Early Maladaptive Schemas are the memories, emotions, bodily sensations, and cognitions associated with the destructive aspects of the individual’s childhood experience, organized into patterns that repeat through life. For both characterological and healthier patients, the core themes are the same: They are themes such as 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 the presence of schemas that differentiates 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 patients with BPD. When we attempted to apply the schema model to these patients, we consistently encountered two problems. First, patients with BPD usually have almost all of the 18 schemas (especially Abandonment, Mistrust/Abuse, Emotional Deprivation, Defectiveness, Insufficient Self-Control, Subjugation, and Punitiveness). To work with so many schemas simultaneously utilizing our original schema approach proved unwieldy. We needed a more workable unit of analysis. Second, in our work with patients with BPD, we (like many other clinicians) were struck by the tendency of these patients to shift rapidly from one intense affective state to another. One moment these patients are angry, the next moment they are terrified, then fragile, then impulsive—to the point at which it became 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 patients with BPD.
The patient with BPD switches continually from mode to mode in response to life events. Whereas healthier patients usually have fewer and less extreme modes and spend longer periods of time in each one, patients with BPD have a greater number of more extreme modes and switch modes from moment to moment. Moreover, when a patient with BPD switches into a mode, the other modes seem to vanish. Unlike healthier patients, who can experience two or more modes simultaneously, so that one mode moderates the intensity of the other, patients with BPD who are in one mode seem to have virtually no access to the other modes. The modes are almost completely dissociated.
We have identified five main modes that characterize the patient with BPD:
Abandoned Child
Angry and Impulsive Child
Punitive Parent
Detached Protector
Healthy Adult
We summarize the modes briefly to provide an overview, then describe each one more fully.
The Abandoned Child mode is the suffering inner child. It is the part of the patient that feels the pain and terror associated with most of the schemas, including Abandonment, Abuse, Deprivation, Defectiveness, and Subjugation. The Angry and Impulsive Child mode is predominant when the patient is enraged or behaves impulsively, because her1 basic emotional needs are not being met. The same schemas may be triggered as in the Abandoned Child mode, but the emotion experienced is usually anger. 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 in an almost robotic manner. The Healthy Adult mode is extremely weak and undeveloped in most patients with BPD, especially at the beginning of treatment. In a sense this is the primary problem: patients with BPD 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, until the patient eventually internalizes the therapist’s attitudes, emotions, reactions, and behaviors as her own Healthy Adult mode. The major goal of treatment is to build up the patient’s Healthy Adult mode in order to nurture and protect the Abandoned Child, to teach the Angry and Impulsive Child more appropriate ways of expressing anger and getting needs met, to defeat and expel the Punitive Parent, and to gradually 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 and Impulsive Child mode has the affect of an enraged or uncontrollable child—screaming and attacking the caretaker who is frustrating the child’s core needs or acting impulsively to get those needs met. The tone of the Punitive Parent mode 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 usually differentiate the modes by listening to the tone of the patient’s voice and observing the manner in which the patient is speaking. The schema therapist becomes adept at identifying the patient’s mode at any given moment and responding accordingly, with strategies designed specifically for working with that mode.
We now describe each of the modes in greater detail: the function of the mode, the signs and symptoms, and the therapist’s broad strategy in helping patients with BPD when they are in that mode.
In Chapter 8, we introduced the Vulnerable Child mode. As we noted, we believe this mode is innate and universal. The Abandoned Child is the version of the Vulnerable Child common to patients with BPD, in this case specifically characterized by the 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 very young age at which the patient’s Vulnerable Child typically functions explains much about these patients’ cognitive styles. Healthier patients have Vulnerable Child modes that are older (typically 4 years or older), whereas patients with BPD have Vulnerable Child modes that are younger (usually less than 3 years old). In the Abandoned Child mode, patients with BPD usually lack 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, increasing 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 mode is largely preverbal and expresses emotions through actions rather than words. Emotions are unmodulated and pure.
The four individual modes can function at different ages in patients with BPD. For example, the Detached Protector is often an adult, whereas the Vulnerable Child and Angry Child modes are childlike. The patient often attributes to the Punitive Parent the power and knowledge young children ascribe to their parents.
