be due to temperamental differences:  perhaps women are more likely than men to have intense, labile temperaments.  However, the gender difference might also be due to environmental factors.  Girls are more often sexually abused, a frequent feature of the childhood histories of borderline patients (***reference).  Girls are more often subjugated and forbidden to express anger.  It is also possible that borderline men are an under-diagnosed group.  Men  manifest the disorder differently than women do.  Men tend to have more aggressive temperaments, and are more likely to be domineering rather than compliant and to act out against others rather than themselves.  Hence, they are probably more likely to be diagnosed with narcissistic or antisocial personality disorders.   

Environmental Factors

    We have identified four factors in the family environment that we believe interact with this hypothesized biological predisposition to lead to the development of borderline personality disorder. 

    The family environment is unsafe.  The lack of safety comes from the threat of abuse or abandonment.  The majority of borderline patients experienced physical, sexual, or verbal abuse as children.  If there was no actual abuse to the patient, then there was usually the threat of explosive anger or violence, or the patient observed another family member being abused.  In addition, usually the child was also abandoned.  The child may have been left alone for long periods of time without a caretaker; or left with an abusive caretaker (such as when one parent abuses the child and the other denies and enables the abuse).  Alternatively, the child’s primary caretaker may have been unreliable or inconsistent, such as happens when a parent has extreme mood swings or uses drugs.  Instead of being secure, the attachment to the parent is unstable and unsafe.         

    The family environment is depriving.  Early object relations are impoverished.  Parental nurturing – physical warmth, emotional closeness and support, guidance,  protection -- is absent or rare.  One or both parents (but especially the primary caretaker) is emotionally unavailable, and provides minimal or no empathy.  Emotionally, the patient is alone.

    The family environment is harshly punitive.  Borderline patients do not grow up in families that are accepting, forgiving, and loving.  Rather, they grow up in families that are critical and rejecting of them, harshly punitive when they make mistakes, and unforgiving.   

    The family environment is subjugating.  The family environment suppresses the  needs and feelings of the child.  Usually there are implicit rules about what the child can and cannot say and feel.  The child gets the message, ":)on't show what you feel.  Don't cry when you’re hurt.  Don't get angry when someone mistreats you.  Don't ask for what you want.  Don’t ever be vulnerable or real.  Just be who we want you to be."  Expressions of the child's emotional pain -- particularly sadness and anger – often make the parent angry and lead to punishment or withdrawal.

DSM-IV Borderline Diagnostic Criteria and Schema Modes

    What follows is a list of DSM-IV diagnostic criteria for borderline personality disorder, matched to the relevant schema mode(s).  We include four modes:  the Abandoned Child, the Angry Child, the Punitive Parent, and the Detached Protector. 
DSM-IV Diagnostic Criteria
   Relevant Schema Modes
1.  Frantic efforts to avoid real or imagined abandonment.
   Abandoned Child mode
2.  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
   All modes.  (It is the rapid flipping from mode to mode that creates the instability and intensity.  For example, the Abandoned Child idealizes nurturers, while the Angry Child devalues and reproaches them.)
3.  Identity disturbance:  markedly and persistently unstable self-image or sense of self.
   Detached Protector mode.  (Because they tend to please others and are not allowed to be themselves, they cannot develop a secure identity.)
Constantly switching from one unintegrated mode to another, each with its own self-image, also leads to unstable self-image.
4.  Impulsivity (e.g., spending money, promiscuous sex, substance abuse, reckless driving, binge eating).
   Angry Child mode (to express anger or get needs met);
Detached Protector mode (to self-soothe or break through numbness).
5.  Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
   All four modes (each for different reasons).
6.  Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety). 
   Hypothesized intense, labile biological temperament.
Rapid switching of modes, each with its own distinctive affect.
7.  Chronic feelings of emptiness.
   Detached Protector mode (cutting off emotions leads to feelings of emptiness).
8.  Inappropriate, intense anger or difficulty controlling anger.
   Angry Child mode.
9.  Transient, stress-related paranoid ideation or severe dissociative symptoms.   Abandoned Child or Detached Protector mode.

