Principles and clinical application of schema therapy for patients with borderline personality disorder - Nysæter & Nordahl (2008) - Article

Borderline personality disorder (BPD) is the most frequently diagnosed personality disorder. Most of the patients are female and present a pattern of labile emotions, impulsivity and unstable interpersonal behaviour and identity, often since childhood. An important aspect of BPD is the fear to be abandoned. Many, but not all individuals with BPD report childhood abuse. Research has shown that psychotherapy for BPD is better than the waiting list condition or treatment as usual (TAU). The cognitive therapy that was used has been adjusted to make it more appropriate for patients with BPD. Patients with BPD often have ambiguous and vaguely defined complaints with chronic features in addition to symptoms as depression or substance abuse. Dialectical Behaviour Therapy, Cognitive Coping therapy, Rational Emotive therapy, Cognitive therapy, Cognitive Evolutionary therapy and Schema therapy are other forms of cognitive therapy used to treat BPD. Schema therapy is developed by Young and colleagues and is meant to treat complex cases.

The model of schema therapy

Schema theory. An assumption of short-term cognitive therapy is that clients have a certain amount of cognitive and behavioural flexibility, however, this is usually not the case in patients with BPD. Patients with BPD often have deeply rooted, rigid, and implicit dysfunctional belief systems and sometimes also an inability to report thoughts or feelings that are linked to this system. How knowledge about onself and the world is organised and structured comes together in a schema. Young defined a subset of schemas called ‘’early maladaptive schema’’ (EMS), schemas that are formed during childhood as a result of needs that have not been met. The schemas have been elaborated upon during the rest of life. Young says that these schemas are used as templates for processing and activating thoughts, feelings and interpersonal behaviours. Young defined 18 EMSs that are related to Abondanment, Defectiveness, Emotional Deprivation, Insuffiient Self- Control, Mistrust/Abuse, Punitiveness, and Subjugation.

Schema mode. Patients with BPD had often many different or almost all EMS and also frequent emotional changes. A schema mode is a facet of the person’s self involving a natural grouping of EMS, mood states and coping strategies. This schema mode may be too distressing to experience and is therefore detached from the person’s self which leads to a disintegrated self-system.

Schema modes in the Borderline patient. The schema modes defined by Young are (1) abandoned child mode, (2) angry and impulsive child mode, (3) punitive parent mode (4) detached protector mode: the patient suppresses needs and detaches from own feelings and behaves obediently in order to stabilise his/her life and psyche. A dysphoric state can be the result of this. (5) healthy adult mode: tries to inhibit maladaptive coping and dysfunctional modes. Works as an executive function in relation to other modes. In patients with BPD this mode is underdeveloped. In understanding the behaviour of a person with BPD, the shift between the schema modes is the main point.

Basic principles in treatment

A collaborative relationship between the patient and the therapist is very important within Schema therapy. Fear of abandonment might be frequently present and should be addressed by the therapist from start. The primary goals of Schema therapy are to learn to cope with the schema modes through encouragement, learning of self-help techniques,

Main treatment objective: coping with the schema modes

The patients have to learn to identify and to cope with the schema modes and to learn to control behaviour. The main goal is to incorporate a healthy adult mode that can react on and ‘’regulate’’ the other modes. Additionally, social skills may be practiced and other treatments such as family intervention or medications might be provided simultaneously.

Bypassing the detached protector. It is crucial to bypass the protector mode in order to be able to restructure the other modes. The detached protector mode causes avoidance of emotions and people. In therapy it might be useful to discuss the development of this mode and the therapist can engage in a ‘’conversation’’ with the representation of the detached mode to make an appointment with the patient to put the protector aside for some time. Antidepressant medications might improve therapeutic compliance.

Limited re-parenting of the abandoned child. In the therapy, the patient learns about the developmental needs of a child. The patient learns to feel empathy for his/her inner child. The patient is helped by the therapist to endure and share feelings and needs which can lead to more openness to intimacy and closeness.

Re-channel the angry child through the therapy relationship. To identify the schemas that become activated in an anger outbursts the patient should express what annoys or irritates him/her. Afterwards the underlying schemas are empathized with and it is determined whether the anger is realistic. Anger control techniques can be teached with the help or role-play.

Combating punitive parent through cognitive restructuring. This can be done by teaching the patient about needs and feelings and to encourage expressing of emotions and needs. Dialogues can be set up between the therapist and punitive parent and later also with the patient to challenge the internalised critical voice of the patients. The therapist becomes a model of acceptance and forgiveness. The self-punitive parts become external. The relation with the existing parent can become violated, something that the therapist should keep in mind. Other nurturing bases should be provided to make the patient less dependent of the parents and if the case, positive qualities of the parents should be acknowledged.

Dealing with suicidal threats and crisis. Suicidal behaviour can have different underlying reasons. It can be a way of obtaining attention and care, self-punishment or it can function as distractor from psychological pain and distress. In each mode suicidal behaviour and self-mutilation have their own psychological meaning that has to be determined. Suicidal behaviour should always be taken seriously. The therapist has to assess the risk and the genuine relationship with the patient should be sthrenghend. Hopelessness and despair should be empathised with.

Termination of therapy and relapse prevention strategies. To avoid relapse after finishing a therapy a procedure should be followed. First, prepare the patient for a relapse and set up a plan for how to manage difficulties. Furthermore, the patient can write a plan similar to that that was used in therapy hat he/she can follow if it becomes very difficult to deal with the negative thoughts. In addition, waning sessions can help the patient to adjust to the idea of termination and can provide exercises to deal with the abandonment schema. Finally the emphasis shifts to life outside therapy and the therapist can tell the patient that he/she will not ‘’disappear from the surface of the earth.’’ Contact can be gradually reduced to give the patient time to adjust to this.

Assessment in Schema therapy

Instruments and inventories in Schema therapy. In the assessment several instruments are used. To assess schemas the Young Schema Questionnaire and the Young Parenting Inventory. The Young-Rygh avoidance inventory and the Young Compensation inventory can be used to identify schema driven behaviour. To assess different schema modes, the Schema Mode Questionnaire is used. Because patients can get in a loyalty conflict with regard to questions about parents, the Young Parenting Inventory and the Young Schema Questionnaire have been matched, therefore, information about the family can be investigated from different perspectives.

Empirical validation of Schema therapy. The schema constructs have been confirmed to be valid. However, only two Dutch studies have investigated the effectiveness of the Schema therapy model. The results of these studies show that Schema therapy was more effective than Transference-focused psychotherapy on all aspects. Also a trail study from the authors of the current article improved after treatment, three of six did not fulfil the criteria for BPD anymore. These studies suggest that Schema therapy might be effective and it creates a strong collaboration which is important in BPD patients. Further research is still needed.