The Abandoned Child mode “carries” the patient’s core schemas. The therapist comforts the child in the grip of these schemas and provides a partial antidote through the limited reparenting of the therapy relationship. When patients with BPD 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, love, empathy, genuine self-expression, and spontaneity.
This is the mode that mental health professionals most frequently seem to associate with patients with BPD, even though it is the one that, in our experience, typical patients experience least often. Most patients with BPD who are seen in outpatient settings spend a majority of their time in the Detached Protector mode—this is their “default” mode. Frequently they flip into the Punitive Parent or Abandoned Child modes. Much less often, when they cannot hold back anymore, they flip into the Angry Child mode, venting the fury they have contained and impulsively acting to get their needs met.
The Detached Protector and Punitive Parent modes operate to keep most of the patient’s needs and feelings suppressed, effectively blocking the needs and feelings of the Abandoned Child mode. 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 or a partner), and the patient flips into the Angry Child mode. The patient suddenly feels irate.
When patients are in this mode, they vent their anger in inappropriate ways. They may appear enraged, demanding, devaluing, controlling, or abusive. They act impulsively to meet their needs, and they may appear manipulative or reckless. They may make suicidal threats and engage in parasuicidal behavior. A patient might, for example, claim she is going to kill or cut herself unless the person does what she wants. (One patient, reacting to feelings of abandonment triggered by the ending of a session, flipped into the Angry Child mode and walked out saying, “I’m on my way to the bathroom to cut my ankles.”) In the Angry Child mode, patients may make demands that seem entitled or spoiled and that alienate others. However, their demands do not really reflect entitlement but rather are desperate attempts to meet their basic emotional needs.
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 meeting their needs.
The function of this mode is to punish the patient for doing something “wrong,” such as expressing needs or feelings. The mode is an internalization of one or both parents’ rage, hatred, loathing, abuse, or subjugation 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 normal needs that their parents did not allow them to express. They punish themselves—for example, by cutting or starving themselves—and speak about themselves in mean, harsh tones, saying such things as that 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 supplant the Punitive Parent.
Except for severe cases, patients with BPD 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 patients with BPD are in the Detached Protector mode, they often appear normal. They are “good patients.” They do everything they are supposed to do and act appropriately. They arrive at their sessions on time, do their homework, and pay promptly. They do not act out nor lose control of their emotions. In fact, many therapists mistakenly 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 whole treatment sessions with a patient without realizing that the patient has been in the Detached Protector mode nearly the entire time. The patient does not make significant progress but just floats from session to session.
Signs and symptoms of the Detached Protector mode include depersonalization, emptiness, boredom, substance abuse, bingeing, 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, to connect to others, and to 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, flip into the Punitive Parent mode to punish herself for expressing the need, and then flip into the Detached Protector mode to escape the pain of the punishment. Patients with BPD often get trapped in these vicious cycles, with one mode triggering another in a self-perpetuating loop.
If we were to rank order the modes in terms of psychological health across a wide range of patients with BPD, the Healthy Adult and the Vulnerable Child are the most healthy; then the Angry Child, who experiences genuine emotions and desires; then the Detached Protector, who maintains control over the patient’s behavior. Finally, the Punitive Parent has no redeeming features whatsoever. The Punitive Parent is the most destructive to the patient over the long term.
In our observation, the majority of patients with BPD have an emotionally intense, labile temperament. This hypothesized temperament may serve as a biological predisposition to developing the disorder.
Three-fourths of patients diagnosed with BPD are female (Gunderson, Zanarini, & Kisiel, 1991). This might be partially the result of 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 patients with BPD (Herman, Perry, & van de Kolk, 1989). Girls are more often subjugated and discouraged from expressing anger. It is also possible that men with BPD are an underdiagnosed 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 against themselves. Hence, they are probably more likely to be diagnosed with narcissistic or antisocial personality disorders (Gabbard, 1994), even when the underlying modes and schemas are similar.
We have identified four factors in the family environment that we believe interact with this hypothesized biological predisposition to lead to the development of BPD.