When a borderline patient is suicidal or parasuicidal, it is important for the therapist to recognize which mode is experiencing the urge.  Is the urge coming from the Punitive Parent mode, and designed to punish the patient?  Or is the urge coming from the Abandoned Child mode, as a wish to end the ceaseless pain of living?  Is it coming from the Detached Protector mode, and an effort to distract from emotional pain with physical pain; or to pierce the numbness and feel something?  Or is it coming from the Angry Child mode, and a desire to punish another person?  Each mode has a different reason for wanting to attempt suicide, and the therapist addresses the suicidal urge in accord with the particular mode that is generating it.

Part II:  Treatment of Borderline Patients

Philosophy of Treatment

    Mental health professionals tend to have a negative view of borderline patients, and to speak about them in pejorative terms.  Professionals often regard borderline patients as though they are manipulative, selfish people.  This negative view of borderline patients is destructive to their treatment.  As soon as the therapist views the borderline patient negatively, the therapist feeds into one of the borderline patient's dysfunctional schema modes.  Often the therapist becomes the Punitive Parent, angry at the patient, critical and rejecting.  Needless to say, this has a damaging effect on the patient.  Rather than building up the patient's Healthy Adult and healing the Abandoned Child, the therapist further reinforces the patient's Punitive Parent mode.
    Working with borderline patients is tumultuous and intense.  Often the therapist's own schemas get triggered.  Later in this chapter we will discuss how therapists can work with their own schemas when treating borderline patients.
The Borderline Patient as Vulnerable Child

    In our view, the most constructive way to view borderline patients is as vulnerable children.  They may look like adults, but psychologically they are abandoned children searching for a parent.  The behave inappropriately because they are desperate, not because they are selfish:  they are “needy, not greedy.”  They are doing what all young children do when they have no one who takes care of them and makes sure they are safe.  Most borderline patients were lonely and mistreated as children.  There was no one who comforted or protected them.  Often they had no one to turn to except the very people who were hurting them.  Lacking a Healthy Adult they could internalize, as adults they lack the internal resources to sustain them when they are alone.  Alone, they feel panicked.
    When therapists become confused in their treatment of borderline patients, we sometimes find that mentally superimposing the image of a small child or infant over the patient can help the therapist understand the patient better and know what to do.  Whether the borderline patient is angry or detached or punitive, underneath she is a forlorn child.
Balancing the Rights of the Therapist and the Rights of the Borderline Patient

    Borderline patients almost always need more than the therapist can provide.  This does not mean that the therapist should attempt to give borderline patients everything they need.  On the contrary, therapists have rights, too.  Therapists have the right to maintain a private life.  Therapists have the right to be treated respectfully.  Therapists have the right to set limits when patients infringe on their rights, including borderline patients.  This does not mean that therapists have to get angry when borderline patients infringe on their rights.  Borderline patients infringe on their rights, not in order to torment them, but because they are desperate. 
    The therapy relationship exists between two people, both of whom have legitimate rights and needs.  In the case of the borderline patient, the patient has the rights and needs of a very young child.  The patient needs a parent.  Since the therapist can only provide the patient with "limited reparenting," it is inevitable that there will be a gulf between what the patient wants and the therapist can give.  No one is to blame for this:  it is not that the borderline patient wants too much; and it is not that the therapist gives too little.  It is simply that therapy is not an ideal way to reparent.  Thus, there is certain to be conflict in the therapist-patient relationship.  It is inherent in the fact that the borderline patient will always have greater needs than the therapist can meet that the patient will become frustrated with the therapist.  Borderline patients are thus apt to view professional boundaries as cold, uncaring, unfair, selfish, or even cruel. 

At some point in therapy, many borderline patients have the fantasy that they will live with the therapist -- perhaps the therapist will adopt them, marry them, move in with them.  This is not usually primarily a sexual fantasy.  Rather, what the patient wants is a parent who is always available.  Borderline patients look for a parent in almost every person they meet -- and in every therapist.  They want their therapist to be their substitute parent.  As soon as the therapist tries to be something other than this parent, borderline patients often act out, get angry, withdraw, or leave.  We believe the therapist must accept this parental role to some degree.  This is our challenge as therapists:  to balance the patient's rights and needs with our own, finding a way to become the patient's substitute parent for a period of time, while still maintaining the sanctity of our private lives. 

Reparenting the Borderline Patient

    The patient's progress in treatment in some respects parallels child development.  Psychologically, the patient grows up in therapy.  The patient begins as an infant or very young child and -- under the influence of the therapist's reparenting -- gradually matures into a healthy adult.  This is why effective treatment of the borderline patient at a deep, emotional level cannot be brief.  To fully treat this disorder requires relatively long-term treatment (at least two years and often longer).  Some borderline patients stay in treatment indefinitely.  Even though they might have improved dramatically, as long as circumstances permit they continue to come to therapy.  Even if the patient stops therapy, the therapist is likely to retain the role of parent figure, and there is a good chance that someday the patient will contact the therapist again.   
    Therapists frequently become frustrated when treating borderline patients.  As we have noted, no matter how much the therapist gives, it still falls short of what the borderline patient requires.  It is never enough.  If the patient becomes demanding or hostile, there is a risk that therapist might retaliate or withdraw, and thus contribute to a vicious cycle with the potential to destroy therapy.  Once again, when therapists become frustrated in this way, we suggest that they try to regain empathy by looking through the patient's adult exterior to the Abandoned Child at the core.
    To be effective, the relationship between the therapist and the borderline patient must be characterized by mutual respect and genuineness.  The therapist must truly care about the borderline patient for therapy to work.  If the therapist does not truly care about the patient, the patient will realize it and act out or leave.  The therapist must be real, not an actor playing the role of therapist.  Borderline patients are frequently very intuitive, and immediately detect any falseness on the part of the therapist.   

Overall Treatment Objectives


    Stated in terms of modes, the overall goal of treatment is to help the patient incorporate the Healthy Adult mode, modeled after the therapist, in order to:

    Empathize with and protect the Abandoned Child;

    Help the Abandoned Child to give and receive love;

    Fight against, and expunge, the Punitive Parent;

    Set limits on the behavior of the Angry Child, and help the Angry Child express emotions and needs appropriately;

    Reassure, and gradually replace, the Detached Protector with the Healthy Adult.

    Tracking modes.  This is the heart of the treatment:  the therapist tracks the patient's modes from moment to moment in the treatment, selectively using the strategies that fit each one of the modes.  For example, if the patient is in the Punitive Parent mode, the therapist uses the strategies designed specifically to handle the Punitive Parent; and if the patient is in the Detached Protector mode, the therapist uses the strategies designed specifically for the Detached Protector.  (We will discuss the strategies for the modes, below).  The therapist learns to recognize the modes and to respond appropriately to each one.  In tracking and modulating the patient’s modes, the therapist enacts the “good parent.”  The patient gradually identifies with and internalizes the therapist’s reparenting as her own Healthy Adult mode. 

Overview of Treatment

    In order to give readers an overview of schema therapy for the borderline patient, we will briefly describe the entire course of treatment over time.  In this section, we present the elements of the  treatment, roughly in the order we introduce them to the patient.  In the next section, we will present a more detailed description of the treatment components.   
    Mirroring early child development, the treatment has two main stages:  1) the Attachment stage; and 2) the Autonomy stage.

Stage I:  Attachment.

The Therapist Bonds with the Patient and Becomes a Stable, Nurturing Base

    The first step is for the therapist and patient to form a secure emotional attachment.  The therapist starts to reparent the patient’s Abandoned Child, providing safety and emotional holding.  The therapist begins asking the patient about current feelings and problems.  As much as possible, the therapist encourages the patient to stay in the Abandoned Child mode.  One reason for this is that keeping the patient in the Abandoned Child mode helps the therapist develop feelings of sympathy and warmth for the patient.  The patient's vulnerability encourages the therapist to bond with the patient and feel empathy for her.  Later, when the other modes start emerging and the patient becomes angry or punitive, the therapist will have the caring and patience to endure it.  Keeping the patient in the Abandoned Child mode also helps the patient bond with the therapist.  This bond keeps the patient from leaving therapy prematurely, and gives the therapist leverage to confront the patient’s other, more dangerous, modes.