1. The family environment is unsafe and unstable. The lack of safety almost always arises from abuse or abandonment. The majority of patients with BPD 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 may have observed another family member being abused. In addition, the child was frequently abandoned. The child may have been left alone for long periods without a caretaker or left with an abusive caretaker (for instance, one parent may abuse the child while the other denies and enables the abuse). Alternatively, the child’s primary caretaker may have been unreliable or inconsistent, such as happens with a parent who has extreme mood swings or is a substance abuser. Instead of feeling secure, the attachment to the parent often feels unstable or terrifying.
2. The family environment is depriving. Early object relations are often impoverished. Parental nurturing—physical warmth, empathy, emotional closeness and support, guidance, protection—is typically absent or deficient. One or both parents (but especially the primary caretaker) may be emotionally unavailable and provide minimal empathy. Emotionally, the patient feels alone.
3. The family environment is harshly punitive and rejecting. Patients with BPD do not grow up in families that are accepting, forgiving, and loving toward them. Rather, they grow up in families that are critical and rejecting of them, harshly punitive when they make mistakes, and unforgiving. The punitiveness is extreme: As children, these patients were made to feel worthless, evil, bad, or dirty, not as though they were just normal children misbehaving.
4. 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: “Don’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 be vulnerable or real. Just be who we want you to be.” Expressions by the child of emotional pain—particularly sadness and anger—often make the parent angry and lead to punishment or withdrawal.
Table 9.1 lists DSM-IV diagnostic criteria for BPD matched to the relevant schema mode(s). We include four modes: the Abandoned Child, the Angry Child, the Punitive Parent, and the Detached Protector.
When a patient with BPD is suicidal or parasuicidal, the therapist must 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 pain of unbearable loneliness? Is it coming from the Detached Protector mode in an effort to distract from emotional pain through physical pain or to pierce the numbness and feel something? Or is it coming from the Angry Child mode in a desire to get revenge or hurt another person? The patient has a different reason for wanting to attempt suicide in each of the modes, and the therapist addresses the suicidal urge in accord with the particular mode that is generating it.
Kate is a 27-year-old patient with BPD. The following excerpts are from an interview Dr. Young conducted with her as part of a consultation. (The patient had recently begun therapy with another schema therapist.)
Kate saw her first therapist at the age of 17. This excerpt illustrates the characteristic vagueness of her presenting problem at that time.
THERAPIST: What was it that brought you into therapy when you first came into treatment?
KATE: That was about 10 years ago. I was just very, very unhappy. I was just extremely depressed and confused and angry, and I was just having a very difficult time functioning—getting up in the morning and talking to people, and just walking down the street. I was just very upset and angry and sad.
THERAPIST: Had anything happened at that time to trigger that reaction?
KATE: No, it was just a bunch of things sort of building up.
THERAPIST: Do you remember what things were building up?
KATE: Just problems at home. Problems with myself and my identity. Not fitting in anywhere. Just general negative feelings.
TABLE 9.1. DSM-IV Diagnostic Criteria for Borderline Personality Disorder and Relevant Schema Modes
| DSM-IV diagnostic criteria | Relevant schema modes |
|---|---|
|
Abandoned Child mode. |
|
All modes. (It is the rapid flipping from mode to mode that creates the instability and intensity. For example, the Abandoned Child idealizes nurturers, and the Angry Child devalues and reproaches them.) |
|
|
|
|
|
|
|
All four modes. |
|
|
|
Detached Protector mode. (The cutting off of emotions and disconnection from others leads to feelings of emptiness.) |
|
Angry Child mode. |
|
Any of the four modes (when affect becomes unbearable or overwhelming). |
THERAPIST: But nothing had happened, like someone died or someone left you?
KATE: No.
The sense of identity diffusion that Kate reports is linked to her Detached Protector mode: Patients with BPD feel confused about who they are while in the Detached Protector mode. When patients with BPD are in this mode, they do not know what they are feeling. They are almost completely focused on complying with other people to avoid abandonment or punishment and to block out their own desires and emotions. Because they do not follow their natural inclinations, they cannot develop a distinct identity of their own. Rather, they feel empty, bored, restless, foggy, or confused.