The Therapist Encourages Expression of Needs and Emotions in Sessions

A silent, reflective therapeutic stance is generally not suitable for borderline patients.  These patients often interpret silence as a lack of caring or as a withholding of support.  The therapeutic alliance is better served by more active participation on the part of the therapist.  The therapist asks open-ended questions that encourage patients to  express their needs and emotions.  For example, the therapist asks, “Do you have any other thoughts about that?” “What are you feeling as you talk about that?” “What did you want to do when that happened?”  “What did you want to say?”  The therapist provides continual understanding and validation of the patient’s feelings.  As the patient begins to bond with the therapist, the therapist especially encourages her to express all her anger.  The therapist is careful not to criticize the patient for expressing anger (within reasonable limits).  The goal is for the therapist to create an environment which is a partial antidote to the one the patient knew as a child -- one that is safe, nurturing, protective, forgiving, and encouraging of self-expression
    As Kate did in the above interview, the patient will spontaneously hold back needs and feelings, thinking the therapist just wants her to be “nice” and polite.  However, this is not what the schema-focused therapist wants.  The therapist wants the patient to be herself, to say what she feels and ask for what she needs -- and the therapist tries to convince the patient of this fact.  This is a message the borderline patient probably never got from a parent.  In this way, the therapist tries to break the cycle of subjugation and detachment in which the borderline patient is caught. 
    When the therapist encourages the patient to express emotions and needs, these emotions and needs generally come from the Abandoned Child mode.  Keeping the patient in the Abandoned Child mode and nurturing the patient is stabilizing to the patient's life:  this is another advantage.  The patient flips less often from mode to mode, and the modes become less extreme.  If the patient is able to express her emotions and needs in the Abandoned Child mode, then she will not have to flip into the Angry Child mode to express them.  She will not have to flip into the Detached Protector mode to shut off her feelings.  She will not have to flip into the Punitive Parent mode, because, in accepting her, the therapist replaces the Punitive Parent with a parent figure who allows self-expression.  Thus, as the therapist encourages the patient to express needs and feelings and then reparents the patient, gradually all of the patient's dysfunctional modes tend to drop away. 

The Therapist Initiates Experiential Work Related to the Patient's Childhood

As therapy progresses and the patient stabilizes, the therapist begins imagery work based upon the non-traumatic aspects of the patient's early childhood experiences.  (Much later, the therapist uncovers any traumatic memories.)  The primary experiential techniques are imagery and dialogues.  The therapist instructs the patient to generate images of each of the modes, to name them, and to carry on dialogues.  Each mode becomes a character in the patient's imagery and the characters speak aloud to one another.  The therapist, modeling the Healthy Adult, helps the other modes communicate needs and feelings effectively and negotiate with each other.

Therapist and Patient Negotiate Limits Regarding Therapist Availability, based upon Severity of Symptomatology and the Therapist’s Personal Rights

Limit-setting is an important part of the early phase of treatment.  Limit-setting is based foremost upon safety.  The therapist must do what is necessary to ensure the patient’s safety, and the safety of those around the patient.  Once the therapist has established safety, then limits are based upon a balance between the patient’s needs and the therapist’s personal rights.  The basic principle is that therapists should not agree to anything they are likely to regret later, and therefore resent.  For example, if the patient wants to leave the therapist a short message on the answering machine each evening, and the therapist feels this is fine and it will not cause the therapist to resent the patient over time, then the therapist might agree.  But if the therapist believes that, eventually, these daily messages will cause the therapist to resent the patient, then the therapist should not agree.  Since sources of resentment are personal matters, the specifics will differ from therapist to therapist. 

The Therapist Deals with Crises and Sets Limits Regarding Self-Destructive Behaviors

Crises usually involve self-destructive behaviors such as suicidality, self-mutilation, and substance abuse.  The therapist reparents, educates, sets limits, and draws upon adjunctive resources.