Characteristically, Kate has experienced an array of Axis I disorders, including depression, bulimia, and substance abuse.
THERAPIST: Are there other symptoms that you have?
KATE: Yeah, I feel just worthless, and just not really a whole person, whatever a whole person is, I don’t even know. I just know that I look at other people, and I just don’t see myself equal to anybody.
THERAPIST: And do you ever do things to punish yourself, that kind of thing?
KATE: Yeah, I used to.
THERAPIST: What things did you do?
KATE: Well, I used to cut myself a lot. I was bulimic for about nine years. Just self-destructive things.
THERAPIST: Do you ever have impulses to do any of those things now?
KATE: Yes.
THERAPIST: Do you act on any of them anymore?
KATE: I haven’t in a while. Sometimes I drink a bit much, but I haven’t done drugs in a while, in a few months.
Kate’s current course of treatment began 2 years ago when she was hospitalized following a suicide attempt. In the next excerpt, the therapist asks Kate to describe the series of events leading up to that hospitalization:
THERAPIST: What was going on at that time?
KATE: I had a drug overdose.
THERAPIST: What drug was it?
KATE: Klonopin.
THERAPIST: That was intentional then?
KATE: Yes.
THERAPIST: Do you remember why you took it at the time? Did something happen then?
KATE: Yes, well, I was married. I was doing well, I was happy, but he met somebody else. And he wanted me just to be out of his life. He said he met somebody else, and just wanted me out of the house, and just wanted me away from him. At first, when it happened, I guess I was in shock, and then I just became so depressed and I just didn’t want to live anymore.
THERAPIST: Do you remember what the feeling was that was making you feel so depressed?
KATE: (speaking passionately) I just felt that I was no good, that I was worthless, and that he finally realized it, and he was doing right by himself, and I was just nobody.
Kate expresses that her suicide attempt arose from her Abandoned Child mode, in which she was flooded with the pain of her Abandonment and Defectiveness schemas. Abandonment by a significant other is a common trigger for this mode.
When we turn to Kate’s history, we see that her childhood was marked by all four of the predisposing environmental factors we named earlier: Her family environment was unsafe, emotionally depriving, harshly punitive, and subjugating of her feelings.
The following excerpt (a continuation of the previous one) illustrates Kate’s childhood deprivation. She had no one who nurtured her, empathized with her, protected her, or guided her.
THERAPIST: Do you know where those feelings came from or started, the feelings of being no good or worthless?
KATE: I’ve just always felt them, just from my family life, just not really feeling that I was important, or like I made a difference, or that I was significant in my family.
THERAPIST: How did they let you know that you weren’t important, that you didn’t make a difference?
KATE: Oh, they just never listened to me, never acknowledged me. I could do whatever I wanted, whenever I wanted.
THERAPIST: So you had complete freedom.
KATE: Right.
THERAPIST: But no one paid any attention.
KATE: Right.
THERAPIST: So you were ignored.
KATE: Right.
THERAPIST: Like no one cared enough …
KATE: (finishing the sentence) … to say anything, to implement any discipline or direction, or anything of that sort, ever.
Kate’s childhood environment was also unsafe. Her older brother was diagnosed with attention deficit disorder and frequently abused her physically and sexually. Neither parent protected her. They were emotionally removed, and both parents blamed her for her brother’s misbehavior.
KATE: Well, my brother was hyperactive. I guess my parents just spent so much time watching him and fearing him. He wasn’t taking medication, so he was out of control.
THERAPIST: He got all the attention because he was sick?
KATE: Yes.
THERAPIST: And there wasn’t anything left for you?
KATE: Yes, for the most part. I think my father was off in his own world. He wasn’t really home a lot. He was very depressed. He always was, and I think it was just a bit much for him.
THERAPIST: So that’s mainly what your father was like? Off in his own world?
KATE: Yes. All the time.
THERAPIST: So it felt like you were all alone?
KATE: Yes.
Kate’s childhood environment was also punitive and rejecting. Her mother was especially critical of her and intolerant of her emotions.
THERAPIST: And how about your mother?
KATE: She and I didn’t get along. I was just very unhappy, and that really bothered her. So there was a lot of tension. She didn’t appreciate the fact that I wasn’t just a happy-go-lucky person, she couldn’t understand why. She figured that something was wrong with me, and she didn’t know what to do with me, and she didn’t like me very much.
THERAPIST: Was she rejecting or critical?
KATE: Yeah, she was very critical, especially as I got older. We were always fighting. She told me she didn’t like me, that I was just hopeless, that I was just so miserable she couldn’t stand it. (Cries.)
THERAPIST: How did it make you feel when she used to talk to you that way?
KATE: Oh, I just believed it, because it was true.
THERAPIST: What was the essence of her statement? What do you feel her main criticism of you was?
KATE: Just that I was so unhappy and that I was nasty to her, and that I was bitchy.
THERAPIST: And you felt she was right?
KATE: Yes.
Kate’s childhood environment was subjugating. Even though she was experiencing serious neglect and abuse, she was not allowed to be sad or angry about what was happening to her. Such manifestations of emotion infuriated her parents and triggered her brother’s abuse of her.
One way Kate tries to suppress her feelings is by flipping into the Punitive Parent mode whenever she becomes angry with others.
THERAPIST: The angry side, the part that feels that she was mistreated, people weren’t there for her, do you ever feel that side?
KATE: Yes. I feel that, but then I feel that I just deserved it, that people had a right to treat me that way. And then I get angry ’cause I think that, but … (pause).
THERAPIST: Could it be that you then become the Punitive Parent and punish the little child for being angry? Does that feel like what you are doing? Like you’re saying, “You’re bad, who are you to think that you have any rights?”
KATE: Yes. That’s what prevents me from sticking up for myself and taking care of myself, because I just don’t feel like I have the right. And I don’t think that anyone has the right to want to take care of me, because I don’t deserve it.
In the course of the interview, Kate experiences all four modes. We provide examples of each one.
Kate starts the interview in the Detached Protector mode. In this segment, which takes place near the beginning of the interview, Kate stops herself from crying. When the therapist comments, Kate answers in the Detached Protector mode.
THERAPIST: Do you feel like crying?
KATE: Yes, but I’m not going to.
THERAPIST: Why are you afraid to cry in here? Are you embarrassed?
KATE: Yes. I know I’m just supposed to be myself, but this is just really hard for me.
THERAPIST: You mentioned that your mother criticized you for being unhappy. Is there any feeling that if you show that side that it’s a bad side? Is that part of it?
KATE: Yeah, just sort of like being what you want me to be. I don’t want to be crying here in front of you.
THERAPIST: What do you feel that I want you to be?
KATE: I don’t know, just very intelligent and articulate.
THERAPIST: Without too many emotions?
KATE: Yes. Like helping you achieve your goals (laughs), even though I don’t know you very well. Just helping, making things easier for you. Making you feel comfortable. Like, I don’t know, I think that’s your drink over there. I was going to offer it to you.
THERAPIST: So your whole focus is really on doing what I want you to do and being what I want you to be.
KATE: Yes. Because I don’t know what it is that I am. I think I’m just a miserable person deep down. That’s just what I think.
THERAPIST: So, since you feel you’re miserable deep down, the best way to overcome that is to be what other people want you to be. What will that do for you? Why would you want to do that?
KATE: It sort of gets me out of myself, I start to emulate people, and just sort of like change myself, and I can be whoever and whatever I want. But what I’ve found is that it’s just made me feel worse, more empty.
THERAPIST: You mean to be what other people want you to be?
KATE: Yes, because I don’t know what I expect. I don’t know what I want. I don’t know what’s important to me. I don’t know. I’m 27 years old and I have no clue.
Kate expresses the sense of identity diffusion characteristic of the Detached Protector mode. Cut off from her needs and emotions, she does not know who she is. She is whoever other people want her to be.
Kate discusses a prior therapy in which she had been in the Detached Protector mode almost the entire time.