The therapist is the primary resource for the borderline patient in crisis.  Most crises occur because the patient is feeling worthless, bad, unloved, or abandoned.  The therapist’s capacity to acknowledge these feelings and respond to them compassionately is what enables the patient to resolve the crisis.  Ultimately, it is the patient's conviction that the therapist truly cares about her and respects her, in contrast with the Punitive Parent, that stops the self-destructive behavior.  As long as the patient is confused about whether the therapist truly cares, she will keep acting out self-destructive behaviors in response to stressful life events. 
    The therapist draws upon adjunctive resources in the community to help manage the patient, such as twelve-step groups, groups for incest survivors, and suicide hot-line numbers.

The Therapist Teaches the Patient Techniques to Manage Moods and Soothe Abandonment Distress

The therapist teaches the patient cognitive-behavioral techniques to contain and regulate affect.  However, it is rare for borderline patients to accept and benefit from cognitive-behavioral techniques before they have faith in the stability of the reparenting bond.  If the therapist introduces the techniques too early, they tend not to be effective.  Borderline patients are usually unable to make much use of cognitive-behavioral techniques until somewhat later in the treatment, after the therapist has assumed a “good enough” reparenting role.  Until then, the borderline patient's whole focus is on the therapist-patient bond -- on making sure the bond is still there -- and she lacks the free attention to focus on cognitive-behavioral techniques. A few borderline patients are able to use the techniques early in treatment, but most reject them as too cold or mechanical.  Whenever the therapist brings up the techniques, these patients feel emotionally abandoned, and say something like, "You don't really care about me.  I’m not a real person to you."  As patients increasingly trust the safety and stability of the therapy relationship, they become more capable of allying themselves with the therapist in the pursuit of therapeutic goals.  Basically, we introduce cognitive-behavioral techniques as soon as we can -- as soon as the patient is able to benefit from them.  We usually begin with cognitive-behavioral techniques designed to teach the patient self-control of moods and self-soothing.  These might include safe-place imagery, self-hypnosis, relaxation, mindfulness meditation, self-monitoring of automatic thoughts, flashcards, transitional objects – whatever appeals most to the patient.   
    There is another point in regard to introducing cognitive-behavioral techniques too early:  the patient might misuse the techniques to strengthen the Detached Protector mode.  Many cognitive-behavioral techniques are simply good strategies for detaching from emotion.  In teaching the techniques to the patient, the therapist risks empowering the Detached Protector.  Since the overriding goal of therapy is to elicit all the modes in session and to treat them, if the therapist teaches the patient techniques that suppress the other modes --  the Abandoned Child, the Angry Child, and the Punitive Parent -- then the therapist is working against this overriding goal.   

Stage II:  Autonomy
The Therapist Initiates Schema-Focused Cognitive Work

The therapist  begins schema-focused cognitive work.  The therapist educates the patient about schemas, and begins to challenge the patient’s schemas using all the cognitive techniques we described in Chapter X.  The patient gradually reads Reinventing Your Life.  The therapist seeks to reduce schema-driven over-reactions and to build the patient's self-esteem.

The Therapist Advises the Patient about Appropriate Partner Choices, and Helps Generalize Changes in Session to Relationships Outside of Therapy

Once the reparenting bond is stable, the therapist begins focusing on the patient's intimate relationships outside of therapy.  When a patient enters treatment in the midst of a self-destructive relationship, the therapist offers advice about appropriate relationships right from the start, but until the reparenting bond is secure the patient is usually unable to follow the advice.  The patient cannot let go of the destructive relationship.  Once the patient bonds with the therapist and the therapist becomes a stable base, often the patient can let go of the destructive relationship and begin forming good relationships.  The therapist helps the patient make better partner choices and behave more constructively in relationships.  The patient learns to express affect in modulated ways, show vulnerability, and ask appropriately to get needs met. 

The Therapist Helps the Patient Discover Her Natural Inclinations and Follow Them in Everyday Situations and Major Life Decisions (e.g., Career Path)

As the patient stabilizes and spends less time in the Detached Protector and Punitive Parent modes, she gradually becomes more able to focus on self-realization.  The therapist helps her identify her life goals and the sources of fulfillment in her life.  The patient learns to discover and follow her natural inclinations.     

The Therapist Gradually Weans the Patient from Therapy by Reducing the Frequency of Sessions

On a case-by-case basis, therapist and patient address termination issues.

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