KATE: I remember the first therapist I saw. I saw him for about five years, and he helped me with some things. But, I don’t know, I was just too busy trying to please him. I really wanted him to just like me, and I was so scared that he was judging me. He said he wasn’t, but I believed he was judging me. I just wanted him to accept me.
THERAPIST: So in a sense you were doing with him what you’ve done with other people in your life, which is to not share what you really feel and who you really are.
KATE: Yes.
This segment illustrates how important it is for the therapist to distinguish the Detached Protector from the Healthy Adult mode. Many therapists, like the one Kate described, mistakenly believe that the patient is improving or healthy when, in fact, the patient has shifted into the Detached Protector mode.
When patients are in the Healthy Adult mode, they can experience and express needs and feelings. When they are in the Detached Protector mode, they are disconnected from their needs and feelings. They may behave appropriately, but it is without affect and it is without regard to their own needs. Patients with BPD are not able to engage in authentic intimate relationships when they are in the Detached Protector mode. They might be in a relationship, as Kate was with her prior therapist, but they are not acting in an intimate, vulnerable way. The body is present, but the soul is gone.
Kate describes how, in the month before her suicide attempt, she had alternated between the Detached Protector and Abandoned Child modes: “I kept detaching myself, and getting involved in other things, but then I just couldn’t do it anymore. I just used up all my resources.” She could not escape her feelings of desolation and worthlessness.
KATE: Right before I swallowed the pills, I went to see my husband at work. I used to go there and, sort of like, bother him. He was just like, “It’s over, that’s it.” Then I just felt so alone, more alone than I’ve ever, ever felt. And I just said, I’d just rather be dead than feel this way. And I’d rather feel dead than hurt, and I can’t take the hurt anymore. I knew that I didn’t know what was going to happen, I took a lot of pills, and I figured it would probably hurt, the way that I would die. But I figured that it would be over, instead of every day just living with pain. Every day. I couldn’t take it anymore.
Patients with BPD sometimes want the comfort of knowing that they could commit suicide if the pain became too great, that they would have some release from their suffering. The therapist does not have to take this comfort away from the patient. The patient can think about committing suicide and talk about committing suicide as much as she needs to do. But she must agree to reach her therapist and discuss her feelings thoroughly before making an attempt.
Most patients with BPD cannot easily discuss or remember their Angry Child mode. Therefore, we often utilize imagery techniques to access it. The therapist asks Kate to generate an image of her Angry Child.
THERAPIST: Would it be too scary to get an image of Angry Kate as a child and see what she looks like?
KATE: No, I have an image.
THERAPIST: And what does Angry Kate look like?
KATE: Just destroying my room.
THERAPIST: And why is she destroying it?
KATE: Because she’s just so mad. She’s mad at everybody.
THERAPIST: Can you get an image of the people she’s mad at?
KATE: Her father and her brother.
THERAPIST: Can you be her now and have her express her anger out loud to them, as they’re standing there? Have her tell them why she’s so mad at them?
KATE: No.
It is the Punitive Parent mode that stops Kate from expressing her anger. She flips into the Punitive Parent mode to prohibit anger or to punish the Angry Child for expressing anger.
This mode contains the patient’s “identification” with the punitive aspects of her parents, now internalized and usually self-directed. In the following segment, Dr. Young helps Kate link the voice of her Punitive Parent mode to her father’s voice. This segment is the continuation of the previous one.
THERAPIST: Why is it hard to express your anger, do you think?
KATE: Because I just don’t have the right to do it.
THERAPIST: Can you have them now saying that to you? Which one would say that to you? Your father or your brother?
KATE: My father. (Cries.)
THERAPIST: Then be your father now, and have him say that to you, that you don’t have the right to be angry. Say it so I can hear what he says.
KATE: He just says, “You always provoke your brother and you make him angry. You know he’s sick, but you get him mad. I just want you to just sit up in your room and be quiet.”
Kate does not have the right to express her anger. In a later segment, when Kate is in the Punitive Parent mode, she says, “I’m just bad, I’m just evil, I’m just dirty.” This is the essential message of this mode.